All About Cholesterol-Lowering Medicines

Healthy lifestyle changes alone may be enough to help some people reach healthy cholesterol levels. Other people will need to take a cholesterol-lowering medicine. Talk with your healthcare provider to see if you need medicine. Work together to find the best option for you.

There are 7 main types of medicine:

• Statins. These include atorvastatin, fluvastatin, lovastatin, pitavastatin, pravastatin, rosuvastatin, and simvastatin. These medicines lower LDL (bad) cholesterol. They typically reduce LDL by about one-third. They can also help raise HDL (good) cholesterol and lower triglycerides (other blood fats). Statins slow the body's production of cholesterol. They also increase the liver's ability to remove LDL from the blood. In research on people who already had heart disease, statins greatly reduced heart attacks and heart disease deaths. They may also prevent first heart attacks in people who are at high risk for heart disease.

• Bile acid sequestrants. These include cholestyramine, colesevelam, and colestipol. These medicines also lower LDL, although somewhat less than statins. These medicines bind with bile acids in the intestines and force them to leave the body through poop instead of being absorbed into the blood stream. The liver needs cholesterol to make bile acids and important growth and stress hormones. As more bile is lost, more cholesterol from your body is used up to make more bile. 

• Nicotinic acid (niacin). This B vitamin increases HDL and lowers triglycerides when taken at levels higher than needed in the diet. Nicotinic acid is sold as both a prescription medicine and a dietary supplement. But only the prescription form should be used to lower cholesterol. Some people don't tolerate the high doses because these medicines cause flushing or a burning or itching sensation.

• Fibrates. These include gemfibrozil and fenofibrate. These medicines lower triglycerides. They may also lead to mild improvements in LDL levels.

• Selective cholesterol absorption inhibitors. An example is ezetimibe. This medicine lowers cholesterol by reducing the amount of cholesterol absorbed by the intestines. Ezetimibe, bile acid sequestrants, and nicotinic acid are sometimes combined with a statin to help people reach their LDL cholesterol-lowering levels.

• PCSK9 inhibitors. These include alirocumab and evolocumab. These newest medicines are injected in the skin and contain antibodies that bind to an important enzyme involved in the removal of LDL from the bloodstream. These medicines may lower LDL levels by almost half and can reduce the risk of heart attack.

• Omega 3 fatty acid ethyl esters. This includes fish oils. This type of medicine is used along with diet and lifestyle to help people lower their triglycerides when the levels are above 500 mg/dL. This type of cholesterol medicine should not be used by anyone with a severe allergy to fish or shellfish due to the risk of a severe reaction.

• Bimpedoic acid. This medicine is for people who can't have statins.

Risk factors

Your healthcare provider can help you find out your own risk and if you need medicine to control your cholesterol. Calculating a risk score is done by looking at certain things that are considered an increased risk for atherosclerosis. The risk calculator tool looks at:

• Ages between 40 and 79 years

• Gender

• Race

• Blood pressure (systolic and diastolic measurements)

• Total cholesterol, HDL cholesterol, and LDL cholesterol levels

• History of diabetes

• Current or past smoking history

• Treatment for high blood pressure

• Treatment of cholesterol with a statin medicine

• Current use of aspirin

If you and your provider are unsure about your risk for developing heart disease, you may have a test to look at the total amount of calcium (plaque) buildup in your arteries. This test is called a coronary artery calcium score (CAC). This is measured using a CT scan. Other blood tests that look at subparticles of cholesterol and other markers for risk of heart disease may also be used.

Talk with your healthcare provider about your treatment goals. Know how your cholesterol and other factors affect your risk for heart disease or other complications. Plan to have regular monitoring and report any side effects from the medicines. Sometimes you may need more than 1 medicine to reach your cholesterol goals. Also make sure you understand how to get ready for cholesterol testing. You often need to fast before you have the test.