Welcome to Dr. Warrick's podcast channel. Warrick is a practicing cardiologist and author with a passion for improving care by helping patients understand their heart health through education. Warrick believes educated patients get the best health care. Discover and understand the latest approaches and technology in heart care and how this might apply to you or someone you love. Hi, my name is Dr Warrick Bishop and welcome to my podcast and videocast station. Today I'm delighted to have for an interview Dr Alistair Begg, a colleague, a cardiologist from Adelaide with lots of experience and interest in rehabilitation, but a general cardiologist with lots of good information to share. So Alistair, welcome and hello. Hello again Warrick, good to talk to you. Yeah, always a pleasure to talk with you as well, Al. Look, today we've got a couple of really interesting ones to cover. I want to talk about side effects and then we're going to go on and talk about monitoring. But often it's the case we're giving people medications. And of course, there isn't a medication in the world that can't possibly have a side effect. I often say to people, I could kill them with water or at least make them very sick. So there's nothing that's without side effects. When you speak with your patients about side effects, how do you cover that conversation and what do you sort of advise them to do if they run into any problems or concerns? Sure. Well, look, I mean, at the end of the day, every treatment, whether it's an operation or a medication, has risks and benefits. So at the end of the day, you have to explain the benefits of why they're taking it and the risks. So maybe the medication has side effects. Maybe it's not going to be 100% effective. Maybe it's going to damage the hip pocket. You know, there's all these different things that you have to think about. And side effects is obviously one of the keys, particularly from a doctor that prescribes a lot of medication, as cardiologists do. It's important that the patients have some understanding of the side effects and the risks and benefits of using these drugs. So specifically, though, we do have to monitor certain things. For instance... The statins, which I know a lot's been talked about, but it is one of the major drugs that cardiologists use. And certainly muscle damage is something that we have to be mindful of. And it's very important to tell patients that because I know that you don't want to suggest a side effect to the patient, but if they experience muscle pain, they can get significant muscle damage from these drugs. And it's important that they're aware of that and have a blood test to check. if there's significant pain for any muscle damage. And you can do that through a simple blood test, which a doctor can organise on a routine specimen. And if that happens with statins, it's often safer not to re-challenge with it again because repeated damage to the muscles can lead to long-term issues. So I'll just... offer a little bit of clarity for those people who are listening there. And I think this is a really important one and one I cover regularly. There's a concept of being allergic to something. And a good example of that would be someone who is allergic to peanuts, being exposed to peanuts, and then having an allergic reaction, which is swelling of the face, the lungs get tight, the breathing gets affected. So that's a true allergy. Because sometimes people say, oh, I'm allergic to this and I'm allergic to that, but they haven't quite understood exactly what an allergy is. So an allergy is a very brisk, severe response, which can kill people. And then there are idiosyncratic reactions. And that's what you're talking about, Alistair, with the bad muscle problems with statins. And that idiosyncratic reaction is a statin. myopathy, which can be severe, it can be life-threatening, but it occurs in about one in 80,000 people. So it's not that common. In fact, peanut allergy, which we all hear about and know is concerning, occurs in one in 70,000 people. So statin myalgia is actually less common. But we do need to be aware of it. Is it idiosyncratic? That means we don't understand it. It can make people very sick. And then the next group of people who may have problems are having what I would call intolerances. And an intolerance means that it's related to the dose and the exposure. And the example I use for people is someone might be intolerant to alcohol. They have one or two drinks and are very intoxicated, whereas some people may be very... tolerant of alcohol, be able to have a bottle or two of wine and still be very coherent. And then there's people who don't have any side effects at all. So sorry to jump in there, but I think that classification of allergic idiosyncratic and tolerance or low tolerance is a really important one. And you're talking exactly about that. statin myopathy. Tell me about the people who have intolerances to statins. Alistair, what do you recommend to those people? Well, sometimes we can get by with very low doses. Receive a statin, sometimes a low dose such as five milligrams or even two and a half milligrams taken three times a week can still get a reasonable benefit because there is a a rule with the statins is that the first five milligrams of the statin gives you the most bang for your buck, if you like. And in fact, doubling the dose only really produces a 6% further reduction in the cholesterol. So if you're already on a fairly decent dose, doubling it will only reduce it by 6%. And then there are people that can tolerate a small dose. in which case we might give another drug in combination that works slightly differently, and that can get a further 20% reduction in the cholesterol. So for people that have statin intolerances, I often give a combination of a statin in low dose and another drug, often either separately or combined with the same drug, to stop the body absorbing cholesterol. And that can lead to a further 20% reduction in the statins. So giving combination of drugs in lower doses is often a way around getting around side effects. And that's the same with blood pressure drugs. If you give the first dose of the blood pressure drug, if you double it, you don't necessarily get the same reduction in the blood pressure. So by combining two different drugs in the same tablet often, you can get more beneficial lowering of your blood pressure without the side effects. Because often when you double the dose of the drug, say a blood pressure tablet, you get more side effects. So this is often what's done in cardiology now, using lower doses of drugs that work differently to each other and putting them in one tablet and getting better side effects. Really what