Statins are the go-to medication for controlling cholesterol because they have the most evidence for preventing heart attacks and strokes, according to Dr. Deborah Koehn, assistant clinical professor of the VCU Department of Internal Medicine. However, sometimes individuals have difficulty tolerating them.
The problems can range from moderate muscle pain “to a rare but life-threatening condition known as rhabdomyolysis. That’s where you have a massive breakdown of the muscles,” explained Koehn. “Once that happens, using statin medications can be more difficult.”
Koehn helps patients who have had difficult-to-treat lipid disorders at Pauley’s Complex Lipid Management Clinic. A graduate of the VCU School of Medicine, Koehn is board certified in internal medicine as well as clinical lipidology. After years of experience, she wanted to start a lipid clinic at VCU Health—and did so, in March 2018, with the encouragement of colleague Dr. Phoebe Ashley.
“Dr. Koehn is an exceptional physician with advanced training in lipidology,” said Ashley. “The complex lipid clinic is a vital addition to Pauley, and our effort to provide comprehensive cardiovascular care. Dyslipidemia is a large problem and for many patients and physicians very challenging to tackle.”
Dyslipidemia refers to the elevation of LDL (“bad” cholesterol) or triglycerides, or low levels of HDL (“good” cholesterol). When left untreated, the condition can lead to atherosclerosis and other cardiovascular diseases.
Koehn sees a range of patients in her clinic, from those with high cholesterol levels who are trying to prevent a heart attack or stroke to those with known heart disease. Some have multiple co-morbidities such as diabetes, fatty liver disease, rheumatoid arthritis, autoimmune disease and HIV.
With HIV patients, for instance, “some of the medications that they’re on can cause lipid abnormalities. And they have a lot of interactions with the statin medications,” she said. “It is important to have the knowledge about the drug combinations but also to be compassionate about lifestyle education.”
Koehn usually receives referrals from primary care physicians and cardiologists when statins fail. “The clinic gives patients an opportunity to have someone on their team to really narrow in and help them work on changing eating habits, exercise habits, weight and medications related to their complex lipid disorders,” she said.
One exciting alternative that’s developed in recent years are PCSK9 inhibitors, an injectable medication without the same side effects of statins. Due to their expense, however, “not everybody can be approved by their insurance company. In those cases, we try to go back and look at some of the older medications as well as lifestyle modifications to get them where they need to be,” she said.
Koehn is also trained in culinary medicine, a new evidence-based field at the intersection of food and medicine.
Her initial appointments can last up to an hour as she gets to know the patient. In addition to finding a good match in medications, “we spend a lot of time talking about nutrition, exercise and weight,” she said. “The clinic is an opportunity to try some different things to get them to their goals.”
The Complex Lipid Management Clinic is located on the VCU Health Stony Point Campus, 9000 Stony Point Parkway in Richmond. To make an appointment, please call (804) 628-4327.