5 Drugs That Can Lower Cholesterol

Lowering your LDL can cut your risk of heart attack and stroke

Merle Myerson, M.D.,

AARP

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En español

Published June 19, 2023

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Cardiovascular Disease Risk Factors

A few important ones include:

High cholesterol
High blood pressure
Smoking
Diabetes
Obesity

Cardiovascular disease remains the leading cause of death in the United States, claiming roughly the same number of lives each year as cancer, lower respiratory diseases and accidents combined. Older adults bear the brunt of this burden: An estimated 80 percent of deaths from the disease occur in adults 65 and older.

The good news, however, is that a lot can be done to prevent cardiovascular disease — a catchall term for several conditions related to the heart and blood vessels (think heart attack, stroke and heart failure). A healthy lifestyle can go a long way. So can controlling risk factors for the disease, a big one being high cholesterol.

What is cholesterol?

First, it’s important to know that cholesterol is not inherently bad. Our bodies produce it in the liver to help build cells and make hormones. You can also get cholesterol from your diet, especially from foods high in saturated fat, such as cheeses and fatty meats.

Too much of it, though, can lead to the buildup of plaque along the walls of the blood vessels, causing them to narrow and increasing the likelihood of a heart attack or stroke.

Getting plenty of exercise and eating a heart-healthy diet can help keep your cholesterol numbers in check. And if your cholesterol is high, medications can help to bring it down. However, research shows that a significant share of people who could benefit from cholesterol-lowering drugs aren’t taking them, and the reasons for opting out range from misinformation to concerns about safety and cost.

Still, experts say, the science stands. Lynne T. Braun, a nurse practitioner affiliated with the Rush Heart Center for Women in Chicago, says decades of research have shown that when cholesterol is elevated — in particular LDL (low-density lipoprotein) cholesterol, sometimes called “bad cholesterol” — so is the risk of heart attack and stroke.

“Conversely, when LDL cholesterol is reduced through lifestyle measures and medication, the incidence of heart attacks, strokes and deaths decreases,” Braun notes. “There is a strong relationship: Lower cholesterol equals fewer heart attacks and strokes.”

Know your numbers

High cholesterol doesn’t come with symptoms, so the only way to know you have it is with a routine blood test. Most healthy adults should have their cholesterol checked every four to six years, according to the Centers for Disease Control and Prevention (CDC), though some may need it tested more frequently.

When you get your blood test report, you’ll see four numbers:

Total cholesterol is the total amount of cholesterol in your blood.
HDL (high-density lipoprotein) cholesterol — also known as “good cholesterol” — helps take the “bad cholesterol” out of your body, so higher numbers are better.
Triglycerides are a form of fat in the blood that is used as an energy source to “fuel” your body. Too much, however, can cause health problems.
LDL cholesterol — the “bad cholesterol” — is the culprit for clogging your arteries.

Prevention of cardiovascular disease focuses on LDL cholesterol and ways to lower it. If your LDL level is elevated, your health care provider will map out a treatment plan based on your risk for having cardiovascular disease.

For some patients with high cholesterol, it’s reasonable to have a two- to three-month trial to see if certain lifestyle modifications — diet, weight loss and exercise, for example — lower LDL levels. If your risk of cardiovascular disease is higher, however, your provider may want to start you on medication right away, along with lifestyle changes.

What medications are available?

Statins are the first-line treatment:

While there are several options available, a class of drugs known as statins are considered first-line treatment for high LDL. Statins, like many medications, can have side effects, but years of research have shown their benefits and safety.

“Numerous studies have found that lowering cholesterol with a statin reduces the chance of having a heart attack or stroke” says Connie Newman, M.D., an endocrinologist and adjunct professor in the Department of Medicine at New York University Grossman School of Medicine.

Effectiveness: Statins can lower cholesterol by 20 to 60 percent, depending on the particular statin and the dose.
Examples: Atorvastatin (Lipitor), fluvastatin (Lescol), lovastatin (Altoprev or Mevacor ), pitavastatin (Livalo or Zypitamag), pravastatin (Pravachol), rosuvastatin (Crestor or Ezallor Sprinkle) and simvastatin (Zocor or FloLipid)
How they work: Statins slow down the body’s production of cholesterol.
Possible side effects: Muscle soreness and achy joints can occur. There’s also a very low risk that some patients develop diabetes.
What else to know: Statins have anti-inflammatory and antioxidant effects.