you're alluding to there is that your first incremental dosing of an agent, whatever it is, blood pressure or statin lowering, often gives you the best bang for your buck in terms of its efficacy. But as you raise the dose, you raise the possibility of side effects. That's sort of what you're saying, isn't it? Yeah, exactly. Well, that applies to statins to some extent and also to blood pressure tablets. So there's a combination. different drugs and they work on different pathways in the body so they often work better than just increasing the dose of the first drug so um what we've talked a bit about stands we've been drawn a little bit down the statin path and we've touched on blood pressure tablets thanks for discussing those as well but we also prescribe things to thin the blood for example And we also provide or prescribe drugs for removing fluid or reducing chest pains or whatever it might be. In general terms, if a patient is having what they think could be problems with their medication, how would you advise the patient to deal with that? And the reason I ask is that I've seen patients who I've commenced on something which would be beneficial for whatever reason, on that risk-benefit analysis that you're talking about, And when I see the patient three months later, I find out that within the first three days, the patient felt they had a side effect from the medication and stopped it, but didn't let me know. How would you be advising patients to deal with those concerns if they arose? Well, certainly talking to a medical professional or a pharmaceutical professional, like your pharmacy, if it's mild, some of these things can be dealt with by the pharmacist. The GP is a key person involved in patient care. So it's important to discuss, you know, side effects with the GP. And then, of course, let the cardiologist know if you decided not to pursue the medication because it may be life-threatening. If they stop taking certain drugs and their stent clogs up, then that can be life-threatening. So it's important that the cardiologist knows if you're not going to take drugs. I think it's very important. Look, I've got a side effect story that I'll share with you because it was rather inadvertent, but it's a good representation. I had a man, he was elderly, he was in his mid-70s. He had severe hypertension. We're talking systolic blood pressure of about 170, 180 or thereabouts. And I was pretty keen to get that blood pressure down. And he was already on a raft of medications and they weren't really shifting his blood pressure. And I gave him a medication called Minipress or Prazosin, which is a blood pressure lowering agent. Prazosin can be prescribed up to a dose of 10 milligrams morning and night, so 20 milligrams in the day. So you can give quite a lot of this agent. But for this man, I said, I want you to take one milligram, which is a fraction, 5% of the maximal daily dose recommended. Well, he had a profound response to this agent. So he is exquisitely sensitive and he had a hypotensive episode. His blood pressure dropped profoundly. Well, this scared him. He called the ambulance. He ended up in hospital and he ended up seeing another cardiologist who he has now decided to stay with, blaming me for causing hypotension in him, which I should have foreseen. But of course, you just can't tell sometimes. But there you go, side effects, they occur. I actually was pretty pleased that we got his blood pressure down, to be honest, and I think there was space there to use fractions of one milligram, like half or a quarter of a tablet, to continue to maintain his medication. Have you had any funny episodes like that? I think the blood pressure story is a bit different to the cholesterol story. Most people have a fairly predictable response to the statins, for example. There's a little bit of variability between patients, but mostly it's a fairly predictable response. Blood pressure tablets, certain ones seem to be more likely to produce sudden drops in blood pressure, and certainly prazosin is one of those. Years ago, when the drugs called the ACE inhibitors were first prescribed, people used to get admitted to hospital for the first dose of captopril, and some of these drugs were quite quick-acting, I'm sure. And Warrick, you remember working with certain cardiologists that used to admit patients for a one-off dose of Captopril. But some of these drugs are actually now a bit more slower onset in action. And so we don't see so much of this in the newer blood pressure drugs. But certainly some of the older drugs, they work quickly and they drop the blood pressure quickly. So you do have to start off pretty low dosage with these drugs. Having said that, there are some drugs that need to be slowly what's called up titrated. So you might start off with a very low dose, for example, of a beta blocker in a patient with heart failure and then slowly increase the dose because, A, the first dose, the patient's very sensitive, but then after a while, the body gets used to it and you actually need to use bigger doses to get the effectiveness of the drug. So they all need to be sort of monitored, basically. That's true. Look, we've gone well over 10 minutes. We're approaching 15 minutes. And I think we'll need to draw a line under it, even though I was pretty keen to talk about monitoring. But I think what we've covered around side effects and the importance of side effects is really valuable. And quickly, there isn't an agent or a chemical or a compound known to man that can't give you a side effect. Anything can happen to anybody. In general terms, the medications we prescribe, we're only allowed to do that because they've been shown to be safe, effective and well tolerated in large trials. If you have problems with your medications, don't just stop them. Let the person who prescribed that medication know because it might be for a really, really important reason. And as Alistair beautifully described, we are able to find solutions for those issues of tolerability. So if you are sensitive to an agent with side effects, we can adjust those doses, use complementary agents, but we can only do that if we're working together. Alistair, I thank you so much for contributing today and sharing some of your wisdom. I've learned something, as I always do, and I hope those listening have learned something as well. Thank you. Thanks, Warrick. Always a pleasure. Till next time. I look forward to speaking with you again, Alistair. And for those listening, thank you for joining us. Take care. Bye for now. And please don't die from a heart attack. Goodbye. You have been listening to another podcast from Dr. Warrick. 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