Tag Archives: amlodipine

Ilene Has High Cholesterol With A “Wonderful Ratio” And A Branch Retinal Vein Occlusion: Should She Take A Statin?

Recently the skeptical cardiologist was asked by Ilene, a reader with an HDL almost as high as her LDL and a history of branch retinal vein occlusion (BRVO) whether she should take the statin her cardiologist had prescribed.

I enjoy reading your articles and would appreciate your opinion on my situation.  I recently took a lipid panel blood test: total cholesterol: 244 HDL:112 LDL:121 VLDL:11  CRP: 1.77 Triglycerides: 57.  Also my Cardiac Agatston  score is 21.
I had a Branch Retinol Vein Occlusion a year ago in my left eye  (it’s healing beautifully) and as a precaution  am now taking Amlodipine 5mg daily (my blood pressure was never too high to begin with) along with a daily baby aspirin.
I am otherwise a healthy 72 year old woman, exercise and eat healthy.
My regular doctor (Integrative MD) says my cholesterol ratio is wonderful….my cardiologist wants me to take a statin (Atorvastatin) in a low dose.  The ONLY med I take is Amlodipine and I am not one to be taking a plethora of meds for the rest of my life (unless “absolutely” necessary.  What is your suggestion…take a statin or not.
While I can’t provide medical advice to Ilene specifically it is worthwhile  to ponder  the general aspects of her case and how I would approach it as it likely applies to thousands of other patients including many of my own.
In my mind there are two questions here: 1) Should Ilene and patients like her take a statin to prevent future heart attacks and strokes and 2) Do statins  effect the Branch Retinal Vein Occlusion (BRVO)?
Although I’m not a fan of integrative or functional medicine Ilene’s integrative MD is correct in saying that her ratio of total cholesterol to HDL cholesterol is wonderful. Perhaps that high  HDL is protecting her from a build-up of atherosclerotic plaque.
On the other hand, Ilene tells me that  “My father did have a heart attack in his 60’s”.  Perhaps she inherited something from him that puts her in a higher than average risk category.
With the information from the CAC we don’t have to guess about the influence of the high HDL and the family history of CAD. Her score is at the 48th percentile, slightly below average for white women her age, thus it would appear she is not destined for her father’s fate.
Frequent readers of skepcard (especially my posts on statin fence sitters) will know I  plug all these numbers (preferably with the calcium score available) into the MESA coronary calcium risk calculator
In this case, the CAC score does not significantly alter our risk estimate as it is so close to the average for her age
Even if we count her as having hypertension because she is on the amlodipine her 10 year risk of heart attack and stroke is low at 3.2%.
Guidelines don’t recommend statin treatment unless risk is >7.5%.
Also, note that I answered yes to “Family history heart disease” but most studies generally only consider this a risk factor if father had heart attack prior to age 55 years. If we make that a no the risk drops to <3%.
Now that we’ve answered Ilene’s real question let’s see if the BRVO warrants statin therapy.
Branch Retinal Vein Occlusion
BRVO is the blockage of a vein from the retina and the second most
common cause of vision loss from retinal vascular disease, following diabetic retinopathy. It typically  results in the painless loss of vision in one portion of one eye due to hemorrhage and edema in the retina.
A reasonable summary of BRVO provided by the American Academy of Ophthalmology can be found here.
BRVO is not clearly related to atherosclerosis or hyperlipidemia and there is no evidence that taking a statin would prevent recurrence or help the condition.

The leading theory for what causes BRVO is that the more delicate and distensible retinal veins are squished or compressed at points where the stiffer and thicker retinal arteries cross them.  Up to Date notes:

Whereas branch retinal vein occlusion (BRVO) appears to be related to compression of the branch vein by retinal arterioles at the arteriovenous crossing points, central retinal vein occlusion (CRVO) is usually associated with primary thrombus formation.