If statins don’t help you get to your cholesterol goal, your doctor may increase the dose or add a second medicine.

Other cholesterol-lowering drugs available:

Bile acid sequestrants

Effectiveness: Can lower LDL cholesterol by 15 to 20 percent.
Examples: Cholestyramine colestipol powder (Colestid) and colesevelam pill (Welchol)
How they work: These drugs lower cholesterol by binding to it in the bile from the liver and preventing absorption.
Possible side effects: Constipation and an increase in triglycerides in some patients. These drugs may interfere with absorption of other medications if taken at the same time.
What else to know: They can improve HbA1c (a measure of blood sugar levels) in patients with diabetes.

Cholesterol absorption inhibitors

Effectiveness: Can lower LDL by 20 to 25 percent.
Examples: Ezetimibe (Zetia)
How they work: These medicines prevent the body from absorbing cholesterol from the intestine.
Possible side effects: Side effects are rare.
What else to know: These medicines are generally well tolerated.

PCSK9 inhibitors

Effectiveness: Can lower LDL by 45 to 60 percent.
Examples: Alirocumab (Praluent) and evolocumab (Repatha)
How they work: These medicines increase removal of cholesterol from the body through the liver.
Possible side effects: Some people may have mild injection-site reactions.
What else to know: These medications are given by injection every two or four weeks and are mostly for patients at higher risk who did not tolerate other medications or did not reach their LDL goal. They are more expensive than other options and may require pre-authorization from your provider.

ACL inhibitors

Effectiveness: Can lower LDL by 15 to 20 percent.
Examples: Bempedoic acid (Nexletol)
How they work: ACL inhibitors prevent the body from making cholesterol.
Possible side effects: These medicines are generally well tolerated.
What else to know: This medication, approved in 2020, can be costly and may require pre-authorization from your provider.

A few others to note: Two newer cholesterol-lowering medications available are inclisiran (Leqvio), which is injected under the skin and taken every six months, and evinacumab (Evkeeza), given monthly by IV infusion. Both are very potent and can lower LDL levels by 50 percent. However, they are expensive and only indicated for those who are at very high risk and not at their LDL goal.

What About Niacin?

Niacin is an older cholesterol-lowering medication that is used less often, in part due to its side effects, like headache and a warm, flushing feeling.

Curious about the “no-flush” or “flush-free” niacin supplements stocked on drugstore shelves? Not so fast. While these pills won’t give you a flush, they won’t lower your LDL levels. Plus, dietary supplements are not regulated like other medications, meaning their ingredients, formulations and effects, some of which can be serious, vary widely.

Be sure to talk with your doctor about the best way to lower your cholesterol and about any supplements you are taking.

Also in the arsenal are drugs to lower triglycerides, including fibric acids, or fibrates, along with omega-3 fatty acids.

Questions to ask your doctor

When you meet with your doctor to discuss your cholesterol-lowing strategy, be sure to ask:

What are my cardiovascular risk factors?
What is my goal for LDL cholesterol?
What lifestyle changes can help? Will lifestyle changes alone bring me to my LDL goal?
If I need medication for my cholesterol, what are the choices? (And be sure that all your drug allergies and past problems with medications are listed in your medical chart.)
What do I need to know about the medication I will be taking? How often do I take it? Should I take it with food?
What are the possible side effects? According to Eliot Brinton, M.D., an endocrinologist in Salt Lake City who’s affiliated with Intermountain Medical Center, “older adults tend to be more sensitive than young adults to side effects of any medication, including those for cholesterol lowering.” If you experience side effects, your doctor may adjust your dose or switch you to a different medication, Brinton notes.
Is any monitoring needed?
When should I have follow-up blood tests to see my LDL improvement?
What should I do if I think I am having a side effect?

Finally, be sure to ask your provider for a copy of your lab tests to take home. Your doctor may also give you a chart to track your numbers in the future.

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Merle Myerson, M.D., is a cardiologist who specializes in health lifestyle and disease prevention. She is a board-certified lipid specialist and has authored many research articles and textbooks on cardiovascular disease.