Medications

For many people with cholesterol that’s higher than it should be, diet and lifestyle changes alone often aren’t enough to lower their chance of heart disease or stroke, despite their best efforts. Medications can help to further lower cholesterol. In addition, we now know from studies that treating elevated cholesterol earlier, to lower targets and for longer results in much greater protection against future heart attack and stroke risk.

Statins

Statins remain the first treatment – in combination with lifestyle changes – to lower cholesterol and reduce the risk of cardiac events like heart attack, stroke and related death. There are seven different statins available with decades of research showing benefits for reducing heart attack and stroke. Statins help by:

• Reducing the amount of cholesterol made by the liver
• Removing cholesterol from the blood
• Reducing cholesterol in plaque
• Reducing inflammation from plaque
• Helping keep a plaque from dislodging or forming a clot that may block an artery 

The goal is to have someone on the highest possible statin dose to gain the most benefit.

As with any medication, it is important to tell your care team about any side effects or problems you experience while taking statins. Though side effects are not common, your clinician can:

• Order a blood test to find out if there may be another cause of your symptoms
• Lower the dose of the statin you are taking or change how often you take it
• Switch you to a different statin
• Prescribe something other than a statin, if appropriate
• Adjust your dose and add a different cholesterol-lowering medication 

Other Medications to Lower LDL

Other non-statin medications may be added to lower LDL-cholesterol. These include: 

• Cholesterol absorption inhibitors (ezetimibe) to lower the amount of cholesterol in the blood. There is also a medication that combines ezetimibe and a statin. 
• Therapies that target PCSK9 may be used for people at high risk for heart disease, including those with familial hypercholesterolemia (FH), those with existing heart disease, or certain high-risk patients without prior heart disease whose LDL-cholesterol levels remain above treatment goals despite lifestyle changes and other lipid-lowering medications such as statins or ezetimibe. These medicines are given as injections under the skin and work by blocking a protein called PCSK9, which helps the body remove more LDL cholesterol from the blood.
• Evolocumab and alirocumab are monoclonal antibodies that inhibit PCSK9 activity.
• Inclisiran stops proteins from being made, allowing the liver to keep removing harmful cholesterol.
• Bempedoic acid to lower cholesterol by blocking a step in cholesterol production in the liver. It may be used for people at high risk for heart disease, including those with familial hypercholesterolemia, existing heart disease, or certain high-risk patients whose LDL cholesterol remains above treatment goals despite other therapies or who cannot tolerate statins. It can be used alone or in combination with ezetimibe.

There are other medications that are used for people with FH.

Medications to Lower Triglycerides

Triglycerides are a type of fat that circulates in the blood. High levels are often related to diet, weight, diabetes, or other metabolic conditions and can increase the risk of heart disease and, when very high, pancreatitis.

The first step in lowering triglycerides is improving overall health habits. This includes:

• Eating healthy foods – cutting down on sugars and unhealthy fats
• Avoid alcohol
• Getting regular physical activity and move your body more
• Lose weight, if needed

For many patients, working with a registered dietitian can be helpful.

If triglyceride levels stay high, medications can help. Medications will depend on your risk of heart problems and pancreatitis. They may include:

Statins – Statins are often the first medicine used. They mainly lower LDL cholesterol, but they also lower triglycerides and help reduce the risk of heart attack and stroke.

Icosapent ethyl (EPA) – This prescription omega-3 medicine can lower triglycerides and has been shown to lower the chance of future heart problems in some high-risk patients who are already taking statins.

Other prescription omega-3 medicines – These medicines can lower triglycerides, especially when levels are very high. Over-the-counter fish oil supplements are not the same as prescription medicines and may not work as well.

Fibrates (such as fenofibrate) – These medicines can lower triglycerides. They may be used when triglyceride levels are very high to help prevent pancreatitis.

Olezarsen – an antisense oligonucleotide that targets and inhibits the production of apolipoprotein C-III (apoC-III) in the liver. Can be considered for patients at high risk for pancreatitis and who have extremely high triglyceride levels of 1000 mg/dL or higher.   

Your care team will choose treatment based on your triglyceride level, your overall heart risk, and your other health conditions. 

Take as Directed

As always, take your medications exactly as directed. That’s the only way to make sure they work as intended. If you have side effects or concerns, talk with your care team before making any changes. Your cholesterol will be re-checked over time. It’s not unusual for your care team to make changes to your medications, perhaps adding a medication or adjusting the amount (dose) you take.

Work with your care team to make sure you get your cholesterol down to a level that will keep you healthy for the rest of your life. Your pharmacist is also a good resource if you have questions.