Any reason not to be on a statin?

[Ho0v-man]

Like I get when it’s indicated and understand the side effects. But is there any reason not to just take one to take one?

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[VA Hopeful Dr]

Yes?

As always: risk v. Benefit. If your ASCVD score is super low with no family history then the potential side effects outweigh the benefits.

 

[NewYorkDoctors]

some people are on the ketogenic diet (a true one... meaning careful measurement of macronutrients to ensure total carbs < 50g, 70-80% of caloric intake comes from fats primarily from unsaturated kinds, no processed foods, low sodium intake - pretty much eat salad without dressing, eat good cuts of meat, avoid processed meats like bacon with too much salt, eggs, MCT oil, avocados, nice cuts of fatty fish, ) will tend to end up with very high LDLs (but high HDL and low triglycerides).

These patients can have LDLS of 250-300 (with normal pre-keto diet baseline values - this rules out a familiar hypercholesterolemia).

this is probably reflecting burning fat as the fuel source and may not have elevated atherosclerosis

For a patient like this, using statins will reduce the LDL values but its uncertain if it confers the same pleiotropic effects of the vasculature as there may not be those findings.

For these patients, they should probably get a more thorough evaluation such as hsCRP for Reynold's risk score, possible CAC or CTCA evaluation, the lipoparticle size evaluation (not all LDL are small atherogenic particles), ultrasoudn exams for subclinical atherosclerosis - all the things you do not do for EVERY patient but would consider in this patient.

Basically if you see someone who is quite fit, lean, low body fat % (their abs are visible or somewhat visible), on keto and has an LDL of 250-300, reaching the the crestor or repatha is not quite the first move...



but I do not advocate for this diet unless the patient is educated and fully bought in (or else the patient is going to use this as a excuse to eat ungodly amounts of bacon and salt and then mix in some cheat cake carbs which will just lead to adipose collection and atherosclerosis)


for a resident or younger physician who seems to think that "everyone is on a statin" and hears "the cardiologists think statins should be in the water," have to realize selection bias is in play. The resident sees a lot of sick patients with CAD, PAD, CVA, CAS, etc... in which statins are clearly indicated for secondary prevention. No argument. THe cardiologist by default sees CAD patients so "evveryone is on a statin."

But once you get out into practice and see "healthier" patients, you begin to realize it was all just selection bias earlier in your training

 

[end stage fibro]

Fantastic post above. I would also add maybe checking an Lp(a) once. Keto in specific ive read may lead to advanced glycation end products, which maybe be bad…?

I do feel ascvd is a little short sighted. Why would i wait for someones 10 year risk to be 10%? I would think it’s better to treat someone who’s 20 year risk is 10%. Or why not 30 year risk…

 

[NewYorkDoctors]

moreover the absolute risk reduction for statins for primary prevention are quite small.
JAMA Internal Medicine had metaanalysis a year ago showing

Association Between Low-Density Lipoprotein Cholesterol Reduction and Relative and Absolute Effects of Statin Treatment

This systematic review and meta-analysis examines the association between absolute reductions in low-density lipoprotein cholesterol levels with treatment with statin therapy and all-cause mortality, myocardial infarction, and stroke.

jamanetwork.com

In adults randomized to treatment with statins, meta-analyses demonstrated declines in the absolute risk of:

• 0.8% (95% CI, 0.4%-1.2%) for all-cause mortality
• 1.3% (95% CI, 0.9%-1.7%) for MI
• 0.4% (95% CI, 0.2%-0.6%) for stroke.

That translates to associated relative risk reductions of 9% (95% CI, 5%-14%), 29% (95% CI, 22%-34%), and 14% (95% CI, 5%-22%), respectively, according to the report.

The authors wrote that their findings "underscore the importance of discussing absolute risk reductions when making informed clinical decisions with individual patients."


I mean for things like Diabetes get LDL < 100 - fair game do it. the insurance will force you anyway for "quality" metrics to get it from 101 to 99.
for secondary prevention do it.

but if it were for primary prevention and their risk score is quite low (and they have no "bad habits") im always re-evaluating if I can have the patient get off of statins

dunno about you but when i took statins (just to try it out..... i took crestor 40 for a bit just to see what happens so i can tell patients i tried it so I am recommending it ) I had quite a bit of myalgias. it was not debilitating but really interfered with my exercise / workouts. no wonder some patients on it begin to tell you
"doctor i'm always so tired! why?"
doctor: "ugh.........."
my AST/ALT and CPK were fine when i checked as a N=1 experiment

 

[VA Hopeful Dr]

Fantastic post above. I would also add maybe checking an Lp(a) once. Keto in specific ive read may lead to advanced glycation end products, which maybe be bad…?

