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Do I Need Medicine?

If your cholesterol is too high, good health habits like exercise, weight loss, and a nutritious diet may help bring it down. If they don’t, your doctor may want you to add medication to your healthy lifestyle. Whether you need it depends on your age, cholesterol numbers, and other things that raise your odds for heart attacks or strokes. When it’s time to start cholesterol treatment, there are many types of drugs you can try.

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Statins

These popular drugs are best for lowering “bad” (LDL) cholesterol. They can also raise the good kind (HDL) and cut blood fats called triglycerides. Statins help your liver make less cholesterol, and they clear out some of it from your blood. They include atorvastatin (Lipitor), fluvastatin (Lescol), lovastatin (Mevacor, Altoprev), pravastatin (Pravachol), rosuvastatin calcium (Crestor), and simvastatin (Zocor). Some are stronger and have more side effects than others.

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Statin Side Effects

Some people say statins make their muscles achy or weak. Gentle stretching or supplements, like CoQ10, may help, but the problem often goes away as your body adjusts to the meds. In very rare cases, they could damage muscles or the liver. Statins could also raise blood sugar, make you feel confused, or give you memory loss. Those issues should clear up when you stop taking the drug, or your doctor cuts your dose or changes your statin.

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Niacin (Nicotinic Acid)

You can buy this B vitamin over the counter as a supplement, but doctors prescribe stronger forms of niacin (Niacor, Niaspan) to treat cholesterol. These meds limit how much LDL your liver can make, so less winds up in your blood. They also bring down triglycerides and may raise HDL levels. While these drugs are regulated by the FDA, niacin supplements are not, so check with your doctor before you buy them at the pharmacy.  

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Niacin: Side Effects and Risks

Even though it’s a natural vitamin, it can raise your odds of some bad side effects, like strokes, type 2 diabetes, liver problems, bleeding, or infections. In fact, it’s not clear that it lowers your chances of heart attacks or strokes, which is why most people take cholesterol drugs in the first place. Unless you can’t take statins, your doctor probably won’t prescribe this drug on its own.

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Fibric Acid Derivatives (Fibrates)

Your doctor may prescribe one of these drugs if you can’t take a statin. They work best at lowering your triglycerides -- they help your liver clear them from your blood. They also boost HDL. They’re not as good at lowering LDL levels, though. Fibrates include clofibrate (Atromid-S), fenofibrate (Antara, Lofibra, Tricor, Triglide), and gemfibrozil (Lopid).

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Fibrates: Side Effects and Risks

While side effects for fibrates aren’t common, these meds could cause stomach pain or dizziness. Muscle and liver damage are rare but can happen. The drugs may cause gallstones, so if you’ve had them in the past, these meds may not be for you. If you take the blood thinner drug warfarin, fibrates can affect how well it works. There’s also a risk that they could make your bad cholesterol go up.

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Bile Acid Sequestrants (Resins)

These meds work in your intestines to remove bile, an acid your liver makes to help you digest food. When there’s not enough bile for digestion, your liver has to make more, and it uses cholesterol to do it. That means less LDL winds up in your blood.

Resins include cholestyramine (Questran, Prevalite, Locholest), colesevelam hcl (WelChol), and colestipol (Colestid). You might add one to your treatment if other meds don’t work well enough.

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Resin: Side Effects and Risks

The typical side effects -- like bloating, nausea, or constipation -- aren’t serious, but they’re too much for some people to handle. If you need relief, ask your doctor if you can switch to a different resin. These drugs can also make it harder for your body to absorb medications like digoxin, beta-blockers, diuretics, and thyroid hormone. This means you won’t get the full effects of these treatments.

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Cholesterol Absorption Inhibitors

This drug, ezetimibe (Zetia), makes your intestines absorb less cholesterol from food. It mostly helps you lower LDL, but it may lower your triglycerides and raise HDL, too. If you already take a statin but have strong side effects from it, you can add this drug to your treatment and lower your statin dose. This combination may ease side effects while still cutting cholesterol.

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Absorption Inhibitor Side Effects

This medication has very few side effects. Mild diarrhea is the most common one. Rarely, some people have muscle weakness. If you take it with a statin, there’s a small chance of liver damage, but it’s rare. 

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PCSK9 Inhibitors

They block a protein in your liver called PCSK9. That helps liver cells clear more LDL from your blood. These powerful drugs -- alirocumab (Praluent) and evolocumab (Repatha) -- can cut your cholesterol numbers by a lot. Right now, doctors mainly prescribe them to treat familial hypercholesterolemia, a genetic disease that causes very high cholesterol. Instead of a daily pill, you take these drugs as a shot every 2 to 4 weeks.

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PCSK9 Inhibitor Side Effects

Some people feel confused or foggy while they use these medications. They can also make you a bit more likely to get colds or other respiratory infections. And since you get them through a shot, you could get an itchy, red reaction at the injection site.

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Omega-3 Fatty Acids

You might know these nutrients as fish oils. If you have high triglycerides, omega-3 fatty acids may help you cut those numbers by as much as half. Mild side effects include a fishy taste after you take the capsule or upset stomach. If you’re allergic to fish or shellfish, you shouldn’t take them. They also may not mix well with other medications, herbs, or supplements. So make sure your doctor knows about everything you’re taking.

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New Treatments Ahead?

Current cholesterol drugs don’t work for everyone, and some have strong side effects. So scientists are still looking for new treatment options. One is bempedoic acid, a pill that lowers LDL cholesterol. Another may be inclisiran, a drug that blocks the PCSK9 protein with only a couple of injections per year. Researchers are testing these medicines in clinical trials.

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Sources | Medically Reviewed on 01/29/2018 Reviewed by Lisa Bernstein, MD on January 29, 2018

SOURCES:

Mayo Clinic: “High Cholesterol,” “Statin side effects: weigh the benefits and risks,” “Niacin can boost ‘good’ cholesterol.”

Harvard Health: “Why You May Need a Statin,” “Help for your cholesterol when the statins won’t do,” “PCSK9 inhibitors: A major advance in cholesterol-lowering drug therapy,” “Managing statin muscle pain.”

CDC: “Cholesterol-lowering Medicine.”

American College of Cardiology: “High Triglycerides.”

American Heart Association: “Cholesterol Medications.”

International Journal of Clinical Practice: “Ezetimibe-associated adverse effects: what the clinician needs to know.”

World Journal of Cardiology: “PCSK9 Inhibitors: a new era of lipid lowering therapy.”

American Family Physician: “Management of Hypertriglyceridemia.”

Expert Opinions in Investigative Drugs: “Evaluating bempedoic acid for the treatment of hyperlipidaemia.”

European Society of Cardiology: “Inclisiran lowers ‘bad’ cholesterol for up to one year (ORION 1).”

Medscape: “PCSK9 Inhibitors: How They Work and Who Should Get Them.”

NIH LiverTox: “Ezetimibe.”

Reviewed by Lisa Bernstein, MD on January 29, 2018

This tool does not provide medical advice. See additional information.

THIS TOOL DOES NOT PROVIDE MEDICAL ADVICE. It is intended for general informational purposes only and does not address individual circumstances. It is not a substitute for professional medical advice, diagnosis or treatment and should not be relied on to make decisions about your health. Never ignore professional medical advice in seeking treatment because of something you have read on the WebMD Site. If you think you may have a medical emergency, immediately call your doctor or dial 911.