What are the main types of cholesterol-lowering drugs. How do statins work to reduce cholesterol levels. Who should consider taking statins for cholesterol management. What are the potential side effects of statin therapy. How do non-statin medications help in managing cholesterol levels. What factors should be considered when choosing a cholesterol-lowering treatment. How can lifestyle changes complement medication in managing cholesterol.

Understanding Cholesterol-Lowering Medications: An Overview

Cholesterol management is a crucial aspect of maintaining cardiovascular health. For many individuals, lifestyle modifications alone may not suffice in controlling cholesterol levels, necessitating the use of medication. This comprehensive guide delves into the various types of cholesterol-lowering drugs, their mechanisms of action, and important considerations for patients and healthcare providers.

Statins: The First-Line Defense Against High Cholesterol

Statins are widely regarded as the most effective and commonly prescribed cholesterol-lowering medications. These drugs work by inhibiting an enzyme called HMG-CoA reductase in the liver, which plays a key role in cholesterol production.

How do statins lower cholesterol?

Statins primarily target low-density lipoprotein (LDL) cholesterol, often referred to as “bad” cholesterol. By reducing the liver’s cholesterol production, statins effectively decrease the amount of LDL cholesterol circulating in the bloodstream. Additionally, these medications can help lower triglycerides and modestly increase high-density lipoprotein (HDL) cholesterol, known as “good” cholesterol.

Who should consider statin therapy?

According to current guidelines, several groups of individuals should discuss statin therapy with their healthcare provider:

• Adults with a history of cardiovascular disease, including atherosclerosis-induced stroke
• Those with LDL cholesterol levels exceeding 190 mg/dL
• Adults aged 40-75 with diabetes
• Adults aged 40-75 with LDL cholesterol levels between 70-189 mg/dL and a 5% to 19.9% 10-year risk of developing cardiovascular disease from atherosclerosis, along with risk-enhancing factors
• Adults aged 40-75 with LDL cholesterol levels between 70-189 mg/dL and a 20% or greater 10-year risk of developing cardiovascular disease from atherosclerosis

It’s important to note that individuals outside these categories may also benefit from statin therapy, depending on their unique risk factors and medical history.

Commonly prescribed statins

Several statin medications are available in the United States, including:

• Atorvastatin (Lipitor®)
• Fluvastatin (Lescol®)
• Lovastatin (Mevacor®, Altoprev™)
• Pravastatin (Pravachol®)
• Rosuvastatin Calcium (Crestor®)
• Simvastatin (Zocor®)

Beyond Statins: Alternative Cholesterol-Lowering Medications

While statins are the primary choice for many patients, alternative medications may be prescribed when statins are insufficient or poorly tolerated. These non-statin options include:

Ezetimibe (Cholesterol Absorption Inhibitors)

Ezetimibe works by preventing cholesterol absorption in the intestine. It is often the most commonly used non-statin agent and can be combined with statin therapy for enhanced cholesterol reduction.

Bile Acid Sequestrants

Also known as bile acid-binding agents, these medications cause the intestine to eliminate more cholesterol. Common bile acid sequestrants include:

• Cholestyramine (Questran®, Questran® Light, Prevalite®, Locholest®, Locholest® Light)
• Colestipol (Colestid®)
• Colesevelam Hcl (WelChol®)

PCSK9 Inhibitors

PCSK9 inhibitors are powerful LDL-lowering drugs that work by binding to and inactivating a protein found in liver cells. This class of medications includes alirocumab and evolocumab.

Adenosine Triphosphate-Citrate Lyase (ACL) Inhibitors

ACL inhibitors are a newer class of cholesterol-lowering medications that work in the liver to block cholesterol production. These drugs may be prescribed when other treatments have not achieved desired results.

Assessing Cardiovascular Risk and Treatment Options

Determining the most appropriate cholesterol-lowering treatment requires a comprehensive evaluation of an individual’s cardiovascular risk factors. Healthcare providers use various tools and assessments to guide their recommendations.

How is cardiovascular risk calculated?

Cardiovascular risk assessment typically involves evaluating multiple factors, including:

• Age and gender
• Blood pressure
• Cholesterol levels (total, LDL, HDL)
• Smoking status
• Presence of diabetes
• Family history of cardiovascular disease

These factors are used to calculate a 10-year or lifetime risk of developing cardiovascular disease, which helps guide treatment decisions.

