Sometimes, one cholesterol medicine just won’t cut it. Even if you live a healthy lifestyle and take your pills correctly, you may need extra help getting your levels down to a healthier range.
But that doesn’t mean you have to live with high cholesterol. Help can come in the form of a second or even a third medication. Work with your doctor to build a better treatment plan.
When Two Meds Are Better Than One
There are a lot of reasons you could need extra help getting your cholesterol under control. Your doctor might recommend adding a medication if:
Your statin hasn’t helped. Statins are a mainstay of cholesterol treatment. But they don’t work well enough for everyone who takes them. If that’s the case for you, your doctor might recommend that you add another medicine to your treatment.
You have side effects from statins. These drugs can cause muscle pain, liver damage, and other problems that make it hard for some people to take them. Doctors can prescribe a lower dose to ease side effects, but that means adding another med to bring down cholesterol.
You have a genetic form of high cholesterol. Familial hypercholesterolemia (FH) is a condition that causes very high levels of cholesterol -- so high that one drug and lifestyle changes won’t do enough. People with FH usually take a statin and one or two other drugs.
You can’t take a statin. The pills aren’t safe for people with liver disease or women who are pregnant or breastfeeding. Doctors will rely on other types of drugs to lower cholesterol.
You have high triglycerides. Some drugs do a better job of bringing down these blood fats than others. Your doctor might add another drug that targets them.
How to Choose
The goal of cholesterol treatment is to help you prevent a heart attack or stroke. So how many and which kind of drugs your doctor prescribes also depends on your chances for heart disease. The higher your risk, the more important it is to get your levels down. Your doctor will add up all of your risk factors and decide which medications will help you the most.
The major risks for heart attacks and strokes are:
- You’ve had a heart attack or stroke before.
- You have diabetes.
- You’re in the late stages of kidney disease.
- You have high “bad” LDL cholesterol (190 or higher).
- Your age: older than 45 for men, older than 55 for women.
- You have a family history of heart disease.
- You smoke.
- You have high blood pressure.
- You have low “good” HDL cholesterol (below 40 for men, below 50 for women).
Along with your chances for heart disease, your doctor also will consider:
- Other medical conditions you have
- Side effects of the medication
- How much it costs
- Other medications you’re taking
- What you feel comfortable with
Your Cholesterol-Lowering Options
Different drugs work in different ways. The ones your doctor adds depend on where your cholesterol needs help. Do you have too much LDL? Not enough HDL? Triglycerides too high? That will guide your doctor to a drug that treats your specific problem.
If your LDL levels are too high, your doctor might recommend:
- Statins,including atorvastatin (Lipitor), fluvastatin (Lescol), lovastatin (Altoprev, Mevacor), pravastatin (Pravachol), rosuvastatin calcium (Crestor), simvastatin (Flolipid, Zocor), or pitavastatin (Livalo)
- Resins, also called bile acid sequestrants, like cholestyramine (Locholest, Prevalite, Questran), colesevelam (WelChol), and colestipol (Colestid)
- Nicotinic acid (niacin). This B vitamin is common as a supplement, but the prescription form (Niaspan) is an extended-release formula.
- Ezetimibe (Zetia)
- PCSK9 inhibitors, including alirocumab (Praluent) and evolocumab (Repatha). Evolocumab as also been approved as a preventative measure against heart attacks and strokes in people who have cardiovascuar disease.
If you don’t have enough HDL cholesterol in your blood, your doctor might prescribe:
- Nicotinic acid (niacin)
Drugs that lower triglycerides:
- Fibrates, including fenofibrate (Antara, Fenoglide, Lipofen, Tricor, Triglide), fenofibric acid (Trilipix), and gemfibrozil (Lopid). You usually take these drugs instead of, not along with, a statin.
- Omega-3 fatty acids. The prescription forms of these fats include Epanova, Lovaza, Omtryg, and Vascepa. Omega-3s also come in supplements.