I do feel ascvd is a little short sighted. Why would i wait for someones 10 year risk to be 10%? I would think it’s better to treat someone who’s 20 year risk is 10%. Or why not 30 year risk…

Because 10 year risk is what we have to work with. That and our own judgement when called for.

 

[InternistDO]

There was a recent study in JACC out of Columbia discussing this. Very theoretical but I suspect in the next 5-10 years we may have more data on earlier initiation and treating younger people with statins.

It's not like Americans are getting any thinner.

 

[NewYorkDoctors]

while that is certainly a compelling article from JACC, it still highlights the fact "if the patient is an unhealthy individual who is on the fast track to ASCVD, then yes use statins even if they are younger. But if the patient is fit, has an isolated higher LDL only, and has no other evidence of ASCVD on a very thorough evaluation, then one should not automatically reflex to statins"

 

[Brigade4Radiant]

It depends I’ll be on one my ApoB is 127 I workout reasonably and in my mid 30s but I’ll be out on a statin since ApoB is the primary driver of atherosclerosis

 

[Brigade4Radiant]

Fantastic post above. I would also add maybe checking an Lp(a) once. Keto in specific ive read may lead to advanced glycation end products, which maybe be bad…?

I do feel ascvd is a little short sighted. Why would i wait for someones 10 year risk to be 10%? I would think it’s better to treat someone who’s 20 year risk is 10%. Or why not 30 year risk…

Yeah we don’t do a calculator about smoking in ten years and if they have a low risk for lung cancer by smoking less than half a pack a day we don’t intervene.

Similar to how the data with blood pressure that the closer to 120/80 the better. If you have high lipids, and they remain high despite dietary and lifestyle change. You should be on a statin. Atherosclerosis and cardiovascular disease is the number one killer.

 

[NewYorkDoctors]

Yeah we don’t do a calculator about smoking in ten years and if they have a low risk for lung cancer by smoking less than half a pack a day we don’t intervene.

Similar to how the data with blood pressure that the closer to 120/80 the better. If you have high lipids, and they remain high despite dietary and lifestyle change. You should be on a statin. Atherosclerosis and cardiovascular disease is the number one killer.

While I fully agree with your statement, I must highlight that not enough effort is done for the "dietary and lifestyle change."
In general (this is not directed at you), most physicians themselves are probably a little out of shape with a tummy themselves and aren't exactly paragons of fitness. (I work 80 hours a week but I find time to get workouts in... so "doctor too busy" is really not an excuse IMO)
That aside, not enough effort is made to get patients educated on various dieting and exercise regimen such as dietitian, referral to exercise trainer (usually not an insurance benefit but if patients are serious...), and all the while saying nice things to motivate the patient (you're beautiful the way you are! but getting a little more healthier goes a long way for your long term health!)

but at the end of the day, we probably cannot lay this all on the doctors' feets because big Food puts processed chemicals that gets people hooked onto high calorie foods then they get sick and Big pharma has us docs puts them on the statin FOREVER.

 

[sloh]

Yeah we don’t do a calculator about smoking in ten years and if they have a low risk for lung cancer by smoking less than half a pack a day we don’t intervene.

Similar to how the data with blood pressure that the closer to 120/80 the better. If you have high lipids, and they remain high despite dietary and lifestyle change. You should be on a statin. Atherosclerosis and cardiovascular disease is the number one killer.

@NewYorkDoctors Am I correct in saying you would disagree with this? For someone who is active, eats healthy, and is lean high lipids (specifically LDL) is NOT an indication that they should be on a statin?

