Author name: arete

Introduction: If “An apple a day keeps the doctor away”, what can an hour of daily exercise do? In my preventative healthcare conversations with patients, the topic of weight loss is often top of mind: “What can I do to lose weight?” “Will I be able to stop my blood pressure or cholesterol medications if I lose 20 pounds?” “How will my health improve with weight loss?” Though these are important questions to be asking, and the dangers of obesity are worth addressing, my response is often to draw attention to an even greater concern from my perspective: poor cardiovascular fitness. The Case for Focusing on Fitness: There have been several major, long-term, cohort studies conducted since the 1950’s that have aimed to capture the impact of various cardiovascular disease (CVD) risk factors such as obesity and cardiorespiratory fitness (CRF) on eventual development of CVD and/or premature mortality. Altogether, the evidence suggests a much stronger association between low cardiovascular fitness and increased mortality when compared to obesity and increased mortality.1-5 A study published in the Journal of American College of Cardiology (JACC) in 2023 looked at 93,060 individuals aged 30 – 95 who were a part of the larger ETHOS (Exercise Testing and Health Outcomes Study) Veteran Affairs cohort and had undergone exercise treadmill stress testing, assessing CRF as measured in metabolic equivalents of a task (METs). This analysis demonstrated a clear, inverse association between CRF and mortality risk: a decline in CRF of >2.0 METs in those with low fitness was associated with a 69% increased risk of mortality (HR: 1.69 (1.45 – 1.96)) for those without a history of cardiovascular disease (CVD) and a 74% increased mortality risk (HR 1.74 (1.59 – 1.91)) for those with CVD.1 A smaller cohort study of 2603 adults over the age of 60, conducted between 1979 – 2003, demonstrated CRF was a significant mortality predictor irrespective of BMI, waist circumference and body fat percentage.2 Lastly, the Henry Ford Exercise Testing Project, conducted between 1991 and 2009 and including 29,257 Americans with a mean age of 53 years without cardiovascular disease, demonstrated a strong, inverse correlation between cardiovascular fitness as measured in METs and all-cause mortality, with a Hazard Ratio (HR) of 0.86 (0.85-0.88). BMI was inversely related to mortality, but to a significantly lesser degree: HR 0.98 (0.97-0.99). This study demonstrated an “obesity paradox”, wherein the highest risk group were individuals with low exercise capacity (<10 METs) and low BMI, which was not observed in the higher exercise capacity, higher BMI group.3 Though there are limitations in assessing excess adiposity through BMI, which can be easily affected by other factors such as higher muscle mass, the evidence repeatedly suggests that poor exercise capacity is the bigger risk concern compared to obesity. My Recommendation: Though the potential health risks of obesity are not to be ignored, for the average individual, given the choice between recommending focus on cardiovascular fitness versus focus on weight loss through cutting calories, I would recommend the fitness focus. From my review of the literature, there is a much stronger body of evidence linking increased mortality risk with poor cardiovascular fitness when compared to obesity. By focusing on fitness, not only is potential longevity likely better protected, but excess weight will often be addressed in tandem. References: 1.     McAuley PA, Blaha MJ, Keteyian SJ, Brawner CA, Al Rifai M, Dardari ZA, Ehrman JK, Al-Mallah MH. Fitness, fatness, and mortality: the FIT (Henry Ford exercise testing) project. The American journal of medicine. 2016 Sep 1;129(9):960-5. 2.     Sui X, LaMonte MJ, Laditka JN, Hardin JW, Chase N, Hooker SP, Blair SN. Cardiorespiratory fitness and adiposity as mortality predictors in older adults. Jama. 2007 Dec 5;298(21):2507-16. 3.     Kokkinos P, Faselis C, Samuel IB, Lavie CJ, Zhang J, Vargas JD, Pittaras A, Doumas M, Karasik P, Moore H, Heimal M. Changes in cardiorespiratory fitness and survival in patients with or without cardiovascular disease. Journal of the American college of cardiology. 2023 Mar 28;81(12):1137-47. 4.     Korpelainen R, Lämsä J, Kaikkonen KM, Korpelainen J, Laukkanen J, Palatsi I, Takala TE, Ikäheimo TM, Hautala AJ. Exercise capacity and mortality–a follow-up study of 3033 subjects referred to clinical exercise testing. Annals of medicine. 2016 Jul 3;48(5):359-66. 5.     Clausen JS, Marott JL, Holtermann A, Gyntelberg F, Jensen MT. Midlife cardiorespiratory fitness and the long-term risk of mortality: 46 years of follow-up. Journal of the American College of Cardiology. 2018 Aug 28;72(9):987-95.

