**EP418: Allergic vs Idiosyncratic vs Tolerance and Doing it Naturally**
**Dr Warrick Bishop:** Welcome, my name's Dr Warrick Bishop. I'm a cardiologist, an author, and a keynote speaker. I'm the CEO of the Healthy Heart Network. I'm all about trying to help people live as well as possible for as long as possible. Heart disease is huge in Australia. Every 20 minutes, someone suffers a heart attack. Most of these could probably have been avoided if only we knew what to do. This podcast is all about helping you understand blood pressure, weight, and cholesterol for better health. If you enjoy this podcast, I would be honoured for a five-star review. You can share it with your family and friends. It may well save someone you love.
**Warwick:** Oh g'day, it's Warwick here, and welcome. Look, thanks for tuning in. I'd like to talk about two conversations that come up fairly commonly. One of them is around statin intolerance or cholesterol-lowering medication intolerance, and the other is around individuals sort of saying, "Well, you know, I don't want to take any medication; I'd rather do this naturally." I think both of these situations are really important, and I'd really like to address both of them and give you some insight into how I have a conversation with a particular patient in those circumstances.
So let's start with statin intolerance. This is really complicated. There is lots of data around the uncertainty of statin intolerance, and there is really good data around the nocebo effect of taking statins. Now, this particular podcast is not about that. I've got other podcasts where I cover the science behind statin intolerance, where we've literally, not me personally, but we, the medical community, have randomized individuals with perceived or reported, I should say, or alleged statin intolerance and randomized those individuals to an active agent and placebo. But this is a slightly different conversation than now.
In this conversation, I want to accept that the individual really has had problems and has gone through the process of testing and can be in the situation where they don't really want to take a medication. But for various reasons, we've got to the point where we recognize that there's going to be a risk-benefit analysis in favor of this person lowering their cholesterol. So when I have a conversation with them, I try and break it down this way. I say, "Look, we're going to reintroduce this statin, but I want you to understand how people can have adverse drug reactions so that you understand why I'm comfortable to gradually reintroduce this agent because I know you've got apprehension."
In the first setting, we think about an allergic reaction. The first type of problem that people can have with a drug is an allergic reaction. Now, we know what an allergic or anaphylactic reaction is. We've heard of people who eat peanuts or are stung by a bee, and they get hives or they swell up or their throat swells up, and they can't breathe. These people are literally at risk of dying, and this is a very significant type of response. It's an eosinophil-driven response; it is called an anaphylactic response. This needs a shot of adrenaline and really quite intensive appropriate medical care.
So I'll say to my patients, "Look, there's no way I would be giving you this sort of agent or looking to reintroduce the statin if indeed you had an allergic reaction because it just wouldn't be right." The next sort of reaction that we can get from a medication is an idiosyncratic reaction. And this is a little bit different. This is where we know that the drug has caused the problem, but we really don't know how. And not only do we not know how, we don't know in whom it will cause the problem.
You might be able to think... you may not be able to think of an example, but I might be able to give you an example that makes it very relatable. An absolute classic example was gifted to us by the COVID pandemic when the AstraZeneca COVID vaccine gave rise to blood clots. You may well remember that. Now, the AstraZeneca vaccine was actually quite effective, but in a very, very small number of people, there was an unpredictable, unexpected, unexplained reaction that we call an idiosyncratic reaction. The significance of that is that we wouldn't challenge someone again who's just had an idiosyncratic reaction. It doesn't make sense; it's too risky.
We're talking about reintroducing statins with people who might have some apprehension. I've already talked about allergic reactions and idiosyncratic reactions and said that, look, we wouldn't even think or entertain reintroducing an agent if either of those sorts of reactions had been observed with the first exposure to that medication, whatever it might be, really.
Reactions to medications all fall under the banner of tolerance, and this is fortunately the most common and also fortunately the most able to be managed. People sort of look at me and they're not sure, and I say, "Look, there isn't a drug out there; in fact, there's barely a compound out there that may not have some degree of tolerance." And I say, "Look, think of tomatoes. There are many people who will eat tomatoes and get a bit of arthritis. There are many people who can eat tomatoes and have no problem at all."
When it comes to tolerance, I love to talk about alcohol as an exemplar for tolerance. So think of my grandmother, for example. If she had a glass of sherry in the afternoon, she'd feel a little bit tipsy. And yet, I have a number of friends who can actually consume a significant amount of alcohol. We're talking five or six pints of Guinness and still be able to solve calculus. What's the difference? Well, I'm embarrassed to say that for some of that, it's training, and that's not okay. But to a large degree, it all boils down to tolerance. So that's really important to know.
If you think of that spectrum between a sherry and five or six pints of Guinness, you can see there's an enormous range between individuals, and this is what I want to get across to people. I say to them, "Look at two extremes. I might ask you to take a lick of a statin and put it back in your medicine chest once a fortnight or take a cup of pills two times a day." At those two extremes, you'd recognize that at one end, if you were having side effects, they're probably in your head. And at the other end, it's not unreasonable because it's a huge dose.
