For some people, lifestyle changes, like a better diet and more exercise, may prevent or treat unhealthy cholesterol levels. For others with high cholesterol, medication may also be needed.
Work with your doctor to develop a treatment plan that’s right for you. If medication is required, be sure to take all medicines as prescribed by your doctor. The potential benefit to your health is well worth making these medications part of your normal routine.
Types of cholesterol-lowering drugs
Various medications are used to lower blood cholesterol levels.
Statins are recommended for most patients. Statins are the only cholesterol-lowering drug class that has been directly associated with a reduction in the risk of heart attack or stroke.
Guidelines recommend that people in any of these groups talk to their doctor about the risks and benefits of statin therapy:
- Adults with a history of known cardiovascular disease, including stroke, caused by atherosclerosis
- Those with LDL-C level of greater than 190mg/dL
- Adults 40-75 years, with diabetes
- Adults 40–75 years, with LDL-C level of 70-189 mg/dL and a 5%to 19.9% 10-year risk of developing cardiovascular disease from atherosclerosis, with risk enhancing factors
- Adults 40–75 years, with LDL-C level of 70-189 mg/dL and a 20% or greater 10-year risk of developing cardiovascular disease from atherosclerosis
It is important to talk to your healthcare provider about your 10-year or lifetime risk. He or she will assess your risk factors to determine your level of risk and work with you to choose the best treatment approach.
Some people who do not fall into these categories may also benefit from statin therapy.
This class of drugs, also known as HMG CoA reductase inhibitors, works in the liver to prevent cholesterol from forming. This reduces the amount of cholesterol circulating in the blood. Statins are most effective at lowering LDL (bad) cholesterol. They also help lower triglycerides (blood fats) and raise HDL (good) cholesterol.
Talk to your doctor about the possible side effects before starting statins. Most side effects are mild and go away as your body adjusts. Muscle problems and liver abnormalities are rare, but your doctor may order regular liver function tests. People who are pregnant or who have active or chronic liver disease should not take statins.
If statins don’t help you enough, or if you develop side effects, your doctor may recommend different medications.
Statins available in the U.S. include:
- Atorvastatin (Lipitor®)
- Fluvastatin (Lescol®)
- Lovastatin (Mevacor®, Altoprev™)
- Pravastatin (Pravachol®)
- Calcium (Crestor®)
- Simvastatin (Zocor®)
Statins are also found in the combination medications Advicor® (lovastatin + niacin), Caduet® (atorvastatin + amlodipine) and Vytorin™ (simvastatin + ezetimibe).
PCSK9 inhibitors bind to and inactivate a protein in liver in order to lower LDL (bad) cholesterol. They can be given in combination with a statin. Some names are alirocumab and evolocumab
Selective cholesterol absorption inhibitors
This relatively new class of cholesterol-lowering medications works by preventing cholesterol from being absorbed in the intestine. Selective cholesterol absorption inhibitors are most effective at lowering LDL cholesterol. They may also have modest effects on lowering triglycerides (blood fats) and raising HDL cholesterol.
The first medication of this class, ezetimibe (Zetia®), was approved in 2002 for treating high cholesterol and certain inherited lipid abnormalities.
This class of LDL-lowering drugs, also known as bile acid sequestrants or bile acid-binding drugs, works in the intestines by promoting increased disposal of cholesterol.
Your body uses cholesterol to make bile, an acid used in the digestive process. These medicines bind to bile, so they can’t be used during digestion. Your liver responds by making more bile. The more bile your liver makes, the more cholesterol it uses. That means less cholesterol is left to circulate through your bloodstream.
Resins available in the U.S. include:
- Cholestyramine (Questran®, Questran® Light, Prevalite®, Locholest®, Locholest® Light)
- Colestipol (Colestid®)
- Colesevelam Hcl (WelChol®)
Fibrates (fibric acid derivatives):
Fibrates are best at lowering triglycerides and in some cases increasing HDL levels. These drugs aren’t very effective in lowering LDL cholesterol.
Fibrates now available in the U.S. include:
- Gemfibrozil (Lopid®)
- Fenofibrate (Antara®, Lofibra®, Tricor®, and Triglide™)
- Clofibrate (Atromid-S)
Niacin (nicotinic acid):
This drug works in the liver by affecting the production of blood fats.
Niacin side effects may include flushing, itching and stomach upset. Your liver functions may be closely monitored because niacin can cause toxicity. Nonprescription immediate-release forms of niacin usually have the most side effects, especially at higher doses. Niacin is used cautiously in diabetic patients because it can raise blood sugar levels.
Niacin comes in prescription form and as a dietary supplement. Dietary supplement niacin must not be used as a substitute for prescription niacin because of potentially serious side effects. Dietary supplement niacin is not regulated by the Food and Drug Administration and may contain widely variable amounts of niacin – from none to much more than the label states. The amount of niacin may even vary from lot to lot of the same dietary supplement brand. Consult your doctor before starting any niacin therapy.
Omega-3 Fatty Acid Ethyl Esters
These medications are derived from fish oils that are chemically changed and purified. They’re used in tandem with dietary changes, to help people with very high triglyceride levels (over 500 mg/dL) lower their levels.
Omega-3 fatty acid ethyl esters may cause serious side effects. They may also interact negatively with other medications, herbal preparations and nutritional supplements. People with allergies or sensitivities to fish, shellfish or both may have a severe adverse reaction to these medications. The same precaution applies to those with sensitivities to certain drug components.
Omega-3 Fatty Acid Ethyl Esters available in the U.S. include:
Marine-Derived Omega-3 Polyunsaturated Fatty Acids (PUFA)
Marine derived omega-3 PUFAs, commonly referred to as omega-3 fish oils or omega-3 fatty acids, are used in large doses to lower high blood triglyceride levels. They help decrease triglyceride secretion and facilitate triglyceride clearance. The amount of marine-derived omega-3 PUFAs needed to significantly lower triglyceride (2 to 4 g) is hard to get from a daily diet alone, so supplementing with capsules may be needed.
Use these supplements only under a doctor’s direction and care, because large doses may cause serious side effects. These can include increased bleeding, hemorrhagic stroke and reduced blood sugar control in diabetics. Negative interactions with other medications, herbal preparations and nutritional supplements are also possible. People with allergies to fish, shellfish or both may have a severe adverse reaction to using these supplements.
Dr. Fariba Hendesi is a cardiologist and blood pressure specialist