As it pertains to the safety and health effects of alcohol, the pendulum has swung back and forth over the years, with prior observational studies potentially even suggesting a benefit to low-level consumption of red wine. Is There a Safe Drinking Limit? Unfortunately for those who do drink alcohol regularly, newer studies using more advanced statistical methods such as Mendelian randomization repeatedly suggest that there is unlikely to be any significant benefit from regular alcohol consumption, and any potential benefit would be strongly outweighed by the multiple, well-established, negative health effects. The current recommendation from the World Health Organization is that there is no safe level of alcohol consumption.1 What are the Health Effects of Drinking Alcohol? Many of you will be well aware that alcohol is a major cause of liver disease and liver failure, but beyond that there are a whole host of additional health concerns. Alcohol is a recognized carcinogen, with strong links to cancers involving the liver, breast, and essentially the full extent of the digestive tract. Regular alcohol use is associated with cardiovascular disease and is a leading cause of pancreatic inflammation.2,3 Regular consumption also has strong links with earlier-onset cognitive impairment and dementia, has adverse implications from a mental health perspective, increases the likelihood of physical injury, and is a well-established cause of fetal developmental issues when consumed during pregnancy.2,4-5 From a metabolic perspective, alcohol is relatively calorically dense at 7 calories per gram, and its disinhibitory effects and effect on acutely lowering blood sugar can often trigger increased hunger and poorer dietary choices.6 Lastly, sleep is notably impacted by alcohol consumption: through its sedative effect, it may be easier to fall asleep, but sleep architecture is affected, with reduced rapid eye movement (REM) sleep and more awakening especially in the 2nd half of the night.7 My Recommendation When I’m speaking with patients of mine regarding their alcohol use, I advise a harm reduction approach, whereby whenever possible alcohol consumption is limited to special social occasions, ideally not more than once per week, and no more than 1 or 2 drinks per sitting. At these levels, risk of harm is relatively low. References 1.     Anderson BO, Berdzuli N, Ilbawi A, Kestel D, Kluge HP, Krech R, Mikkelsen B, Neufeld M, Poznyak V, Rekve D, Slama S. Health and cancer risks associated with low levels of alcohol consumption. The Lancet Public Health. 2023 Jan 1;8(1):e6-7. 2.     Gapstur SM, Bouvard V, Nethan ST, Freudenheim JL, Abnet CC, English DR, Rehm J, Balbo S, Buykx P, Crabb D, Conway DI. The IARC perspective on alcohol reduction or cessation and cancer risk. New England Journal of Medicine. 2023 Dec 28;389(26):2486-94. 3.     Levesque C, Sanger N, Edalati H, Sohi I, Shield KD, Sherk A, Stockwell T, Butt PR, Paradis C. A systematic review of relative risks for the relationship between chronic alcohol use and the occurrence of disease. Alcohol: Clinical and Experimental Research. 2023 Jul;47(7):1238-55. 4.     Prince M, Albanese E, Guerchet M, Prina M. World Alzheimer Report 2014. Dementia and Risk Reduction: An analysis of protective and modifiable risk factors(Doctoral dissertation, Alzheimer’s Disease International). 5.     Livingston G, Huntley J, Liu KY, Costafreda SG, Selbæk G, Alladi S, Ames D, Banerjee S, Burns A, Brayne C, Fox NC. Dementia prevention, intervention, and care: 2024 report of the Lancet standing Commission. The Lancet. 2024 Aug 10;404(10452):572-628. 6.     IARC Monographs on the Evaluation of Carcinogenic Risks to Humans. Alcohol consumption and ethyl carbamate. 7.     McCullar KS, Barker DH, McGeary JE, Saletin JM, Gredvig-Ardito C, Swift RM, Carskadon MA. Altered sleep architecture following consecutive nights of presleep alcohol. Sleep. 2024 Apr 1;47(4):zsae003.