 

[NewYorkDoctors]

im no lipid expert. so no one should quote me on anything.

but just having high LDL alone in the setting for primary prevention should invite some degree of introspection on the case rather than a reflex maximum statin time

Yes I know the ACC/AHA guidelines state:
4. In patients 20 to 75 years of age with an LDL-C level of 190 mg/dL (≥4.9 mmol/L) or higher, maximally tolerated statin therapy is recommended.S4.3-2,S4.3-20–S4.3-25 Included from recommendations in the 2018 Cholesterol Clinical Practice Guidelines.S4.3-1

Moreover, the UTD authors state:
LDL-C greater than or equal to 190 mg/dL — For all patients with LDL-C ≥190 mg/dL (≥4.9 mmol/L), we do a work-up for familial hypercholesterolemia (FH), and if present, treat accordingly. The work-up and management of FH are discussed separately. (See "Familial hypercholesterolemia in adults: Overview" and "Familial hypercholesterolemia in adults: Treatment".)

If the patient does not have FH, we treat them with a high-dose statin therapy. As an example, we may start these patients on atorvastatin 40 mg daily or rosuvastatin 20 mg daily. The dose and intensity of different statin medications are described in detail separately.

A CVD risk calculation may be unnecessary for individuals with an LDL-C ≥190 mg/dL (≥4.9 mmol/L), because we usually prescribe statin therapy for them based on the elevated LDL-C level alone.

It is interesting how these recommendations do NOT provide citations

A quick review of the Pubmed shows:

https://www.ahajournals.org/doi/10.1161/CIRCULATIONAHA.117.027966?url_ver=Z39.88-2003&rfr_id=ori:rid:crossref.org&rfr_dat=cr_pub%20%200pubmed

Low-Density Lipoprotein Cholesterol Lowering for the Primary Prevention of Cardiovascular Disease Among Men With Primary Elevations of Low-Density Lipoprotein Cholesterol Levels of 190 mg/dL or Above​

Analyses From the WOSCOPS (West of Scotland Coronary Prevention Study) 5-Year Randomized Trial and 20-Year Observational Follow-Up

Results​

Among 5529 individuals without vascular disease, pravastatin reduced the risk of coronary heart disease by 27% (P=0.002) and major adverse cardiovascular events by 25% (P=0.004) consistently among those with and without LDL-C ≥190 mg/dL (P-interaction >0.9). Among individuals with LDL-C ≥190 mg/dL, pravastatin reduced the risk of coronary heart disease by 27% (P=0.033) and major adverse cardiovascular events by 25% (P=0.037) during the initial trial phase and the risk of coronary heart disease death, cardiovascular death, and all-cause mortality by 28% (P=0.020), 25% (P=0.009), and 18% (P=0.004), respectively, over a total of 20 years of follow-up.

Conclusions:​

The present analyses provide robust novel evidence for the short- and long-term benefits of lowering LDL-C for the primary prevention of cardiovascular disease among individuals with primary elevations of LDL-C ≥190 mg/dL.

Okay if you just read the abstract and decided to call it a day because you're a busy doctor who can't be bothered to read the whole thing because... EMRs are hard....

You would have missed the the fact that many of the enrolled patients are not quite "healthy."

look at the baseline lipids. those are the classic dyslipidemic patients with high totla, high LDL, low HDL, and high triglycerides. plus their BP was already in the 2017 AHA class 1 hypertension range and half of the smoked!
You will get zero arguemtns from me that these kind of "unhealthy metabolic syndrome patients" should be on statins for primary prevention if their ASCVD, Reynold's, or Framingham risk score is high.


There is very little high quality data on the ketogenic diet lipid profile. Most pro keto physicians state that (on a case by case basis) these patients have low hsCRP, low small desnity LDL particles, no evidence of subclinical ASCVD when doing things like CAC, CTCA, CAS U/S, aorta U/S, etc.....

Granted, this they will never fund this kind of research because eating healthy will ultimately ruin the bottom line of Big Food and Big pharma, but I digress.

ASCVD (Atherosclerotic Cardiovascular Disease) 2013 Risk Calculator from AHA/ACC

The ASCVD (Atherosclerotic Cardiovascular Disease) 2013 Risk Calculator from AHA/ACC determines 10-year risk of heart disease or stroke.

www.mdcalc.com

but if we just use the good old fashioned AHAACC ASCVD risk score calculator for... a 40 year old.. who went full keto (and also made sure not to go sodium overload) who is normotensive 110/70, no DM, no smoking whose profile is let say... Total Chol 350 HDL 90 TG 50 LDL (calculated) 250 (i'm going to include all the possibilities of sex and race)

Male - White - 1.1% 10 year
Male - AA -2.3%
Male - Other - 1.1%
Female - White 0.5%
Female - AA - 0.1%
Female - Other - 0.5%

