Medically reviewed in September 2022
Updated on September 22, 2022
About 94 million Americans ages 20 and older have high cholesterol, but only about 55 percent of those are being treated with medication 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 healthy living to emerging treatments to gold-standard drugs—and scientists are always working on newer, better methods.
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. In your blood, it’s packaged two main ways: high-density lipoprotein (HDL) and low-density lipoprotein (LDL).
LDL is the "bad" cholesterol. When you have too much in your blood, it forms a 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, causing a heart attack, or to the brain, which could result in 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 the gold standard for cholesterol lowering,” says Vinayak Manohar, MD, an interventional cardiologist in Grand Rapids, Michigan. 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 Dr. Manohar. “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.
Though most people tolerate them well, Manohar notes that statins are not without side effects. One common complaint is muscle aches, known as statin myalgia. But a 2022 meta-analysis published in The Lancet found this pain to be relatively uncommon, mostly mild, and only rarely caused by the statins themselves. Muscle symptoms were more common in more intensive statin treatments. Researchers concluded that statin benefits greatly outweighed the risk of muscle symptoms.
Headache, fatigue, and stomach troubles are among the other reported side effects. In rare and severe cases, damage to the muscles, kidneys, or liver may occur.
Speak with your healthcare provider about side effects, or if you experience any new, sudden, or unusual symptoms when you’re taking statins.
Newer medication options
While statins remain the medication of choice for lowering cholesterol, other drugs have entered the scene in recent years.
PCSK9 inhibitors: Where statins reduce the amount of cholesterol the liver makes, a newer type of drug called PCSK9 inhibitors help remove cholesterol from the bloodstream.
Among the PCSK9 inhibitors approved by the U.S. Food and Drug Administration to treat high cholesterol in certain patients are evolocumab and alirocumab, which are administered via injection one or two times each month. Inclisiran, a twice-yearly injection, was given the go-ahead in 2021, to be used in conjunction with dietary changes and statin therapy.
Studies have shown PCSK9 inhibitors can reduce the risk of cardiovascular events like heart attack and stroke—but not necessarily reduce the number of associated deaths. 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 was originally listed at more than $14,000 per year—and the uncertainly about whether they save lives have presented barriers to the wider use of the drugs. As a result, pharmaceutical companies have taken steps in recent years to help lower prices.
Cholesterol absorption inhibitors: Another class of drugs called selective cholesterol absorption inhibitors focuses 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 often prescribed to be used in combination with a statin.
Bempedoic acid: In February 2020 the FDA approved bempedoic acid for the treatment of high LDL cholesterol in some patients. Shortly afterward, they gave the go-ahead to a combination bempedoic acid/ezetimibe pill. Unlike PCSK9 inhibitors, which are injected, these drugs come in a once-daily pill; typically, people who need to lower their cholesterol would take it along with their statins.
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 healthy foods before taking away less nutritious options 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.”