A Blood Test for Cancer?  For many types of cancers there is no reliable screening method, and unfortunately once symptoms develop, it’s often too late. In recent years, a new form of cancer screening technology has been developed that aims to screen for dozens of types of cancer using a single blood test. How Does it Work? The technology centers around detecting cell-free DNA, which are fragments of DNA that are shed by dividing tumors into the bloodstream. The best-established test in this space is the Galleri® test, made by an American company called GRAIL. The Pathfinder Study The original study validating the Galleri® test was called the PATHFINDER study, which was released in the Lancet in 2023.1 This study showed 74% sensitivity for 12 deadly cancers, and a positive predictive value of 43%, meaning that 4 out of 10 times a test is positive – cancer is diagnosed.1 In the cancer world, where many cancer screening tests have a positive predictive value as low as 5%, this is actually relatively good. The test is better for detecting more actively dividing cancers that are shedding more tumor DNA into the bloodstream and is thus more likely to miss slow-growing, or indolent tumors. PATHFINDER 2 is currently underway, looking at adding the Galleri® test to standard cancer screening in over 35,000 adults.2 According to a recent press release from the company this June, provisional results are showing “substantially higher positive predictive value” compared to the original PATHFINDER study.3 Where Can You Get the Test? This technology is not yet readily available in Canada, but can be coordinated through centers in the States. If further promising data continues to come out, this form of technology may become a widespread tool for screening for cancer in years to come. References 1.     Schrag D, Beer TM, McDonnell III CH, Nadauld L, Dilaveri CA, Reid R, Marinac CR, Chung KC, Lopatin M, Fung ET, Klein EA. PATHFINDER: A Prospective Cohort Study of Blood-Based Multi-cancer Early Detection. Lancet (London, England). 2023 Oct 7;402(10409):1251. 2.     PATHFINDER 2: a multi-cancer early detection study. ClinicalTrials.gov. Updated December 30, 2024. Accessed June 19, 2025. https://clinicaltrials.gov/study/NCT05155605 3.     GRAIL announces positive top-line results from the Galleri PATHFINDER 2 registrational study. News release. Grail Inc. June 18, 2025. Accessed June 19, 2025. https://grail.com/press-releases/grail-announces-positive-top-line-results-from-the-galleri%e2%93%a1-pathfinder-2-registrational-study/

What is a Whole Body MRI? Contrary to the name, a “whole body MRI” typically involves a MRI scan from the head down to the pelvis, and doesn’t include ones’ limbs. In Canada, whole body MRIs are done through private imaging centres, and are only available through a physician referral. These scans have been growing in popularity, fueled by celebrity endorsers. For anyone considering a whole body MRI, it’s important to understand the potential pros and cons. View this post on Instagram A post shared by Almira Medical (@almiramedical.toronto) What are the Potential Benefits? Those who advocate for whole body MRI point to cases where a whole-body MRI has identified an early-growing cancer or other potentially serious condition before any symptoms have developed. This, in theory, would allow for earlier actions to be taken. Considering the dangers of late cancer diagnosis, this potentially could improve outcomes. Other benefits include the fact that contrary to CT scans or nuclear scans, MRI scans carry no radiation, and a large area of the body can be scanned in one appointment. What are Potential Concerns? The biggest concern is with over-diagnosis and false positive results. The MRI cannot always tell the difference between a potentially cancerous lesion which requires action and a benign one. As a result, this can lead to further tests, such as CT scans which carry radiation, invasive biopsies, or the need for long-term monitoring with serial scans every 6 – 12 months to make sure the lesion isn’t growing. This