Let's do 65 year old now
Male - White - 10.4%(can have discussion about changing the keto diet first rather than using statins)
Male - AA - 7.5% (can have discussion about changing the keto diet first rather than using statins)
Male - Other - 10.4% (can have discussion about changing the keto diet first rather than using statins)
Female - White - 4.6%
Female - AA - 8.3% (can have discussion about changing the keto diet first rather than using statins)
Female - Other - 4.6%




bottom line - dont look at LDL > 190 and automatically reflex to statins. I admit most patients are "unhealthy less fit metabolic syndrome" and at the end of the day we will start them anyway.... but we are doctors! Not NPs/PAs who follow an algorithm only.

Again I don't go out of my way to promote the keto diet. most patients mess it up due to not cutting the carbs down enoguh and just eating too much unhealthy fats and salt ("dirty keto").

 

[sloh]

@NewYorkDoctors thanks for the reply. I ask because I have friends within my natural bodybuilding circle who perseverate on their "not ideal" LDL numbers thinking they definitely need to be on a statin. These are guys who are relatively lean, active, and eat a healthy diet.

Statins also aren't great for connective tissue/tendon health.

 

[gutonc]

@NewYorkDoctors thanks for the reply. I ask because I have friends within my natural bodybuilding circle who perseverate on their "not ideal" LDL numbers thinking they definitely need to be on a statin. These are guys who are relatively lean, active, and eat a healthy diet.

Statins also aren't great for connective tissue/tendon health.

Yeah, but those dudes are perseverating on about 200 other ridiculous things as well, so take that with a grain of salt.

 

[NewYorkDoctors]

@NewYorkDoctors thanks for the reply. I ask because I have friends within my natural bodybuilding circle who perseverate on their "not ideal" LDL numbers thinking they definitely need to be on a statin. These are guys who are relatively lean, active, and eat a healthy diet.

Statins also aren't great for connective tissue/tendon health.

Since those individuals are into the health lay media , refer them to that “doctor” on twitter who is jacked (probably on TRT) and did a ctca and cac on himself and was totally clean

 

[sloh]

Since those individuals are into the health lay media , refer them to that “doctor” on twitter who is jacked (probably on TRT) and did a ctca and cac on himself and was totally clean

Then they'll get swindled into a bunch of other questionable tests, supplements, and "therapies" 😂

 

[rokshana]

im no lipid expert. so no one should quote me on anything.

but just having high LDL alone in the setting for primary prevention should invite some degree of introspection on the case rather than a reflex maximum statin time

Yes I know the ACC/AHA guidelines state:
4. In patients 20 to 75 years of age with an LDL-C level of 190 mg/dL (≥4.9 mmol/L) or higher, maximally tolerated statin therapy is recommended.S4.3-2,S4.3-20–S4.3-25 Included from recommendations in the 2018 Cholesterol Clinical Practice Guidelines.S4.3-1

Moreover, the UTD authors state:
LDL-C greater than or equal to 190 mg/dL — For all patients with LDL-C ≥190 mg/dL (≥4.9 mmol/L), we do a work-up for familial hypercholesterolemia (FH), and if present, treat accordingly. The work-up and management of FH are discussed separately. (See "Familial hypercholesterolemia in adults: Overview" and "Familial hypercholesterolemia in adults: Treatment".)

If the patient does not have FH, we treat them with a high-dose statin therapy. As an example, we may start these patients on atorvastatin 40 mg daily or rosuvastatin 20 mg daily. The dose and intensity of different statin medications are described in detail separately.

A CVD risk calculation may be unnecessary for individuals with an LDL-C ≥190 mg/dL (≥4.9 mmol/L), because we usually prescribe statin therapy for them based on the elevated LDL-C level alone.