Potential Side Effects and Considerations of Cholesterol-Lowering Medications

While cholesterol-lowering medications are generally safe and effective, it’s essential to be aware of potential side effects and considerations associated with their use.

Statin side effects

Most side effects associated with statin use are mild and often subside as the body adjusts to the medication. However, some individuals may experience:

• Muscle pain or weakness
• Liver enzyme abnormalities
• Digestive issues
• Increased blood sugar levels

It’s important to note that serious side effects, such as severe muscle problems or liver damage, are rare. Your healthcare provider may recommend regular liver function tests to monitor for any issues.

Who should avoid statins?

Certain individuals may not be suitable candidates for statin therapy, including:

• Pregnant women
• People with active or chronic liver disease
• Individuals with a history of severe allergic reactions to statins

Always consult with your healthcare provider about your medical history and any concerns before starting statin therapy.

Complementary Approaches to Cholesterol Management

While medications play a crucial role in managing cholesterol levels for many individuals, lifestyle modifications remain an essential component of a comprehensive cholesterol management plan.

Diet and nutrition

Adopting a heart-healthy diet can significantly impact cholesterol levels. Key dietary recommendations include:

• Reducing saturated and trans fat intake
• Increasing consumption of fruits, vegetables, and whole grains
• Incorporating lean proteins and plant-based protein sources
• Limiting dietary cholesterol
• Moderating alcohol consumption

Physical activity

Regular exercise can help improve cholesterol levels by:

• Increasing HDL cholesterol
• Lowering LDL cholesterol and triglycerides
• Promoting weight loss and maintaining a healthy body weight

Aim for at least 150 minutes of moderate-intensity aerobic activity or 75 minutes of vigorous-intensity aerobic activity per week.

Monitoring and Adjusting Cholesterol Treatment

Managing cholesterol is an ongoing process that requires regular monitoring and potential adjustments to treatment plans.

How often should cholesterol levels be checked?

The frequency of cholesterol testing depends on individual risk factors and treatment goals. Generally, healthcare providers may recommend:

• Initial testing every 4-6 weeks after starting or changing medication
• Follow-up testing every 3-12 months once levels stabilize
• More frequent testing for individuals with high cardiovascular risk or unstable cholesterol levels

Adjusting treatment plans

Based on the results of regular cholesterol tests and overall health status, healthcare providers may adjust treatment plans by:

• Modifying medication dosages
• Adding or switching to different cholesterol-lowering drugs
• Recommending changes to lifestyle habits
• Addressing other cardiovascular risk factors

The Future of Cholesterol Management

As research in cardiovascular health continues to advance, new approaches to cholesterol management are emerging. Some promising areas of development include:

Gene therapy

Researchers are exploring gene therapy techniques to address genetic factors contributing to high cholesterol levels. These approaches aim to modify genes involved in cholesterol metabolism, potentially offering long-term solutions for individuals with inherited cholesterol disorders.

Novel drug targets

Ongoing studies are investigating new molecular targets for cholesterol-lowering medications. These efforts may lead to the development of more effective and targeted therapies with fewer side effects.

Personalized medicine

Advancements in genetic testing and biomarker analysis are paving the way for more personalized approaches to cholesterol management. This individualized approach may help healthcare providers tailor treatments more effectively to each patient’s unique genetic and metabolic profile.

In conclusion, managing cholesterol levels is a critical aspect of cardiovascular health that often requires a multifaceted approach. While statins remain the cornerstone of cholesterol-lowering therapy for many individuals, a range of alternative medications and complementary lifestyle modifications can be employed to achieve optimal results. By working closely with healthcare providers, staying informed about treatment options, and actively participating in their care, individuals can effectively manage their cholesterol levels and reduce their risk of cardiovascular disease.

Cholesterol Medications | American Heart Association

Help to control your cholesterol levels

For some people, lifestyle changes, such as a healthier 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 it as prescribed. The potential benefit to your health is worth making these medications part of your normal routine.

Types of cholesterol-lowering drugs

Various medications can lower blood cholesterol levels.

Statins are recommended for most patients and have been directly associated with a reduction in the risk of heart attack or stroke. Statins continue to provide the most effective lipid-lowering treatment in most cases.

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 cardiovascular disease, including stroke, caused by atherosclerosis
• Those with LDL-C level of greater than 190 mg/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 and 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

Some people who don’t fall into these categories may also benefit from statin therapy.

It’s important to talk to your healthcare professional about your 10-year or lifetime risk. They will assess your risk factors to determine your level of risk and work with you to choose the best treatment.