process can be anxiety-provoking, and in some cases such as with invasive biopsies can cause harm. In addition, a whole-body MRI is relatively quick and may not provide the same level of detail as a dedicated MRI of a specific body part. Lastly, MRI is also not always the best type of imaging for looking at certain body parts, such as bones. My Recommendation Where I’ve personally landed on this topic is that for most healthy, younger individuals a whole-body MRI is neither necessary nor recommended. For select individuals who are at higher risk, such as those with a long-term smoking history, strong family history of cancer, or increased risk for cancers of the pancreas and biliary tree, there’s a potential role. Either way, it’s a conversation making sure an individual understands the pros and cons before they have the scan done

How Can You Lower Blood Pressure Through Dietary Changes? High blood pressure is a leading cause of stroke, heart disease, and kidney failure. As a hypertension specialist, I’ve seen first-hand on multiple occasions the power of dietary changes on controlling blood pressure, especially when such changes are combined with other lifestyle changes such as increasing exercise, weight loss, alcohol avoidance and stress reduction. View this post on Instagram A post shared by Almira Medical (@almiramedical.toronto) Sodium Intake If there’s one thing to avoid, it’s sodium. Some individuals have a particularly ‘salt-sensitive’ form of hypertension and can see a significant decline in their blood pressure readings by cutting down on their sodium intake. The maximum recommended sodium intake for those with hypertension is 2000mg per day.1 For perspective, living in North America, it’s common to have in the range of 3000 – 5000mg of sodium per day if we’re not careful and paying attention to labels. Many of my patients tell me that this is not an issue for them as they don’t add salt to their food, which is a great start, but most of the sodium that we consume is hidden in our food, especially in foods that come pre-packaged, canned, or from restaurants. The DASH Diet The diet that has the best evidence for lowering blood pressure is called the DASH diet, with DASH being an acronym that stands for Dietary Approach to Stopping Hypertension. This is a Mediterranean-type diet that contains less-processed and more naturally occurring foods such as fruits and vegetables, low-fat dairy products such as low-fat Greek yoghurt or skim or 1% milk, lean protein such as fish and poultry instead of red meats, and beans, nuts, and seeds. This diet was shown in a landmark study in the New England Journal in 1997 to reduce blood pressure as much by 5.5mmHg systolic and 3 mmHg diastolic over an 8-week period when compared to a standard Western control diet that contained the same amount of sodium.2 Part of the reason that the DASH diet is likely effective in lowering blood pressure is due to the higher fibre content found in fruits and vegetables. Recent evidence in mice has shown that increasing dietary fibre has beneficial effects for lowering blood pressure by acting through our gut microbiota to form short chain fatty acids.3 This is certainly something I’m keeping my eye on as we continue to learn more about the importance of a health gut microbiota in preventing disease, and the damaging and inflammatory effects of ultra-processed foods. Conclusion If you’re worried about your blood pressure, making changes starts with your choices at the grocery store. References 1.  Guideline: Sodium intake for adults and children. Geneva: World Health Organization; 2012:1-56. 2. Appel LJ, Moore TJ, Obarzanek E, Vollmer WM, Svetkey LP, Sacks FM, Bray GA, Vogt TM, Cutler JA, Windhauser MM, Lin PH. A clinical trial of the effects of dietary patterns on blood pressure. New England journal of medicine. 1997 Apr 17;336(16):1117-24. 3. Avellaneda-Franco L, Xie L, Nakai M, Barr JJ, Marques FZ. Dietary fiber intake impacts gut bacterial and viral populations in a hypertensive mouse model. Gut microbes. 2024 Dec 31;16(1):2407047.