So that allows a conversation where we can talk to people and say, "Look, maybe we try a low dose just a couple of times a week, or we try half a tablet slightly more regularly," or whatever it might be. This is really, really important because for every individual, they will have a level that when they get to it, they get aches and pains or the symptom that they've reported. But below that level, they are okay. When I'm speaking with my patients, my objective is to find that level where they're constantly happy because we don't want them... or we don't really want to set up a situation where we want them to live as long as possible but be miserable while they do so. We want them to live as well as possible for as long as possible. And it also means they're much happier when they come back and see me each visit.
So I hope that makes a bit of sense. When we're talking about the reintroduction of statins for people who've had a problem, we're talking around tolerance. What is your tolerance? Is it a lowish dose every day? Is it a lowish or intermediate dose several days a week? I don't know; it will be different for everyone.
Well, let's talk about the other conversation that comes up pretty regularly. I go to prescribe maybe cholesterol-lowering therapy or blood pressure-lowering therapy, and quite reasonably I get the question, "Doc, I don't really want to take medication; I want to do it naturally." I get that this is a very reasonable and fair instinct and is understandable, even admirable. But when I confront people with this desire, what I want to do is let them know that we have to step back and actually consider our evolutionary past. Nature didn't actually design us to live long lives.
Well, what do I mean by that? Well, think about our DNA, which is our biological blueprint. It's the thing that defines really how we're made and how long we last based on how good our recovery mechanisms are. Maintenance strategies are all in our DNA, and remember this was shaped two to three million years ago back on the African plains. Back then, if you made it to your late teens or early 20s, you were doing pretty well, and that's what natural selection was built around—this early survival and reproduction. We didn't live into our 70s, 80s, or 90s and then reproduce. You getting it? We didn't evolve to live to a long age.
Interestingly, our medicines and public health issues and not being eaten by saber-toothed tigers and all that stuff has meant that we've been able to outlive our original biological blueprint. Not by just a bit, but by a lot. It's important to understand our genetics; our DNA hasn't really evolved with us to allow us to grow older. We know this by comparing with other primates.
So here's the reality I really try and get across to my patients. If we want to live for as long as possible and well into our later years, we are literally pushing beyond what nature expects us to do—what nature prepared us for. If that's the case, we need to be as smart as possible trying to, if you like, take advantage of anything we can to cheat that biological clock. So if you do want to age well, to stay healthy, mobile, and independent, then you really need to outsmart your DNA and do anything you can—using modern medicine, sensible lifestyle choices, or whatever it might be—to do that. You can't rely on your genetics alone because they did not set you up for a blueprint that will guarantee longevity.
So much as I absolutely 100% applaud people wanting to do things naturally, once you pass about 20 or 30 years of age, if a medication is going to help you and it's going to give you a chronological or time or age advantage, I'd really encourage you to take it. And that's what I say to my patients. Because this isn't about giving in to Big Pharma, actually. And I have issues with that; that's a different podcast. Again, this is about giving yourself the very best shot at a longer and healthier life.
So if you've struggled in the past with medications, let's think about the why. When we think about problems with taking a medication, there can be anaphylaxis or allergic reactions—don't do it again. It can be idiosyncratic—don't do it again. If it's a tolerance-related issue, then be reassured. You can find a level of tolerance that suits you. If you are apprehensive about taking medications, then think about whether you're apprehensive about having a DNA blueprint which only is expecting you to live 30 odd years, absolute tops, and was really designed for you to live somewhere around 20 odd years. And then figure if you think taking advantage of current science makes a bit of sense for you.
Well, I really hope that that's been beneficial for you. They are conversations that I pretty regularly have with my patients. I may well have touched on them before, but I've had a couple of people this week specifically raise these conversations, and in fact, two people just today in my clinic. And so I wanted to share because if I have talked about them before, you may have missed that podcast. And here's your chance to listen now.
Anyway, I'm going to wrap it up there. I'm going to give a shout out to my newest book, which I will have written with Associate Professor Karam Kostner, co-authored with Penny Edmond. That should be out by the time you're listening to this, and if not, it'll be days or only weeks at tops away. That's going to be called *Cholesterol Explained*. Now, if you don't want to shell out the money for it, I completely understand with interest rates and everything else, but please just go to your local library and ask for a copy of *Cholesterol Explained*, and the library will be resourced and they'll track down copies for you. So please do that. In fact, I'd love to have my book in as many libraries across Australia as possible.
So if you are outside of Hobart, because I know the library at Hobart has my books, I have an obligation to give them a two—donate books to their book repository. That's an obligation of local authors. If you're outside of Hobart, please wander along to your local library and say, "Look, I'd really like to read Dr. Warwick Bishop's Explained series." That would really help me get my book out there and hopefully help other people.
I'm going to sign off now. I hope you found today interesting. I really think it's such an important conversation. I love having that conversation with my patients, and I hope you found it valuable or valuable for someone you love and care for. I'm going to jump. Thank you for listening. If you've got any queries or questions or suggestions, hit us up at info@drwarwickbishop.online. Until next time, I hope you live as well as possible for as long as possible. Take care and bye for now.
**Warwick:** Hi. Ever wondered what your risk of heart attack is? You should. It's the single biggest killer in the Western world. We're talking one death less than every 30 minutes in Australia. One death less than every 60 seconds in the United States. Nine million deaths globally per annum. Well, how do you check your risk? Well, you can go to www.virtualheartcheck.com.au. You'll find out about your risk and what can be done beyond that to be even more precise.
