Spotlight On: Medications for High Cholesterol

By Donna White, UVA Pharmacist

What medications, besides statins, are used to lower cholesterol? 

Four other medication classes help lower cholesterol. These include:

• bile acid sequestrants
• nicotinic acid
• fibric acid derivatives 
• cholesterol-absorption inhibitors  

Here’s a quick review of what HDL and triglycerides are and how each medication class works. HDL helps remove the bad cholesterol (LDL) from the blood and increases the disposal of bad cholesterol. Fat is stored in the blood as triglyceride. Elevated triglycerides and low HDL levels are associated with higher risks of heart disease. 

How bile acid sequestrants work: Around since the 1960s, these medications lower LDL but have little or no effect on HDL or triglycerides. These medications bind to bile acids. This action increases the excretion of bile acid in the stool and increases the conversion of cholesterol to bile acids, thereby reducing cholesterol formation in the liver.

How nicotinic acid works: Also known as niacin, this is the oldest known lipid-lowering agent. Prescription niacin is the medication of choice to increase HDL levels. It also has significant triglyceride-lowering ability and lowers LDL. Niacin is thought to slow the removal or clearance of HDL and reduces the formation of triglycerides in the liver. It is important to note that over-the-counter niacin is not federally regulated so its effectiveness is undetermined. 

How fibric acid derivatives work: Also known as fibrates, these primarily lower triglyceride levels by inhibiting the production of substances that carry triglycerides and speed up their removal from the blood. They are moderately effective in increasing HDL and have little effect on LDL. 

How cholesterol-absorption inhibitors work: This medication is most often used in combination with a statin drug to further low LDL or when statins are not tolerated by the patient. This medication reduces the absorption of cholesterol from the intestine. It does not affect triglycerides and has a moderate effect on LDL lowering when used alone. 

Are these drugs taken for life, like statins?  

Most likely. Sometimes, lifestyle changes may be enough to control triglycerides. However, increasing HDL is much more difficult than lowering LDL and often requires medication. 

How do these drugs compare to statins? 

None of these drugs offers the same potency or degree of LDL cholesterol-lowering ability as statins. However, they are used to specifically raise HDL or lower an elevated triglyceride level. They also may be taken along with a statin drug to help further low LDL. 

What about herbal and nutritional supplements? 

Herbal and nutritional supplements are sometimes referred to as CAM (complimentary alternative medicines). They are not regulated by the Food and Drug Administration (FDA) and, therefore, their safety and efficacy remains mostly unknown. Most importantly, it means they have not been put through the rigorous studies that prescription or regulated over-the-counter medications have been through. 

Certainly, some dietary interventions have been shown to decrease cholesterol. These include: omega-3 fish oil, plant sterols/stanols, soluble fiber, dark chocolate and limited alcohol intake. 

Garlic, for example, once thought to be beneficial in lowering cholesterol, has been proven NOT to reduce cholesterol.  

Red yeast rice contains compounds that block the formation of cholesterol. One of these compounds acts similarly to statin drugs. But because this herbal is unapproved and not standardized in its formulation, the FDA continues to warn against its use. All over-the-counter medications, herbals, supplements and vitamins should be discussed with your pharmacist or healthcare provider.  

What are the considerations for which type of medication to take? 

Some of these medications are used along with statin drugs for further lowering of LDL, while others are to specifically decrease triglycerides and/or increase HDL. Your provider can help determine what regimen is best for you. Remember, that the cholesterol goals in women are different; LDL cholesterol less than 100mg/dl; HDL greater than 50mg/dl and triglyceride levels less than 150mg/dl. 

Healthier eating, exercise and quitting tobacco remain an important part of keeping your cholesterol and your heart healthy and safe!