What is Lipoprotein (a)? Have you ever heard of a young, relatively healthy person sudden dropping dead from a heart attack? A major cause of early cardiovascular disease is a genetic type of high cholesterol called Lipoprotein (a), or “L P Little a” for short. This type of cholesterol is particularly sticky to the walls of our arteries and causes disproportionate clogging of our arteries, such as the coronary arteries in the heart. Lp(a) increases risk of coronary heart disease and cardiac death by 20%.1 For people who have levels in the highest 5%, this doubles the risk of having a cardiac event.2 View this post on Instagram A post shared by Almira Medical (@almiramedical.toronto) Genetic Prevalence High Lp(a) affects roughly 25% of the global population and is more common in Black and South Asian individuals, compared to White individuals.3 This type of cholesterol is strongly genetic, with >90% determined by genes, and only a very small percentage determined by lifestyle.4 If a first degree relative of yours, such as a parent or sibling, has high Lp(a), there’s a roughly 2/3rds likelihood that you’re also affected.2 Why to Get Lp(a) Checked Chances are, even if you’ve had standard cholesterol levels checked with your family doctor, you likely have never had this checked. The Canadian Cardiovascular society recommends that everyone should get their Lp(a) checked once in their lives, with Lp(a) levels reaching a steady state from roughly 5 years old. So, if you check it and it’s high, it’s likely been high from a very young age. Treatment Options What can you do if your levels are high? To date, there has not been an effective treatment option available for Lp(a), with standard statin medications having essentially no effect at all on lowering levels. The Canadian Cardiovascular society recommends healthy eating, exercise, and other lifestyle changes, though in truth, while these changes are important, they have minimal effect on lowering levels and focus more on overall cardiovascular risk.5 Thankfully, new therapies are just around the corner: 2 medications in development appear particularly promising for lowering Lp(a). These medications, called pelacarsen and olpasiran, have been shown in early trials to decrease Lp(a) levels by 80 and over 95%, respectively.6,7 Phase 3 trials are underway for both these medications with results for pelacarsen expected later in 2025. If the treatment effect is substantiated without major adverse effects, FDA approval will likely follow. Ask your physician about getting your Lp(a) checked today – in Ontario it’s covered by OHIP and is a simple blood test that can be done any time of day without fasting. References

Have you ever looked at the ingredients list of a favourite packaged food and not recognized even half of the ingredient names? Names such as disodium guanylate, monocalcium phosphate, or silicon dioxide? Chances are that what you’re eating is an ultra-processed food. View this post on Instagram A post shared by Almira Medical (@almiramedical.toronto) What are Ultra-processed Foods? Most foods have some degree of processing, such as turning a whole cob of corn into canned corn, or making cream from milk. Ultra-processed foods, however, involve adding various chemical compounds to make the foods that we eat last longer, store better, keep certain textures and shapes, and taste better. It’s the reason a package of potato chips or licorice could stay on a store shelf for a decade and still look and taste the same. While this has allowed us to better transport and store food, in recent years we’ve been learning increasingly more about the potentially major effects on our health when eating these foods and chemical compounds. What are the Dangers of Ultra-processed Foods? Studies have shown that not only do many of these foods have low nutritional value, but they can cause increasing levels of inflammation, particularly in our gut, with links to serious health conditions such as diabetes, colorectal cancer, heart disease and depression.1-5 How Can You Get Around Eating Ultra-processed Foods? Start by getting into the habit of locking at food package labels to see if you recognize all the ingredients, and try sticking to foods that are minimally processed or non-processed, such as fruits and vegetables, low-fat dairy products and lean protein. Often these foods require refrigeration or have shorter-term expiration dates. References