Although BRVO is more common in patients with hypertension and atherosclerosis it is not clear that one causes the other or that treatment of hypertension or atherosclerosis diminishes the risk of BRVO.  So statins are not recommended.
More Questions
Every patient case for me leads to more questions,  more investigations and more knowledge. Here are some questions that occurred to me from ilene’s case.
-Why would someone with no symptoms and no heart problems be seeing a cardiologist?
(“I started seeing a cardiologist just to make sure all systems were “go” and stayed that way!… we take care of our cars so why not my body. )
I kind of like this answer and I definitely see lots of patients with that philosophy but if we extrapolate the car analogy: going to a cardiologist would be like taking your car to a mechanic who only works on engines or perhaps one specific part of the engine (help me out here people who know about cars.)
-Why was Ilene unwilling to take a statin? (I pretty much know the answer to this (see here) for most patients.
‘m just afraid of the horrible muscle related side effects of statin drugs…and that’s why I’m taking Berberine 500mg twice a day.
Yep. I feel a post abut Berberine may be in the works!
-Finally, should a 72 year old with a CAC score of 21 and BRVO be taking a baby aspirin?
I’ve generally advocated aspirin in primary prevention for scores >100  so wouldn’t advise it for prevention of cardiovascular events in this situation.
In addition, I have seen nothing in the literature that recommends aspirin for BRVO. These two BRVO experts do not recommend either aspirin or anticoagulants.
Proretinally Yours,
-ACP
N.B. If you have a blockage of the the artery that supplies blood to the retina or a branch retinal artery occlusion ( BRAO)
you might benefit from a statin as this is often caused by a clot or plaque flying out of the heart or the carotid artery.

The Skeptical Cardiologist Begins Pill Splitting: Best Practice or Patient Folly?

Recently the skeptical cardiologist certified his entry into the geriatric fraternity by acquiring a pill splitter.

Why Split Pills?

I’ve been prescribing half doses of various medications to my patients for decades. Sometimes it’s because I need to lower the dosage of, let’s say, a blood pressure medication just a little bit or I  need to up the dosage of a heart failure medication but want to be more cautious than doubling the dosage would allow.

The second reason I have my patients splitting pills is to save money. With generics (which I try to use whenever possible) like amlodipine which often only costs $5 per month this is usually not the issue but for brand name drugs it is huge.

Take rosuvastatin, for example, the widely prescribed, most powerful statin drug which is only available as an expensive brand name drug, Crestor.

My Epocrates iphone app says thirty 10 mg Crestor tablets cost $200 whereas thirty 20 mg tablets costs $189. This is the cost to a patient with no health insurance. Most of my patients have insurance and will be paying a higher tier co-pay for Crestor, perhaps 50$ versus $25. If I prescribe 20 mg tablets to my patient who needs 10 mg tablets and have the patient split them in two, the Crestor will last twice as long and the patient’s cost is halved.

My Pill Splitter and Amlodipine

I had always been vaguely aware of the mechanical issues surrounding pill splitting based on reports from my patients. Concerns about uneven splits or crumbling of the tablets were often expressed.

But I had never personally put a pill in a pill splitter and experienced the act of dividing for myself.

IMG_4360
Amlodipine, about to undergo the guillotine.

The pill in question was 10 mg of amlodipine, a generic calcium channel blocker used widely for control of blood pressure. In 2014, amlodipine was the #5 most prescribed generic drug in the US with 76 million prescriptions written.

Amlodipine has a long half-life and is usually prescribed as  once daily but it’s peak effects occur 6-12 hours after taking it. For this reason, if patients are noting very high blood pressures right before they take their morning amlodipine combined with very low pressures in the afternoon I will have them divide their pills and take them twice daily. This often eliminates mid afternoon sluggishness and lowers the early morning blood pressure to acceptable levels.

I decided I wanted to take 1/2 of my prescribed a amlodipine twice daily to smooth out its effects. At first I tried to break it in half with my fingers. I failed. I just couldn’t get them to break. (I was able to do this with another blood pressure pill, a long, large, oblong shaped tablet).