View an interactive slideshow to see how cholesterol drugs work.

Some of the major types of commonly prescribed cardiovascular medications are summarized in this section. We’ve included generic names as well as major trade names to help you identify what you may be taking. Please understand that the American Heart Association is not recommending or endorsing any specific products. If your prescription medication isn’t on this list, your doctor and pharmacist are your best sources of information. It’s important to discuss all the drugs you take with your doctor and to understand their desired effects and possible side effects. Never stop taking a medication or change your dosage (or frequency) without first consulting your doctor.
Some cholesterol-lowering medications may interact with grapefruit, grapefruit juice, pomegranate and pomegranate juice. Please talk to your doctor about any potential risks.

Statins

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. Women who are pregnant or people who have active or chronic liver disease should not take statins. 

Statins available in the U.S. include:

• Atorvastatin (Lipitor®)
• Fluvastatin (Lescol®)
• Lovastatin (Mevacor®, Altoprev™)
• Pravastatin (Pravachol®)
• Rosuvastatin Calcium (Crestor®)
• Simvastatin (Zocor®)

If statins don’t help you enough, or if you develop side effects, your doctor may recommend different medications.

Statins are also found in the combination medications Caduet® (atorvastatin + amlodipine) and Vytorin™ (simvastatin + ezetimibe).

If you have CVD and are already taking the highest tolerated statin and your LDL-C is still 70 or above, one or more of the following medicines may be prescribed. They all can be taken in combination with a statin.

Ezetimibe (cholesterol absorption inhibitors)

Prevents cholesterol from being absorbed in the intestine. It’s the most commonly used non-statin agent.

Bile Acid Sequestrants

Also called bile acid-binding agents, cause the intestine to get rid of more cholesterol. 

Those available in the U.S. include:

• Cholestyramine (Questran®, Questran® Light, Prevalite®, Locholest®, Locholest® Light)
• Colestipol (Colestid®)
• Colesevelam Hcl (WelChol®)

PCSK9 inhibitors

PCSK9 inhibitors are powerful LDL-lowering drugs. They bind to and inactivate a protein on cells found in the liver to lower LDL (bad) cholesterol. Some names are alirocumab and evolocumab.

Adenosine triphosphate-citrate lyase (ACL) inhibitors*

ACL inhibitors work in the liver to block the production of cholesterol. They are used in combination with lifestyle changes and statins to further decrease LDL cholesterol in adults with familial heterozygous hypercholesterolemia and patients with heart disease that need to further lower their LDL.

• Bempedoic acid (Nexletol)
• Bempedoic acid and ezetimibe (Nexlizet)

*Adenosine triphosphate-citrate lyase (ACL) inhibitors are not in the current Guideline on the Management of Blood Cholesterol, as they were FDA approved in 2020. For more information on ACL inhibitors visit the National Library of Medicine(link opens in new window).

The following triglyceride-lowering drugs have mild LDL-lowering action, but data doesn’t support their use as an add on to statins.

Fibrates

Fibrates are especially good for lowering triglyceride (blood fat) levels and have a mild LDL-lowering action. 

Fibrates available in the U.S. include:

• Gemfibrozil (Lopid®)
• Fenofibrate (Antara®, Lofibra®, Tricor®, and Triglide™)
• Clofibrate (Atromid-S)

Niacin (nicotinic acid)

Niacin is a B vitamin that limits the production of blood fats in the liver. Take this only if your doctor has prescribed it. It lowers triglycerides and has mild LDL-lowering action.

Niacin side effects may include flushing, itching and upset stomach. 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 are derived from fish oils that are chemically changed and purified. They’re used in tandem with dietary changes, to help people with high triglyceride levels.

Omega-3 Fatty Acid Ethyl Esters available in the U.S. include:

• Lovaza®
• Vascepa™
• Epanova®
• Omtryg®

Marine-Derived Omega-3 Polyunsaturated Fatty Acids (PUFA)

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 clear triglycerides. 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.

Written by American Heart Association editorial staff and reviewed by science and medicine advisors. See our editorial policies and staff.

Last Reviewed: Nov 11, 2020

Cholesterol-Lowering Medicines | cdc.gov

If you have high low-density lipoprotein (LDL) cholesterol, your health care team may prescribe medicine in addition to lifestyle changes to manage your LDL cholesterol level.

What are the types of medicines that treat high cholesterol?

Several types of medicines help lower LDL cholesterol. The chart below describes each type and how it works.

