THE WELCH COMPANY
440 Davis Court #1602
San Francisco, CA 94111-2496
415 781 5700
rod@welchco.com


S U M M A R Y


DIARY: December 16, 2013 00:28 AM Monday; Rod Welch

VA SFMC letter prepared meeting Dec 19, treat hyperlipidemia arterialsclorsis.

1...Summary/Objective
2...Hyperlipidemia Not Controlled Cholesterol Elevated Despite Exercise
3...Cholesterol Elevated Despite Exercise Discuss Clinical Trial
4...Clinical Trial Considered Lower Cholesterol Without Statin Drugs

ACTION ITEMS.................. Click here to comment!

1...Need to add subjects for past few records since 131121.

CONTACTS 

SUBJECTS
VA Prescribe Atorvastin 10 MG Trial 4 Weeks Evaluate Side Effects In                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                
                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                        
1303 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                     
1303 -    ..
1304 - Summary/Objective                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                  
1305 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                     
130501 - Follow up ref SDS 46 0000. ref SDS 45 0000.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                           
130502 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
130503 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
130504 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
130505 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
130506 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
130508 -  ..
1306 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                     
1307 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                     
1308 - Background                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
1309 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                     
1310 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                     
131001 - Lab on 131015, showing cholesterol remained high, 131015 0724,                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                    
131002 - ref SDS 38 BE6O, conflict with increased exercise and weight loss,                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                          
131003 - discussed in the letter to the medical team yesterday on 131016 1632.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                             
131004 - ref SDS 39 IW57                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                             
131006 -  ..
131007 - On 131017 1000 VA medical chart Progress Notes assessment report                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                  
131008 - patient status CAD stable, asymptomatic. hyperlipidemia not                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                       
131009 - controlled. ref SDS 40 T24N                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                 
131011 -  ..
131012 - On 131017 1000 Doctor Egan proposed referring patient for clinical                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                
131013 - trial to reduce cholesterol with new "targeted" drugs. ref SDS 40 179N                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                      
131015 -  ..
131016 - On 131017 1000 VA medical chart Progress Notes assessment report                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                  
131017 - patient status hyperlipidemia not controlled, ref SDS 40 PSXT; Doctor                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                       
131018 - Egan makes referral to SF VA Medical Center for consult on                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                        
131019 - participation clinical trials, ref SDS 40 EU9F, with experimental                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                           
131020 - agents such as AMG 145 and REGN 727 to resolve multiple statin                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                    
131021 - intolerances. ref SDS 40 CN4H                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                               
131023 -  ..
131024 - On 131103 received letter from VA SF Medical Center scheduling meeting                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                            
131025 - on 131121 1000, to consider clinical trial for lowering cholesteral.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                              
131026 - ref SDS 41 YT4N                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                             
131027 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
131028 -            Thursday November 21, 2013 1000 METAB-FELLOW-THRUSDAY Clinic                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                       
131030 -  ..
131031 - On 131112 New York Times published several articles reporting that the                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                            
131032 - day before on 131113, American Heart Association published new                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                    
131033 - guidelines for treating CAD patients that expand use of statin                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                    
131034 - medication regardless of cholesterol levels, ref SDS 42 0001, and                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                           
131035 - further raise the LDL 70 to LDL 190, as a target for cardiovascular                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                               
131036 - risk. ref SDS 42 CW6H                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                       
131038 -  ..
131039 - On 131114 New York Times published several articles reporting that the                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                            
131040 - day before on 131113, American Heart Association published new                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                    
131041 - guidelines for treating CAD patients. ref SDS 43 SH6G                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                       
131043 -  ..
131044 - On 131121 1000 meeting with Doctor Diana Alba, Va San Francisco                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
131045 - Medical Center prescribes Atorvastatin 10 MG 4 weeks. ref SDS 44 HY6O                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                       
131047 -  ..
131048 - On 131121 1000 at 1125 meeting with Karen and Doctor Shunk, Va San                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                
131049 - Francisco Medical Center seemed to support Doctor Alba's prescription                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                             
131050 - for Atorvastatin 10 MG 4 weeks; further suggested trying Chia seeds to                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                            
131051 - lower cholesterol without medication. ref SDS 44 MS7G                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                       
131053 -  ..
131054 - On 131125 0005 letter to Karen submits understandings from meetings at                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                            
131055 - VA on 131121 with Doctor Alba, ref SDS 45 UK43, and requests that                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                           
131056 - Karen submit to Doctor Alba. ref SDS 45 UK5J  Presented patient                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                             
131057 - history showing increased exercise lowered cholesterol, but later                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                 
131058 - cholesterol rose even while increasing exercise. ref SDS 45 UK6R                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                            
131059 - Notified VA taking Atorvastatin 40 mg on 4-week trial. ref SDS 45 UK49                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                      
131060 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
131061 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
131062 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
131063 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
131065 -  ..
1311 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                     
1312 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                     
1313 - Progress                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                     
1314 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                     
131401 - Hyperlipidemia Not Controlled Cholesterol Elevated Despite Exercise                                                                                                                                                                                                                                                                                                                                                                                                                                                                                              
131402 - Cholesterol Elevated Despite Exercise Discuss Clinical Trial                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                     
131403 - Clinical Trial Considered Lower Cholesterol Without Statin Drugs                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                 
131404 - 
131405 - Follow up ref SDS 46 HY6O, ref SDS 26 HY6O.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                           
131406 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
131407 - Need to add subjects for past few records since 131121.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
131409 -  ..
131410 - Sent letter to Doctor Alba saying...                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                              
131411 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
131412 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
131413 -    1.  Subject:  Pending Issues VA Meeting 19 Dec 0930, Clinical Trials Non-statin Solutions                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                      
131414 -        Date:  2013-12-16 02:26                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                    
131423 -         ..