It is interesting how these recommendations do NOT provide citations

A quick review of the Pubmed shows:

https://www.ahajournals.org/doi/10.1161/CIRCULATIONAHA.117.027966?url_ver=Z39.88-2003&rfr_id=ori:rid:crossref.org&rfr_dat=cr_pub%20%200pubmed

Low-Density Lipoprotein Cholesterol Lowering for the Primary Prevention of Cardiovascular Disease Among Men With Primary Elevations of Low-Density Lipoprotein Cholesterol Levels of 190 mg/dL or Above​

Analyses From the WOSCOPS (West of Scotland Coronary Prevention Study) 5-Year Randomized Trial and 20-Year Observational Follow-Up

Results​

Among 5529 individuals without vascular disease, pravastatin reduced the risk of coronary heart disease by 27% (P=0.002) and major adverse cardiovascular events by 25% (P=0.004) consistently among those with and without LDL-C ≥190 mg/dL (P-interaction >0.9). Among individuals with LDL-C ≥190 mg/dL, pravastatin reduced the risk of coronary heart disease by 27% (P=0.033) and major adverse cardiovascular events by 25% (P=0.037) during the initial trial phase and the risk of coronary heart disease death, cardiovascular death, and all-cause mortality by 28% (P=0.020), 25% (P=0.009), and 18% (P=0.004), respectively, over a total of 20 years of follow-up.

Conclusions:​

The present analyses provide robust novel evidence for the short- and long-term benefits of lowering LDL-C for the primary prevention of cardiovascular disease among individuals with primary elevations of LDL-C ≥190 mg/dL.

Okay if you just read the abstract and decided to call it a day because you're a busy doctor who can't be bothered to read the whole thing because... EMRs are hard....

You would have missed the the fact that many of the enrolled patients are not quite "healthy."

View attachment 369919

look at the baseline lipids. those are the classic dyslipidemic patients with high totla, high LDL, low HDL, and high triglycerides. plus their BP was already in the 2017 AHA class 1 hypertension range and half of the smoked!
You will get zero arguemtns from me that these kind of "unhealthy metabolic syndrome patients" should be on statins for primary prevention if their ASCVD, Reynold's, or Framingham risk score is high.


There is very little high quality data on the ketogenic diet lipid profile. Most pro keto physicians state that (on a case by case basis) these patients have low hsCRP, low small desnity LDL particles, no evidence of subclinical ASCVD when doing things like CAC, CTCA, CAS U/S, aorta U/S, etc.....

Granted, this they will never fund this kind of research because eating healthy will ultimately ruin the bottom line of Big Food and Big pharma, but I digress.

ASCVD (Atherosclerotic Cardiovascular Disease) 2013 Risk Calculator from AHA/ACC

The ASCVD (Atherosclerotic Cardiovascular Disease) 2013 Risk Calculator from AHA/ACC determines 10-year risk of heart disease or stroke.

www.mdcalc.com

but if we just use the good old fashioned AHAACC ASCVD risk score calculator for... a 40 year old.. who went full keto (and also made sure not to go sodium overload) who is normotensive 110/70, no DM, no smoking whose profile is let say... Total Chol 350 HDL 90 TG 50 LDL (calculated) 250 (i'm going to include all the possibilities of sex and race)

Male - White - 1.1% 10 year
Male - AA -2.3%
Male - Other - 1.1%
Female - White 0.5%
Female - AA - 0.1%
Female - Other - 0.5%

Let's do 65 year old now
Male - White - 10.4%(can have discussion about changing the keto diet first rather than using statins)
Male - AA - 7.5% (can have discussion about changing the keto diet first rather than using statins)
Male - Other - 10.4% (can have discussion about changing the keto diet first rather than using statins)
Female - White - 4.6%
Female - AA - 8.3% (can have discussion about changing the keto diet first rather than using statins)
Female - Other - 4.6%




bottom line - dont look at LDL > 190 and automatically reflex to statins. I admit most patients are "unhealthy less fit metabolic syndrome" and at the end of the day we will start them anyway.... but we are doctors! Not NPs/PAs who follow an algorithm only.

Again I don't go out of my way to promote the keto diet. most patients mess it up due to not cutting the carbs down enoguh and just eating too much unhealthy fats and salt ("dirty keto").

It’s funny how you say you dont go out of your way to promote a keto diet, but you have had numerous posts where you kinda do…it’s not a diet that is necessarily safe or healthy and for most, not sustainable in the long run…

 

[NewYorkDoctors]

It’s funny how you say you dont go out of your way to promote a keto diet, but you have had numerous posts where you kinda do…it’s not a diet that is necessarily safe or healthy and for most, not sustainable in the long run…

It’s funny how you don’t bother to read my prior post in this thread stating I don’t promote it but if a patient is on it then what am I going to say to this patient ?