Dementia is a progressive and irreversible disease. In a world where treatments for dementia have limited effect, prevention is key. View this post on Instagram A post shared by Almira Medical (@almiramedical.toronto) The Zostavax Study In April 2025, a study from Stanford was published in Nature, a major scientific journal, analyzing public health data from Wales after the introduction of a live shingles vaccine, Zostavax, in September 2013.1 When the vaccine was rolled out, individuals who were 79 years old at that time were eligible to receive it, and those who were 78 would become eligible the following year. Those who were 80 years or older were never eligible for the vaccine. Because of the way the vaccine was introduced with strict age cut-offs for a whole population, this presented a unique opportunity for analysis similar to a large randomized controlled trial, with a treatment arm (those who received the vaccine) and a natural control arm. The researchers focused on comparing people who had just turned 80 and didn’t receive the vaccine versus people who were just still 79 and had received the vaccine and seeing if there was any difference in dementia onset in the following 7 years. In essence, these individuals were only weeks apart in age.1 Results What the study authors found was that the 79-year-olds who received the shingles vaccine Zostavax were 20% less likely to develop dementia over a follow-up period compared to the 80-year-olds who didn’t. The response was found to be stronger in women than men. This is an impressively large reduction. This finding has reportedly been replicated in similar analyses of data from Australia, New Zealand, England, and Canada. How is the vaccine thought to be preventing dementia? More research will be needed to understand if the vaccine is helping by activating certain protective immune system effects or through reducing reactivation of the herpes zoster virus that causes shingles.1 Conclusions In more recent years, vaccine programs have shifted to non-live vaccines such as Shingrix which are more effective at preventing shingles. We don’t yet have data to know if these newer vaccines will have the same preventative effects. If you’re worried about developing dementia later in life, not to mention avoiding all the potentially serious effects of getting shingles, this vaccine may be something to consider. References

An individualized supplement regimen can be a helpful tool in your preventative health toolbox, especially when combined with effective lifestyle changes. However, unlike prescription medications, over-the-counter supplements are not regulated for safety and efficacy in the same way. This lack of oversight can lead to misinformation and exaggerated claims of benefit, with potential for harm when supplements are taken in excess or used as substitutes for more effective measures View this post on Instagram A post shared by Almira Medical (@almiramedical.toronto) 1. Am I certain that I have a dietary insufficiency that requires this supplement? Some vitamin and mineral deficiencies, like magnesium or vitamin D, are relatively common in clinical practice, and supplementation may help improve overall health. Other nutrients, such as folate and vitamin C, are easily obtained through a balanced diet, and deficiencies are less likely. Exceptions remain, for example folic acid is recommended before and during pregnancy to prevent fetal neural tube defects. If you’re unsure whether a supplement is necessary, consult with your healthcare provider to avoid unnecessary costs and pill burden. 2. Is there high-quality evidence supporting the use of this supplement? Health misinformation is increasingly commonplace online, and supplements aren’t held to the same safety and efficacy standards as prescription medications. As a result, supplement manufacturers and influencers may promote products based on low-quality studies, making unsupported claims of potential health benefits. Before adding a new supplement to your routine, check for high-quality research, such as large randomized controlled trials (RCTs) or meta-analyses published in reputable medical journals. This can help you determine whether the supplement’s benefits are supported by scientific evidence – and why some supplements may not be recommended for widespread use by major health organizations. 3. Am I considering this supplement as a substitute for a proven prescription medication or a necessary lifestyle change? Supplements can seem like an easy alternative to prescription medications or lifestyle medications, which may involve side effects or require more effort. However, in the case of chronic conditions, supplements generally lack the efficacy of proven treatments, and are typically more effective as non-essential preventative agents. For example, no supplement can replace the combination of prescription medications, carbohydrate reduction, and weight loss in managing Type 2 diabetes. Relying on supplements instead of evidence-based therapies can delay effective treatment and cause harm in the long run. 4. Does this supplement interact with any of my current medications or other supplements? Many supplements can interact with prescription medications or other over-the-counter products, either enhancing or reducing their effectiveness. For example, the herbal remedy St. John’s wort can reduce the effectiveness of oral contraceptives, increasing the risk of unintended pregnancy. Similarly, excessive vitamin K can interfere with blood thinners like warfarin, reducing their effectiveness and increasing the risk of blood clots.1 Always check with your healthcare provider or before starting a new supplement, especially if you are already taking multiple medications or supplements. 