Cholesterol Lowering Medications

Type of Cholesterol-Lowering Medicine	How It Works
Statins	Statin drugs lower LDL cholesterol by slowing down the liver’s production of cholesterol. They also increase the liver’s ability to remove LDL cholesterol that is already in the blood.1
Bile acid sequestrants	Bile acid sequestrants help remove cholesterol from the bloodstream by removing bile acids. The body needs bile acids and makes them by breaking down LDL cholesterol.
Niacin, or nicotinic acid	Niacin is a B vitamin that can improve all lipoprotein levels. Nicotinic acid raises high-density lipoprotein (HDL) cholesterol levels while lowering total cholesterol, LDL cholesterol, and triglyceride levels.2
Fibrates	Fibrates lower triglycerides through several complex mechanisms including reducing triglyceride production in the liver.  They may also increase removal of LDL particles and increase apoA-I and apoA-II in the liver which may contribute to increase in HDL cholesterol levels.1
Injectable medicines	Medicines called PCSK9 inhibitors lower cholesterol-increasing LDL receptors. This results in a decrease in LDL cholesterol circulating in the bloodstream.2 These medicines are used in people who have familial hypercholesterolemia (FH), a genetic condition that causes very high levels of LDL cholesterol and people with clinical ASCVD who require lower LDL cholesterol levels.3

All drugs may have side effects, so talk with your health care team, including your pharmacist, on a regular basis. Once your cholesterol levels have improved, your health care team will monitor them to ensure they stay in a healthy range.

Who needs cholesterol-lowering medicine?

Your treatment plan for high cholesterol will depend on your current cholesterol levels and your overall risk of heart disease and stroke.

Your health care team may prescribe medicine if:³

• You have already had a heart attack or stroke or have peripheral arterial disease.
• Your LDL cholesterol level is 190 mg/dL or higher.
• You are 40–75 years old and have diabetes and an LDL cholesterol level of 70 mg/dL or higher.
• You are 40–75 years old and have a high risk of developing heart disease or stroke and an LDL cholesterol level of 70 mg/dL or higher.

Talk with your health care team about how you can lower your risk for heart disease.

More information

CDC and Million Hearts^®

• About High Cholesterol
• The Scoop on Statins: What Do You Need to Know?

Other organizations

• U.S. Food and Drug Administration (FDA): Controlling Cholesterol with Statins
• American Heart Association (AHA): Cholesterol Medications
• National Heart, Lung, and Blood Institute (NHLBI): Blood Cholesterol

References

1. Stone NJ, Robinson JG, Lichtenstein AH, et al. 2013 ACC/AHA guideline on the treatment of blood cholesterol to reduce atherosclerotic cardiovascular risk in adults: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines. Circulation. 2014;129(25 Suppl 2):S1-45.
2. Staels B, Dallongeville J, Auwerx J, Schoonjans K, Leitersdorf E, Fruchart JC. Mechanism of action of fibrates on lipid and lipoprotein metabolism. Circulation. 1998 Nov 10;98(19):2088-93.
3. Roth EM, Davidson MH. PCSK9 Inhibitors: Mechanism of Action, Efficacy, and Safety. Rev Cardiovasc Med. 2018;19(S1):S31-S46.
4. Grundy SM, Stone NJ, Bailey AL, Beam C, Birtcher KK, Blumenthal RS, et al. 2018 AHA/ACC/AACVPR/AAPA/ABC/ACPM/ADA/AGS/APhA/ASPC/NLA/PCNA guideline on the management of blood cholesterol: a report of the American College of Cardiology/American Heart Association Task Force on Clinical Practice Guidelines. Circulation. 2019;139(25):e1082–e1143.

Lowering cholesterol: 17 tips to avoid heart disease

HOW TO LOWER THE LEVEL OF CHOLESTEROL: MEDICATION AND NON-DRUG METHODS

Contents:

According to the Ministry of Health, heart and vascular diseases are the main cause of death in Russia. The higher the cholesterol, the more likely you are to die from heart problems or get complications. To protect yourself, it is important to know the norm indicators and ways to reduce high cholesterol.

Why should you monitor your cholesterol levels?

Controlling your cholesterol is a proven way to protect yourself from serious illness. The double danger is that high cholesterol does not manifest itself for a long time, and symptoms appear only against the background of complications.

The sooner you start monitoring its level, the higher the chance to avoid irreversible consequences:

• heart attack;
• stroke;
• atherosclerosis;
• coronary heart disease;
• heart failure;
• diseases of the central and peripheral vessels.

