What other drugs besides statins lower cholesterol?

Jonathan A. Fialkow, MD
Cardiology (Cardiovascular Disease)
Statins have been the first-line drugs for lowering cholesterol since the late 1980s. But in about one-fifth of people, a statin doesn’t lower cholesterol enough.

In July 2015, the U.S. Food and Drug Administration (FDA) approved a new class of cholesterol-fighting drugs, called PCSK9 inhibitors.

In a study, people with primary hypercholesterolemia (a genetic condition that causes high LDL levels) and mixed dyslipidemia (high LDL cholesterol and triglyceride levels) were given PCSK9 inhibitors, along with statins. In this study, PCSK9 inhibitors were shown to further lower cholesterol levels.

More studies are needed to confirm the long-term safety and effectiveness of this drug for lowering LDL cholesterol.
Doctors can prescribe one or a combination of the following drugs to help lower your cholesterol:
  • Statins. Numerous statin drugs are available in the United States including atorvastatin (Lipitor), fluvastatin (Lescol), lovastatin (Mevacor, Altoprev), pravastatin (Pravachol), simvastatin (Zocor), rosuvastatin (Crestor) and pitavastatin (Livalo). In addition, statins are found in the combination medications lovastatin plus niacin (Advicor), atorvastatin plus amlodipine (Caduet) and simvastatin plus ezetimibe (Vytorin).
  • Nicotinic acid. More commonly known as niacin, this compound is a water-soluble B vitamin. Unfortunately, you can't lower your cholesterol by taking a vitamin supplement; to have such an effect, it must be taken in doses well above the daily vitamin requirement. Although nicotinic acid is inexpensive and available over the counter, never take it to lower your cholesterol without guidance from a healthcare professional because of potential side effects, especially on the liver.
  • Bile acid sequestrants. The three main bile acid sequestrants currently prescribed in the United States are cholestyramine sucrose (Questran), colestipol (Colestid) and colesevelam (WelChol). When combined with statins, they can lower LDL cholesterol even more.
  • Fibrates. Fibrate medications include gemfibrozil (Lopid), fenofibrate (TriCor) and clofibrate (Atromid-S).
  • Cholesterol absorption inhibitors. The only approved drug in this class is ezetimibe (Zetia). Zetia may work best in combination with a statin, providing a dual mechanism for reducing cholesterol levels. Since Zetia has not been proven to prevent heart attacks, the use of this drug should be reserved for people who are already on a maximally tolerated statin and who need more lipid lowering, or who do not tolerate statins.
Anthony L. Komaroff, MD
Internal Medicine
Have you tried niacin yet? It is an excellent drug for reducing cardiac risk in almost every way -- it lowers harmful LDL cholesterol, raises beneficial HDL, and reduces cardiac complications. One reason it plays second fiddle to statins is that it causes side effects like itching and flushing in many people. These side effects can often be minimized or even eliminated by taking an aspirin before niacin, by gradually building up the dose, or by taking the intermediate-release type called Niaspan, which is available by prescription only.

Two other drugs that may be used in place of a statin are ezetimibe (Zetia) and colesevelam (Welchol). Both of these medications work in the intestines, rather than the bloodstream, and so are less likely than statins to cause side effects. Ezetimibe blocks cholesterol in food from crossing the intestinal wall and getting into the bloodstream. Colesevelam grabs cholesterol-rich bile acids in the intestine and locks them into a watery goo that is excreted in the stool.

Ezetimibe has been controversial since trials showed it adds little to cardiac protection. Colesevelam might be a good choice if you have diabetes because it lowers blood sugar as well as cholesterol.
The Harvard Medical School Guide to Lowering Your Cholesterol (Harvard Medical School Guides)

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The Harvard Medical School Guide to Lowering Your Cholesterol (Harvard Medical School Guides)

This title is from the experts at one of the world's most respected medical schools - your complete guide to managing cholesterol and staying healthy for life. Everybody knows that high cholesterol...

Cholesterol is a waxy like substance that is transported in the blood plasma of all living animals.  If we have a high level of cholesterol in our blood, we may clog our arteries and cause heart disease.  There are a number of ways to lower the cholesterol level.  Many people may see a drop in their cholesterol if they adhere to a strict diet and exercise regime.  If diet and exercise do not work, cholesterol lowering drugs may be prescribed.  Statins are often the first class of drugs that may be recommended.  They reduce cholesterol by blocking an enzyme and cholesterol production in the liver.      

A commonly prescribed alternative to a statin is niacin, a B vitamin.  Niacin blocks the release of triglycerides contained in body fat.  It is naturally found in foods such as leafy greens like spinach and kale.  Broccoli, asparagus, mushrooms, meats, and eggs also contain niacin.  It is also found in seeds, nuts, and legumes.  Doses of niacin higher than what is found in foods may be recommended by your doctor by prescription.  

A third class of drug used for cholesterol is bile-acid sequestrants.  These drugs limit the amount of circulating cholesterol in the blood through a complex mechanism.  Two common names of these sequestrants are Colestipol ( Colestid ) and cholestyramine ( Questran ). 

Phytosterols are natural substances found in vegetable oil that lowers cholesterol absorption.  These plant derived substances have proven to lower human blood cholesterol levels.  Phytosterols can be found in products such as Earth Balance and Smart Balance butter substitute. 

The newest drug to treat high cholesterol is Zetia which goes by the generic name of Ezetimibe.  It works by not allowing the intestines to absorb large amounts of cholesterol during a meal.  At times Zetia will be prescribed in combination with a statin.                                                  

Dr. Jack Merendino, MD
Endocrinology Diabetes & Metabolism
There are several other classes of medications that can help lower LDL cholesterol levels, and some of these medications may also have beneficial effects on triglycerides and HDL cholesterol levels, though the effects are usually small. Ezetimibe (brand name Zetia) blocks the absorption of cholesterol from the intestine. Used with statin drugs, this medication lowers LDL cholesterol impressively, and the drug Vytorin contains a combination of simvastatin along with ezetimibe. However, studies have yielded somewhat conflicting results in terms of whether ezetimibe reduces the risk of heart and vascular disease. Since there is strong evidence that the statins reduce the risk of heart disease, most experts in this field suggest that a person be treated first with a statin, and that the statin drug be increased as necessary until the cholesterol is controlled. Zetia should be added if the statin drug alone is not adequate to control the cholesterol, or if the person cannot tolerate high-dose statin therapy because of side effects.
Other drugs also lower LDL cholesterol. Niacin (also called nicotinic acid) is a B vitamin; at high doses it lowers LDL cholesterol and triglycerides, and it's more effective at raising HDL cholesterol than other cholesterol-lowering drugs. There are many brands, and the main side effect is an uncomfortable flushing. Niacin comes in immediate-release and slow-release forms, and the latter may reduce the flushing somewhat. Many niacin preparations are sold as supplements and are not subject to the same degree of oversight by the FDA as prescription drugs. Some over-the-counter forms of slow-release Niacin have been associated with liver damage, but the prescription form Niaspan has not. Niacin sometimes raises blood sugar levels, so it has to be used cautiously in people with diabetes.
The bile acid sequestrants, including the drugs cholestyramine (Questran, Questran Light, Prevalite, Locholest, and Locholest Light), colestipol (Colestid), and colesevelam (Welchol) lower LDL cholesterol, but the drugs cause severe constipation in many people and often raise triglyceride levels.
The Best Life Guide to Managing Diabetes and Pre-Diabetes

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Important: This content reflects information from various individuals and organizations and may offer alternative or opposing points of view. It should not be used for medical advice, diagnosis or treatment. As always, you should consult with your healthcare provider about your specific health needs.