131424 -    2.  Thanks for your letter received on 131210 (shown below),                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
131425 -        requesting pending issues for meeting in your office scheduled                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                             
131426 -        on the 19th. ref SDS 46 HY6O                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                         
131428 -         ..
131429 -    3.  You can bookmark to follow daily exercise, vitals, medications,                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                            
131430 -        and diet shown in case study on 120101. ref SDS 14 LJ6H                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                              
131432 -         ..
131433 -    4.  Medications show daily use and cumulative to date.  Exercise                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                               
131434 -        shows daily and cum per week.  Vitals show left and right side                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                             
131435 -        with differentials, generally after exercise, sometimes before                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                             
131436 -        and after.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                 
131438 -         ..
131439 -    5.  Progress Notes for meeting on 131121, seem accurate and                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                    
131440 -        comprehensive.  Comments are available for review, if time                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                 
131441 -        permits (see line 500402. ref SDS 44 NV6H                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                            
131443 -         ..
131444 -    6.  Pending issues...                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                          
131445 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
131446 -        1.  VA guidance to adjust diet, exercise and medications, e.g.,                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                            
131447 -            reduce Atorvastatin to 10 mg and add Zetia; or, switch to                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                              
131448 -            non-statin clinical trial like Alirocumab presented in the                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                             
131449 -            letter on 131125. ref SDS 45 YU5X                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                
131451 -             ..
131452 -            Some authorities list orange juice and cranberry juice for                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                             
131453 -            increasing HDL.  Can lemon and grape juice substitute for                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                              
131454 -            raising HDL?                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                           
131456 -             ..
131457 -        2.  Review VA record investigating non-statin clinical trials                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                              
131458 -            for lowering cholesterol.  Who was contacted; what follow                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                              
131459 -            up is pending, e.g., Doctor Bikle, other VA venues,                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                    
131460 -            implementing work plan on 131121.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                      
131462 -             ..
131463 -        3.  Since 2010, ratio TG/HDL has tracked < 2, on 10 labs until
131464 -            recently.  The last lab on 131015, TG suddenly increased to                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                            
131465 -            109, i.e., above 100, while hiking increased over past 6                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                               
131466 -            months by orders of magnitude, averaging 11 miles and 3                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                
131467 -            hours per day. [...cited in prior letter to VA on 131125                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                               
131468 -            0005, ref SDS 45 UK7K, shown in case study on 120101 0900.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                       
131469 -            beginning on 130427. ref SDS 14 F35N...].  That's a lot of                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                       
131470 -            effort.  Since diet is unchanged, shown in case study on                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                               
131471 -            120101, what caused HDL to fall, instead of rise?  Is this                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                             
131472 -            an aging process, or have we broken something?  Can it be                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                              
131473 -            fixed, so that HDL tracks exercise?                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                    
131475 -             ..
131476 -        4.  Discordant LDL-C and LDL-P issue is complex. [...shown in                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                              
131477 -            research on 131125 0005. ref SDS 45 PQ74...].  Authorities                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                       
131478 -            say measuring LDL-P is expensive, 131125 0005, ref SDS 45                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                        
131479 -            G45J...], but maintaining TG/HDL ratio below 2 indicates                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                               
131480 -            low LDL-P (< 1000), that signals low risk for CVD. [...
131481 -            shown on 131125 0005, ref SDS 45 EH9J, and, ref SDS 45                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                     
131482 -            QS9F...].  VA guidance is appreciated.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                 
131484 -             ..
131485 -        5.  Side effects taking Atorvastatin 40 mg have been minimal.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                              
131486 -            Accordingly, trial with Ezetimibe (Zetia) 10 mg added to                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                               
131487 -            Atorvastatin 10 mg seems feasible and promising shown by                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                               
131488 -            research on 131125 (see line 132063. ref SDS 45 WL7I                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                             
131490 -         ..
131491 -    7.  Peripheral neuropathy seems nearly totally resolved, a year                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                
131492 -        after ending Rosuvastatin on 121206.  There has been no                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                    
131493 -        resumption after 4-weeks taking Atorvastatin 40 mg.  As well,                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                              
131494 -        there has been no evident myopathy that occurred with                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                      
131495 -        Simvastatin 2 years ago.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
131497 -         ..
131498 -    8.  Prior chronic pain in hips, back, neck, etc., has been fully                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                               
131499 -        resolved with increased hiking the past year, as shown in the                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                              
131500 -        case study.  Very grateful to VA for supporting patient hiking                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                             
131501 -        protocol.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                  
131503 -         ..
131504 -    9.  Chia seeds have proven easy to incorporate into daily diet, and                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                            
131505 -        preliminarily seem to increase energy, while reducing appetite                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                             
131506 -        that supports weight loss.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                 
131508 -         ..
131509 -   10.  Anxious to see effects on the next lipid panel working with VA                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                             
131510 -        on new drugs combined with diet and exercise.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                              
131512 -         ..
131513 -   11.  Grateful as well for strong doctor/patient partnership shown by                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                            
131514 -        your letter yesterday asking for pending issues.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                           
131516 -         ..
131517 -   12.  Looking forward to seeing the team on Thursday.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                            
131518 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
131524 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
131525 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
131526 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
131527 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
131528 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
131529 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
131530 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
131531 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
131532 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
131533 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
1316 -