It is completely impossible to get rid of cholesterol, and it is not necessary, because it performs important vital functions in the body. “Good” cholesterol is part of cell membranes, promotes cell repair, synthesizes the substances we need: vitamin D, sex hormones and bile.

Therefore, it is important to monitor your cholesterol levels regularly, and this can be done with a blood test. For starters, you can take a simple analysis that will show total cholesterol. Further, if the results are high, the doctor will refer you to a detailed analysis – a lipid profile. It shows the ratio of “good” and “bad” cholesterol, as well as the amount of triglycerides in the blood. Based on the results, you will be able to start treatment in a timely manner.

Is the norm for everyone the same?

Cholesterol levels vary for certain people. And what is high for some is normal for others. Only a doctor will give the correct interpretation of your tests, since acceptable indicators will vary from person to person and depend on pressure, blood sugar, and the presence of other diseases. Norm indicators may differ depending on:

Age. The older the person, the higher the risk of developing hypercholesterolemia. Therefore, starting from the age of 35, it is necessary to regularly check and monitor cholesterol levels. It is a mistake to think that this problem concerns only the elderly. High cholesterol is diagnosed in young people, and even in children.

Inheritance. The predisposition to high cholesterol can be inherited. Familial hypercholesterolemia is a genetic disorder that affects the liver’s ability to regulate “bad” cholesterol. The disease can manifest itself in childhood and be severe, requiring medication, or in adulthood, in a milder form. If your close relatives have high cholesterol or problems with the heart and blood vessels, then this is a reason to start taking control of your health.

Sex. In middle age, high cholesterol is more often found in men, but during and after menopause, women become prone to this problem as often as men. In addition, cholesterol in women rises during pregnancy – it is necessary for the proper development of the child. The following shows how the scores vary by gender:

Medications to lower cholesterol

If the scores are high, the patient is prescribed special medications to lower “bad” cholesterol. These drugs include statins, vitamin B, omega-3s, bile acid, and fibrates.

Statins are the first line of treatment for high cholesterol. They enhance the processing of “bad” cholesterol and suppress its synthesis, and also contribute to the prevention of atherosclerosis and heart disease.

However, synthetic drugs can have side effects and should only be taken as directed by a physician. An alternative may be non-drug treatment, which we will discuss below.

Non-drug ways to lower cholesterol

Dietary supplements, dietary changes, daily exercise, bad habits, weight management are few that can be called non-drug treatments. Here the desire of the person himself to switch to the right lifestyle and lower cholesterol levels is important. For non-drug treatment, doctors recommend the following:

HEALTHY HEART FORMULA

Give up bad habits. Alcohol abuse and smoking increase the growth of “bad” cholesterol, which settles on the walls of blood vessels. Treatment will be meaningless if you continue to drink and smoke.

Make physical activity a habit. Sport is a faithful assistant on the way to recovery. Active physical activity makes it possible not only to reduce “bad” cholesterol in men and women, but also to increase “good”. Cardio exercises are best suited for this: walking, brisk walking, aerobics, jogging. The main thing is regularity, otherwise no loads will work.

Normalize nutrition. A proper diet involves avoiding trans fats and saturated fats. They are found in fast food, fried foods, meat and dairy products, convenience foods and margarine. This food should be excluded from the diet, as it affects the growth of cholesterol. What foods lower cholesterol?

• Fiber is a proven remedy for high cholesterol. Vegetables, fruits, beans, berries, white rice and wheat, oats, barley and nuts contain fiber, vitamins and beneficial elements.
• Legumes will help reduce “bad” cholesterol and have a positive effect on digestion. The legume family includes beans, peas, chickpeas and mung beans.
• Whole grains remove excess cholesterol and reduce the risk of complications.
• Nuts contain a large amount of unsaturated fatty acids and useful elements. The main thing is not to overeat, because they have a lot of calories.
• Spices help lower cholesterol. Garlic will have a beneficial effect, due to the high content of natural statins in it. But this method is not suitable for people with digestive problems.

Vitamin and probiotic complexes

As we already know, synthetic drugs are not for everyone, as they have side effects, including sarcopenia. An alternative can be a probiotic complex Lactoflorene® Cholesterol.

The complex includes:

• Natural statin – red fermented rice (Monacolin K 10 mg),
• Nicotinomide (vitamin of the PP group),
• Powerful antioxidant Coenzyme Q10 studied bifidobacteria Bifidobacterium longum BB536.