What I found shocking about McCain’s doctor taking him off Vytorin (20/10) was not so much the poor logic used, but the even worse thought process that took place in putting him on simv 20. The lower the strength of the statin, the greater the comparative efficacy of the Zetia component in lowering LDL. In that regard, he should have expected the ~48% increase in LDL he got from March to May. Why didn’t he double the simvastatin dose to 40mg? His peers are reading about it right now and thinking, what was he thinking?

But, seriously, I agree. As discussed elsewhere on the ‘Lot, Prevacid, for example, does not have some of the interaction issues that the other PPIs have (and probably vice versa)

Whether I personally will be able to tolerate a different statin remains to be seen. Going on the CYP theory, prava may be next best try.

For Mark - I think there is still more to know re: primary prevention with statins. First, there are a range of permutations of age/gender/risk factors over time that I’m not sure we know about. Second, it is certainly possible that some of those who end up dying of cancer, or falling off a ladder, would have had a fatal MI earlier. While I agree that the primary prevention benefits have been oversold (and I have serious doubts re: NCEP guidelines), still more to learn, I think.

Your case demonstrates exactly why we need multiple drugs in each class despite the rantings of “experts” such as Marcia Angell. People react differently to different meds and need to have multiple options available.

Atlex

There is a huge amount of data on Statins. Unfortunately, the primary prevention trials failed when you look at total mortality. More data won’t change this fact.

I wasn’t taking anything else (meds or supplements) that I think could have competed on the metabolic pathway (I follow these things pretty carefully) so I think I must just be a very poor metabolizer of the drug. My guess is that the plasma levels were much higher than such dosing would suggest, which would also explain why I got such dramatic results in a short time.

Did you start on 1/2 a dose of Lipitor? I’m sure you are aware that the smallest pill available is 10mg.

Atlex

Thanks for disclosure, Paul. I developed a permanent neuropathy on 5 mg. of Lipitor (!) but had 60% drop in LDL (to about 70), and significant increases in HDL, lowering of TC’s etc. So…different strokes (so to speak). And different CYPs.

But that’s why I also react a little stickily when I hear someone say, “just give him Lipitor,” etc.. It is rarely simple, even though I realize my own experience was unusual, and despite the fact that neuropathies are increasingly noted and recognized as not-incidental AEs for all statins.

Anyway, I don’t think there will be any debate that there is a place for many approaches, in whatever combos, etc., and also that we need much better data on the endpoints that count rather than all the surrogates, whether LDL, carotid appearance, etc.).

The part that I took issue with was the assumption that “hysteria” and Nissen were responsible for so many people switching off Vytorin. As noted, I know many docs who have done so, and they are not hysterionic types. And more folks than Nissen have advised Vytorin as a third-line option for _most_ pts, at this point.

Further disclosure - my own wife also uses Vytorin, and it seems to be a reasonable choice for her at this point.

Lipitor and Crestor are very good but are not combos. They are both better at lowering TC and LDL (and raising HDL) a bit more than simvastatin alone, but not quite as good as simva+zetia, i.e. Vytorin. You could push the doses of Lipitor or Crestor high up to get the same effects but two things can happen, the HDL increases are less at the higher doses and you risk more AEs like increased enzymes, muscle pain, etc.

You are not wrong, L and C are good alternatives, but Vytorin is not a bad one.

Disclosure: I have cycled through all the statins. best that has worked for me, and without any problems, is Vytorin.