Cholesterol Levels Slideshow Pictures Lower Cholesterol Slideshow: Avoid Heart Disease Take the Cholesterol Quiz

Medical Author:

Benjamin Wedro, MD, FACEP, FAAEM

Benjamin Wedro, MD, FACEP, FAAEM

Dr. Ben Wedro practices emergency medicine at Gundersen Clinic, a regional trauma center in La Crosse, Wisconsin. His background includes undergraduate and medical studies at the University of Alberta, a Family Practice internship at Queen's University in Kingston, Ontario and residency training in Emergency Medicine at the University of Oklahoma Health Sciences Center.

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Medical Editor:

Melissa Conrad Stöppler, MD, Chief Medical Editor

Melissa Conrad Stöppler, MD, Chief Medical Editor

Melissa Conrad Stöppler, MD, is a U.S. board-certified Anatomic Pathologist with subspecialty training in the fields of Experimental and Molecular Pathology. Dr. Stöppler's educational background includes a BA with Highest Distinction from the University of Virginia and an MD from the University of North Carolina. She completed residency training in Anatomic Pathology at Georgetown University followed by subspecialty fellowship training in molecular diagnostics and experimental pathology.

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Medical Treatment

If following a low-saturated fat, low-cholesterol diet, increasing physical activity, and losing weight have not lowered the risk for developing coronary heart disease after about 3 months, your doctor may consider prescribing a cholesterol-lowering medication. If your doctor prescribes medicine, you must still:

1. follow your cholesterol-lowering diet;
   
   
2. be more physically active;
   
   
3. lose weight if you are overweight; and
   
   
4. control or stop all of your other coronary heart disease risk factors (including controlling high blood pressure and diabetes, and quit smoking).

Taking all these steps together may lessen the amount of medicine a person needs or make the medicine work better, which reduces the risk for developing coronary heart disease. The doctor may prescribe medication from the following categories:

Statins: Statins lower LDL cholesterol levels more than other type of drug. They lower cholesterol by slowing down the production of cholesterol and by increasing the liver's ability to remove the LDL cholesterol already in the blood.

• Studies using statins have reported 20%-60% lower LDL cholesterol levels in people taking them. Statins also reduce high triglyceride levels modestly, and produce a mild increase in HDL cholesterol.
  
  
• Results from statin medications are seen after several weeks. After 6-8 weeks, a patient's doctor may recheck blood tests. A second measurement of LDL cholesterol level must be averaged with the first to help adjust medication dosing.
  
  
• Statins are well tolerated, and serious side effects are rare. Rarely, widespread muscle breakdown, known as rhabdomyolysis, may occur. The symptoms include diffuse muscle pain, weakness, and dark colored urine. This may signal a medical emergency: if you develop these symptoms, stop taking the statin medication and contact your health care practitioner immediately.
  
  
• Other side effects may include an upset stomach, gas, constipation, and abdominal pain or cramps. These symptoms are usually mild to moderate and generally go away as your body adjusts to the medication.
  
  
• Monitoring of liver function by blood tests is usually ordered in patients taking statins.
  
  
• There are many statin drugs (available by prescription). The choice made by the health care practitioner and patient will depend upon the clinical situation. Examples include:
  
  
  • atorvastatin (Lipitor),
    
    
  • fluvastatin (Lescol),
    
    
  • lovastatin (Mevacor, Altocor),
    
    
  • pravastatin (Pravachol),
    
    
  • simvastatin (Zocor), and
    
    
  • rosuvastatin (Crestor).

Bile acid sequestrants: These drugs bind with cholesterol-containing bile acids in the intestines and allow them to be eliminated in the stool. Bile acid sequestrants may lower LDL cholesterol by about 10%-20%. Bile acid sequestrants are sometimes prescribed with a statin to enhance cholesterol reduction.

• Cholestyramine (Questran, Questran Light), colestipol (Colestid), and colesevelam (WelChol) are the three bile acid sequestrants currently available. These three drugs are available as powders or tablets and are are not absorbed from the gastrointestinal tract.
  
  
• Bile acid sequestrant powders must be mixed with water or fruit juice and are taken once or twice daily with meals. Tablets must be taken with large amounts of fluids to avoid stomach and intestinal complaints including constipation, bloating, nausea, and gas.

Cholesterol absorption inhibitors: These drugs inhibit cholesterol absorption in the gut and has few, if any, side effects. Cholesterol absorption inhibitors may be rarely associated with tongue swelling (angioedema). Ezetimibe (Zetia) reduces LDL cholesterol by 18%-20%. It is probably most useful in people who cannot tolerate taking statins. When used in addition to a statin, ezetimibe is equivalent to doubling or tripling the statin dose.

Nicotinic acid or niacin: Nicotinic acid lowers total cholesterol, LDL cholesterol, and triglyceride levels, while raising HDL cholesterol levels.

• There are two types of nicotinic acid: immediate release and extended release.
  
  
• The immediate-release form of crystalline niacin is inexpensive and widely accessible without a prescription, but, because of potential side effects, it should not be used for cholesterol lowering without monitoring by a health care practitioner. (Nicotinamide, another form of niacin, does not lower cholesterol levels and should not be used in place of nicotinic acid.)
  
  
• Nicotinic acid reduces LDL cholesterol levels by 10%-20%, reduces triglycerides by 20%-50%, and raises HDL cholesterol by 15%-35%.
  
  
• A common and troublesome side effect of nicotinic acid is flushing or hot flashes, which are the result of blood vessels dilating. Most people develop a tolerance to flushing, which can sometimes be decreased by taking the drug during or after meals or by the use of aspirin or other similar medications prescribed by your doctor 30 minutes prior to taking niacin. The extended-release form may cause less flushing than the other forms.
  
  
• The effect of high blood pressure medicines may also be increased while taking niacin causing blood pressure to potentially drop. A variety of gastrointestinal symptoms, including nausea, indigestion, gas, vomiting, diarrhea, and peptic ulcers, have been experienced with the use of nicotinic acid. Other major side effects include liver problems, gout, and high blood sugar.
  
  
• Extended-release niacin is often better tolerated than crystalline niacin. However, its liver toxicity (liver damage) is probably greater. The dose of extended-release niacin is usually limited to 2 grams per day.

Fibrates: These cholesterol-lowering drugs are effective in lowering triglycerides.

• gemfibrozil (Lopid),
  
  
• fenofibrate (Tricor), which is more effective at lowering triglycerides and LDL cholesterol.

Side effects of fibrates may include stomach or intestinal discomfort, gallstones, and may affect anticoagulation medication effects in thinning blood.