Thus began my quest for a pill splitter.

Screen Shot 2015-08-09 at 5.38.56 AMAfter doing a bit of due diligence I purchased the Apex Deluxe Pill Splitter for $5.89 ( unsponsored link here) from Amazon and it was delivered for free, arriving the next day.

I found that people are remarkably passionate and analytical about their pill splitters. There are 677 reviews on the Apex pill splitter on Amazon and they are often detailed. If you’d like to spend your day learning the nuances of these devices, there is probably no better place than Amazon.

pill splitter
My first attempt at splitting. I lowered the guillotine too slowly and there was much crumbling. The guillotine must be quickly and sharply lowered to reduce pain and crumbling to the tablet. At the bottom is a previously sliced 160 valsartan tablet. The oblong shape is not as amenable to halving.

The bottom line for me was that my circular 10 mg amlodipine tablets were split very nicely by the device.
There is definitely some crumbling and loss of a few micrograms of material and when you put the split pill in your mouth you can taste the bitter split pill powder much more quickly than a whole pill.

Issues With Pill Splitting

Superficial  reviews of this topic often say that the American Medical Association formally opposes the practice of pill splitting but the most recent document I found is from the AMA’s Medical Letter which concludes “tablet splitting may not have adverse consequences and can reduce costs for both patients and institutions”

Studies have demonstrated that the practice is safe for a variety of tablets.

Consumer Reports has a document (here) that was created in 2006 and which is widely referenced which lists medications that are considered safe to split but I have not found any documentation to support this.

The FDA studied pill splitting and issued this guidance in 2013.

  • If a tablet is FDA-approved to be split, this information will be printed in the “HOW SUPPLIED” section of the professional label insert and in the patient package insert. Also, the tablet will be scored with a mark indicating where to split it.
  • If a tablet does not include such information in the label, FDA has not evaluated it to ensure that the two halves of a split tablet are the same in weight or drug content or work the same way in the body as the whole tablet. You should discuss with your healthcare professional whether to split this type of tablet.
  • If your healthcare professional asks you to split your tablets, do not split the entire supply of tablets at one time and then store them for later use. That is, make sure that both halves are taken before splitting the next tablet. This is important because split tablets may be affected by factors such as heat, humidity and/or moisture content. For example, a split tablet stored in a damp environment such as in a bathroom medicine cabinet could be affected.
  • Your healthcare professional may be able to recommend the best method by which to split a tablet. In many cases, a tablet splitter may be appropriate. However, some tablets may not be suitable for this method because of their unique shape and size—even if they appear to be scored. It is important to discuss this issue with your healthcare professional to determine what is best for you.
  • Most sustained, controlled, or timed release medications are not meant for splitting. In those rare instances where splitting is recommended for this type of medication, such information will be printed in the “HOW SUPPLIED” section of the professional label insert and in the patient package insert and will be scored.
  • When you switch from one brand of medicine to another, you and your healthcare professional should confirm whether the newly prescribed tablet is splitable, even if the original tablet could be split. The same medications can be manufactured differently, thus may not have been developed to be split.

Personally, on my recent trip to Europe, I violated the third FDA recommendation as I “pre-split” my amlodipine tablets because I didn’t want to take the pill splitter with me.

My Advice To Patients on Pill Splitting

The vast majority of the time it is fine to split tablets for saving money or making medication adjustments.

Use a pill splitter. They are cheap and effective and the act of vigorously slicing your pills with the guillotine-like blade provides a sensory thrill that will get your mornings started on the right note.

Don’t do this with timed-release tablets or capsules (although I have one resourceful patient who opens her capsules and splits the powder within and it seems to work well for her).

Common sense can be our guide as to whether the process of splitting is resulting in fairly equal portions and an acceptable level of crumbling. Ideally, however, even if the resulting fragments seem relatively equal, it is best not to split into quarters (although I have a few patients who have divided their tablets into eighths with no adverse consequences!).

Splitting pills but not hairs and crumblingly yours,

-ACP