Cholesterol MedicationsUnderstanding Your Treatment Options

When lifestyle changes aren't enough to bring cholesterol to target levels, medications can make a dramatic difference. Modern cholesterol drugs, particularly statins, are among the most studied medications in history, with decades of evidence supporting their safety and effectiveness in preventing heart attacks and strokes.

Understanding your medication options helps you have informed conversations with your doctor and feel confident about your treatment plan. This guide covers the major classes of cholesterol-lowering drugs, how they work, what benefits to expect, and how to manage potential side effects.

Statins

Statins are the first-line treatment for high LDL cholesterol and the most prescribed cholesterol-lowering drugs worldwide. They work by blocking an enzyme in the liver that produces cholesterol, forcing the liver to pull more LDL from the bloodstream.

Available Statins

Generic Name	Brand Name	LDL Reduction
Atorvastatin	Lipitor	High-intensity (39-60%)
Rosuvastatin	Crestor	High-intensity (45-63%)
Simvastatin	Zocor	Moderate-intensity (25-35%)
Pravastatin	Pravachol	Moderate-intensity (22-34%)
Lovastatin	Mevacor	Moderate-intensity (20-30%)
Fluvastatin	Lescol	Lower-intensity (15-25%)
Pitavastatin	Livalo	Moderate-intensity (30-40%)

Benefits Beyond LDL Lowering

Statins do more than just lower LDL. They stabilize existing plaques, making them less likely to rupture and cause heart attacks. They reduce inflammation in artery walls. Some evidence suggests they improve the function of the endothelium, the inner lining of blood vessels. These effects explain why statins' benefits in preventing cardiovascular events exceed what LDL reduction alone would predict.

Who Should Take Statins

Current guidelines recommend statins for:

• People with established cardiovascular disease (previous heart attack, stroke, or peripheral artery disease)
• People with LDL 190 mg/dL or higher
• People with diabetes ages 40-75
• People with 10-year cardiovascular risk of 7.5% or higher

Side Effects

Most people tolerate statins well, but side effects can occur:

Muscle symptoms: The most commonly reported side effect, ranging from mild aches to rare serious muscle damage. About 5-10% of people report muscle symptoms, though many prove to be nocebo effect (expectation of side effects causing symptoms). If muscle symptoms occur, your doctor may try a different statin, lower dose, or alternate-day dosing.

Liver effects: Statins can slightly elevate liver enzymes. Significant liver damage is extremely rare. Routine liver monitoring is no longer recommended for most patients.

Diabetes risk: Statins slightly increase the risk of developing type 2 diabetes, particularly in people already at risk. However, the cardiovascular benefits far outweigh this risk for people who need statins.

Cognitive effects: Some people report memory problems, though studies haven't consistently shown this effect. The FDA requires a warning label, but cognitive symptoms are rare and reversible upon stopping.

Ezetimibe (Zetia)

Ezetimibe works differently from statins—it blocks cholesterol absorption in the intestines rather than reducing cholesterol production. It lowers LDL by about 15-20% when used alone and is often combined with a statin for additional effect.

When It's Used

Ezetimibe is commonly prescribed when:

• A statin alone doesn't achieve target LDL
• Someone can't tolerate higher statin doses
• Very aggressive LDL lowering is needed

Side Effects

Ezetimibe is generally well-tolerated with few side effects. It doesn't cause the muscle symptoms associated with statins and can be a good option for people who are statin-intolerant.

PCSK9 Inhibitors

PCSK9 inhibitors are newer, injectable medications that can lower LDL by 50-60% on top of what statins achieve. They work by blocking a protein that normally degrades LDL receptors on liver cells, allowing the liver to clear more LDL from the blood.

Available PCSK9 Inhibitors

• Evolocumab (Repatha): Injected every 2-4 weeks
• Alirocumab (Praluent): Injected every 2-4 weeks
• Inclisiran (Leqvio): Newer option requiring injections only twice yearly

When They're Used

Due to their high cost, PCSK9 inhibitors are typically reserved for:

• People with familial hypercholesterolemia
• People with established cardiovascular disease who can't reach LDL goals on other medications
• People who can't tolerate statins

Side Effects

The most common side effects are injection site reactions. Overall, these medications have good safety profiles in clinical trials.

Bempedoic Acid (Nexletol)

Bempedoic acid is a newer oral medication that lowers LDL by about 15-25%. It works similarly to statins but is active only in the liver, not in muscles, making it an option for people with statin-related muscle symptoms.

When It's Used

Bempedoic acid is typically added to other treatments when additional LDL lowering is needed, particularly in people who can't tolerate statins or need more reduction beyond their current regimen.

Fibrates

Fibrates primarily lower triglycerides (by 25-50%) and modestly raise HDL. They're not primarily used for LDL lowering but may be prescribed for people with very high triglycerides.

Available Fibrates

• Fenofibrate (Tricor, Fenoglide)
• Gemfibrozil (Lopid)

Cautions

Combining fibrates with statins increases the risk of muscle problems. Fenofibrate is safer to combine with statins than gemfibrozil.

Prescription Omega-3s

High-dose prescription omega-3 fatty acids can lower triglycerides by 30-50%. These are different from over-the-counter fish oil supplements, which contain lower doses and less pure compounds.

Available Options

• Icosapent ethyl (Vascepa) – EPA only; has shown cardiovascular benefit
• Omega-3 acid ethyl esters (Lovaza) – EPA and DHA combination

Bile Acid Sequestrants

These older medications bind bile acids in the intestine, forcing the liver to use more cholesterol to make new bile acids. They lower LDL by 15-30% but can cause gastrointestinal side effects and interfere with absorption of other medications.

Available Options

• Cholestyramine (Questran)
• Colesevelam (Welchol)
• Colestipol (Colestid)

Combination Therapy

Many people need more than one medication to reach their cholesterol goals. Common combinations include:

• Statin + ezetimibe: The most common combination, lowering LDL by 50-65%
• Statin + PCSK9 inhibitor: For very high-risk patients, can lower LDL by 75% or more
• Statin + fibrate: When both LDL and triglycerides need treatment