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Cholesterol Treatments You Need to Know About

Cholesterol Treatments You Need to Know About

Find out which medications and lifestyle habits can help lower your cholesterol for a healthier heart.

About 78 million Americans have high cholesterol, but only about 55 percent of those are being treated for it. High cholesterol raises your risk for heart disease, the nation’s number one killer of both men and women.

Luckily there are a number of ways to lower cholesterol, from emerging treatments to gold standard drugs to good old healthy living. We asked Vinayak Manohar, MD, an interventional cardiologist with Mercy Health Saint Mary’s in Grand Rapids, Michigan, about tried and true treatments and some of the newer drugs.

The perils of high cholesterol
Cholesterol is a waxy substance found in the bloodstream and all the cells in your body. It’s made by the liver, and you also can get a small amount from food. It comes in several forms in the blood, including high-density lipoprotein (HDL) and low-density lipoprotein (LDL).

LDL is the "bad" cholesterol. When you have too much in your bloodstream, it forms a waxy substance called plaque that sticks to the inside of your blood vessels. This plaque can break open and cause a blood clot to form. A big enough clot can block blood flow to the heart, which is a heart attack, or to the brain, a stroke.

HDL, on the other hand, clears LDL from your bloodstream. That’s why it’s often called the good kind of cholesterol. You want high levels of HDL and low levels of LDL to have healthy cholesterol.

The top cholesterol treatment
Statins are now the gold standard for cholesterol lowering,” says Dr. Manohar. Statins tell the liver to produce less LDL cholesterol. The drugs might also help dissolve plaque.

 “A lot of people see a big benefit with statins,” says Manohar. “For the time being, it’s a workhorse.” Statins are given to people at high risk for heart disease to prevent either a first heart attack or stroke, or subsequent heart attacks and strokes.

“Statins are not without side effects,” says Manohar. “Muscle aches are the most common.” Up to 15 percent of people on statins may have these muscle aches. Muscle injury is usually temporary and reversible. In rare and severe cases permanent damage to the muscles and kidneys may result.

Muscle aches related to statins are known as statin myalgia. “There’s a lot of conjecture on why we see muscle aches and myalgia, but studies have shown an increase in muscle enzymes, which often means muscles have been damaged,” says Manohar. “The bottom line is, I take patients seriously if they’re having these symptoms.” 

Newer medication options
Where statins reduce the amount of cholesterol the liver makes, a newer type of drug called PCSK9 inhibitors help remove cholesterol from the bloodstream. 

A 2017 trial including more than 27,000 people found that one of these drugs, called evolocumab, was effective in dropping LDL cholesterol down to very low levels—from an average of 92 mg/dl, which is an already-low level, all the way down to 30. It reduced the risk of heart attacks by 27 percent and stroke by 21 percent in the group who were also taking statins.

The trial found no reduction in the risk of death from heart disease, but earlier, shorter-term trials have suggested a reduction in mortality from PCSK9 inhibitors. Manohar says more studies are needed to figure out the best use for these drugs in treating high cholesterol. 

The high cost of PCSK9 inhibitors—evolocumab had an original list price of more than $14,000 per year—and the uncertainly about whether they save lives have thus far presented a barrier to the wider use of the drugs. But in October 2018, the manufacturer of evolocumab announced plans to lower the price to less than $6,000 per year in the hopes that making the drug more affordable would help increase prescriptions.

Another relatively new class of drugs called selective cholesterol absorption inhibitors focus on lowering LDL cholesterol by blocking the absorption of cholesterol in the intestine. Ezetimibe is the first drug in this class of medications. It’s typically prescribed to be used in combination with a statin. 

Make smart lifestyle choices
A good diet and regular exercise provide plenty of benefits for your heart and beyond. “Lifestyle is huge,” says Manohar, but he notes that for people with elevated LDL levels, lifestyle and medication together may be needed.

“Once your numbers start getting high, cholesterol is more difficult to control with lifestyle alone,” he says. “But if you use the cholesterol-lowering medications and if you’re successful with diet, we can talk about cutting back the drugs.”

Manohar finds that adding good foods before taking away bad foods helps people stay on track better. “I ask people to get six servings of fruits and vegetables, but then I ask them if they can think of some fruits and veggies they like eating. It’s a gentle approach that tends to yield longer-term change,” he says.

Saturated and trans fats are some of the worst food offenders because they tell your liver to make more LDL cholesterol. Trans fats also reduce your HDL level, and diets high in both trans and saturated fats are linked with higher risk of death from heart disease.

To help people eat better Manohar also recommends they swap unhealthy foods for healthier versions. “For example, if you like ice cream, switch to sorbet,” he says. “Patients are usually receptive to making small changes when they can still have similar things. It’s all about customizing a diet plan for each patient.”

This article was updated on November 8, 2018.

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