I’ll work with this patient then will tell them to stop

Anyway show me the data that a keto diet is harmful long term .
A high salt diet with high animal fat with processed foods indeed has been linked to bad outcomes yes (dirty keto - basically eating fast food just no bread - think bacon cheeseburger minus bread every meal or carnivore diet). Can you prove a good keto diet that is low on carbs , no processed foods , lots of fibrous veggie , good quality meats , good quality fish , mct oil , macaddmic nuts , avocado , etc is a bad thing ? It’s basically Mediterranean diet minus the starches and fruit.

I can’t prove it’s better than the Mediterranean dash diet . But I’m willing to work with patients provided they are educated and taking the right steps . Are you ? Try to keep an open mind in things and no be so rigid with things

Be aware of the data and he humble to know when the data is not generalizable to a specific patient.

Addendum: Although I did not erase anything I wrote earlier, I will point out my post did read a little antagonistic to rokshana (who is an endocrinologist and has more knowledge on this topic than I. I am merely speaking from my Internal medicine standpoint). The point is not to mudsling. My philosophy is trust the data but know when the data is not generalizable to unique patient situations. These cases must be assessed accordingly based on available data that can be applied to the patient. When a gray area arises, then use the "art of medicine." While I respect academic doctors for all their hard work bringing new research to the forefront, I find "fake-academic" doctors who say things like "if there isn't evidence for it I aint doing it" to be counterproductive for patients when a square patient is not fitting into a round hole. On the other hand, the "i don't get paid enough for this ish" private practice doctor who dismissively just says "do statins. im an older paternalistic/maternalistic doctor. do as I say not as I do" to be very counterproductive as well.

 

[TooMuchResearch]

If I DM any of you intelligent IM docs my Cardio IQ data, will you tell me what to do with it? Not in a "medical advice" way, but in a "friends having a casual conversation" way?

 

[NewYorkDoctors]

If I DM any of you intelligent IM docs my Cardio IQ data, will you tell me what to do with it? Not in a "medical advice" way, but in a "friends having a casual conversation" way?

I wouldn't know what I am talking about lol. I am just talking about this topic as an Internist and someone interested in this topic.
I did Quest CardioIQ when I tried "clean" keto for a while. I had an a lipid profile of 350 / 90 / 50 / 250 (baseline was something like TG 150 HDL 45 LDL 110 and wahtever the total calculates out to i cant remember now) so and in the short term things were okay and my small LDL particles were "medium." maybe that's not the best thing in the world after all. I did do carotid U/S, CAC scoring, and CTCA and things were fine. But I am aware that atherosclerosis takes years to develop.
(I hope this sheds light for rokshana for my n=1 experience)

Of note, I tried keto for a while. Feels great. Lost a lot of fat/adipose weight (yes I am aware of the Rockefeller university metabolic studies showing keto is not superior to other diets.) for my n=1 experience. This is why I do not advertise this diet (because the RCTs do not pan out) but will support any patient who wants to do it and is motivated and promises me not to eat processed and salty keto (eating nonstop bacon, egg yolks, sticks of butter and mounds of heavy cream only is not a good idea... that old Atkins diet is not a good idea) I open my email to these patients and I ask them to send me their macro nutrient records, pics of their food, their BHB meter readings, etc...

Don't knock it if you haven't tried it everyone. though I readily admit there is no data about long term outcomes for those on a "permanent keto diet." This is why I would endorse a patient who feels motivated to use that diet for weight loss (i.e. improving health - that is the goal at the end of the day right? and not just sticking patients on statins / GLP-1s / aspirin / etc... forever) to use it in the short to medium term provided we keep a close eye on things but cannot endorse it as a permanent life change.

For disclosure, I'm back to a "normal" healthy diet now (basically mediterranean diet without the wine) since I need some carbs sometimes for my workouts. It's kind of hard to stimulate anabolic growth without insulin release. (my fasting insulin on keto was undetectable though Cpeptide was low but present) but this is the diet I usually recommend to my patients as recommended by ACC/AHA. I'm not some maverick at the end of the day peddling snake oil. but I do keep an open mind and I try not to be so dogmatic to patients. At the end of the day, I don't know everything. but you bet ill read uptodate, pubmed, etc... to find a reasonable answer.

 

[sloh]

I'm not a fan of keto but if a patient insists, I say don't let perfect be the enemy of good. Calorie control is the most significant variable here.