5. What is the recommended dose, and what are the risks of taking this supplement in excess? While prescription medications come with clear, individualized dosage instructions, the optimal dose of supplements can often be unclear, and accidental harm may arise from excess consumption. For example, vitamin E is a fat-soluble vitamin with antioxidant properties found in foods like nuts, eggs, and leafy greens. In excessive amounts, however, vitamin E has been linked with an increased risk of prostate cancer and bleeding, particularly for those on blood thinners. For most individuals, high dose vitamin E supplementation is unnecessary and should be avoided.2-3 Always research the recommended dose and be aware of the potential dangers of exceeding it. Supplements can play a valuable role in supporting long-term health and preventing disease. Supplement use should be tailored to an individual’s risk profile to maximize benefit and to avoid unnecessary or even potentially harmful use. Due to the lack of regulation and the potential for misinformation, it is important to fully educate yourself before adding a new supplement to your routine. Asking the five questions outlined above can help you make informed decisions when evaluating a prospective new supplement. If you’d like to review your current supplement regimen directly with Dr. Finlay or need help creating a personalized supplement plan, consider booking an appointment at Almira Medical today. References

High Cholesterol and ASCVD Risk High cholesterol is a major risk factor for atherosclerotic cardiovascular disease (ASCVD). Statins are relatively inexpensive and offer a potent way of reducing cholesterol levels and therefore lowering ASCVD risk. Most individuals have no or very mild side-effects while taking a statin medication, especially when the statin is prescribed at a low to medium dose. Most of the potential cholesterol-lowering benefit of a given statin medication comes from taking just a quarter of its maximum potential dose. Of the statin family, rosuvastatin and atorvastatin offer the most potent cholesterol-lowering effect (Table 1). % LDL Reduction Simvastatin (Zocor) Atorvastatin (Lipitor) Lovastatin (Mevacor) Pravastatin (Pravachol) Fluvastatin (Lescol) Rosuvastatin (Crestor) Pitavastatin (Livalo) 27 10mg – 20mg 20mg 40mg – – 34 20mg 10mg 40mg 40mg 80mg – 1mg 41 40mg 20mg 80mg 80mg – – 2mg 48 80mg 40mg – – – 10mg 4mg 54 – 80mg – – – 20mg – 60 – – – – – 40mg – 54 – 80mg – – – 20mg – 60 – – – – – 40mg – Table 1: Comparison of Different Statins on LDL-Cholesterol Reduction.1 Statin Intolerance and Potential Side Effects Some individuals have intolerable side-effects such as myalgias (muscle pains) while taking a certain statin (Figure 1). Switching to a different statin medication or taking a lower dose may be helpful to alleviate these symptoms. Common concerns with statins are from mild worsening of liver blood tests and a small increase in likelihood of developing diabetes mellitus2. Statins may cause more rare but potentially serious health issues such as rhabdomyolysis, a condition that involves rapid breakdown of muscle cells. In those who have had a prior stroke, statin use has been linked to a small increase in risk of hemorrhagic stroke (brain bleed).3 Large-scale reviews and analyses suggest that there is no definitive evidence for statin use in causing dementia, contrary to some claims.4,5 Figure 1: Benefits and Adverse Effects of Statins.3 Statins vs. Newer Cholesterol-Lowering Agents For the broader healthcare system, the benefits and affordability of statins favour their use for those with elevated cholesterol levels. Newer, more expensive agents such as bempedoic acid and PCSK9-inhibitors are effective alternatives to statins with fewer side effects and safety concerns. At present, most drug plans do not cover these medications for most individuals, and individuals may have to pay out of pocket to use these promising alternatives. In time the affordability of these agents should improve, and they may eventually replace statins as first-line medical therapy. References