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The Moral of the Zetia Story

LDL is only called bad cholesterol because we call it that.


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The drug of the week is Zetia—another tale of a good drug potentially gone bad. Zetia lowers bad cholesterol (LDL) by preventing it from being "recycled" in the intestines. This is different from the more commonly used "statins" that prevent bad cholesterol from being formed in the liver. The news stories have highlighted research suggesting that lowering your cholesterol with Zetiamay not have the same benefits as doing so with statins. There is even a suggestion that Zetia may have a negative effect on fat deposits in blood vessels.

This story has a lot of angles. There are allegations that these new data were not released in a timely manner. Other stories suggest that guidelines encouraging ultralow levels of bad cholesterol were influenced by the makers of Zetia. Some of the more insightful stories have pointed out that Zetia, unlike statins, has never been shown to have clinical benefits.

There is some merit to all of these concerns. For me, though, the big question is what this new information tells us about treating heart disease in general and LDL in particular. Over the past few years, many studies have shown that statins prevent heart disease and stroke, saving lives. The medical community has centered on the role of LDL in this story, with the mantra being that lower is better. But statins do much more than lower LDL—they affect the function of the lining of our blood vessels and reduce some markers of inflammation, for instance.

Why then the emphasis on LDL? Probably because it's something that makes intuitive sense: Statins save lives. Statins lower LDL. So a lower LDL must save lives. (Kind of like the old Woody Allen joke: Socrates is a man. All men are mortal. So all men are Socrates.) What the Zetia story tells us is that there’s more to preventing heart disease than lowering LDL, and that how we lower LDL may be more important than we thought.

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