If you’ve been diagnosed with high cholesterol, your first step is to make lifestyle changes, such as eating a heart-healthy diet and getting regular exercise.
But, if lifestyle changes alone aren’t enough to lower your level of low-density lipoprotein (LDL, or “bad”) cholesterol and boost your level of high-density lipoprotein (HDL, or “good”) cholesterol, you may need to talk to your doctor about prescription medications designed to help you control your cholesterol.
If it’s your first time taking cholesterol medication, you’ll likely have questions about your new treatment. Here are some common questions to consider asking your doctor — and a brief summary of how they may respond.
1. What Are the Target Levels for LDL and HDL Cholesterol?
Before learning what target cholesterol levels are, it helps to understand the different types of cholesterol, a waxy, fatlike substance made by your liver and also found in certain foods. LDL is known as the bad cholesterol, because it can build up in your arteries, increasing your risk of heart attack and stroke. HDL removes LDL from arteries and carries it back to the liver, where it’s broken down and flushed from your body.
According to the Centers for Disease Control and Prevention (CDC), the target LDL level for most adults is less than 100 milligrams per deciliter (mg/dL), and the HDL target is 40 mg/dL or higher for men and 50 mg/dL or higher for women. They also recommend a total cholesterol level of 125 to 200 mg/dL. Total cholesterol is calculated by adding up your LDL and HDL, plus 20 percent of your level of triglycerides — another type of fat that can raise heart disease risk.
But, most cardiologists focus less on these numbers and more on your risk of heart disease when managing cholesterol, according to Peter Schulman, MD, an attending cardiologist and professor of medicine at University of Connecticut Health in Farmington. “We don’t really require specific numbers anymore, because the research on LDL levels to date has been inconclusive,” he explains. Still, depending on your age and overall health, if your LDL and total cholesterol are above the recommended targets, you should talk to your doctor about how you can improve them.
2. How Will I Know if I Need Medication to Treat My Cholesterol?
These days, most cardiologists will determine your need for cholesterol-lowering drugs based on your risk of heart disease and stroke, using a tool called the Atherosclerotic Cardiovascular Disease (ASCVD) Risk Estimator Plus. The tool is available online and as a mobile app, but it’s best to use the calculator with your doctor, Dr. Schulman says. The calculator measures your 10-year risk of coronary artery disease, heart attack, and stroke by taking into account your age, blood pressure, cholesterol, and other factors, such as whether you have diabetes or are being treated for high blood pressure. Generally, if your ASCVD risk is 7.5 percent or higher, your doctor will recommend cholesterol-lowering drugs, Schulman says. Also, if you’ve had a heart attack or stroke, or you have coronary artery disease, “You should be on a cholesterol-lowering medication to reduce your risk of having another heart problem in the future,” he adds.
3. What Medications Are Available to Treat High Cholesterol? How Do They Work?
If diet and exercise aren’t enough to help you maintain healthy cholesterol levels, the American Heart Association (AHA) recommends treatment with drugs called statins. They work in the liver to prevent cholesterol from forming and reduce the amount of cholesterol circulating in your blood, according to the AHA. They’re most effective at lowering LDL levels but can also help reduce triglycerides and raise HDL. The AHA recommends statins for adults with a history of heart disease or stroke caused by atherosclerosis, as well as adults ages 40 to 75 with high cholesterol. If your LDL levels are over 190 mg/dL while taking statins, your doctor may recommend “high-intensity” (high-dose) statin treatment, with the goal of dropping your bad cholesterol by 50 percent or more.
If statins are insufficient or not well tolerated, other cholesterol-lowering drugs may be prescribed. These include PCSK9 inhibitors, which remove cholesterol from the blood; selective cholesterol absorption inhibitors, which prevent cholesterol from being absorbed in the intestines; and resins or bile acid–binding drugs, which help the intestines increase cholesterol disposal. In addition, fibrates, niacin, and omega-3 fatty acid–based medications can be used to boost HDL and reduce triglycerides. All of these non-statin drugs can be used alone or in combination with statins to manage cholesterol. Your doctor will help you determine which medication, or combination of medications, is right for you.
4. How Often Should I Have My Cholesterol Levels Tested?
Once you’ve started a new treatment plan to manage your cholesterol, your doctor should check your levels in 4 to 12 weeks, using a fasting or non-fasting lipid test, according to the AHA. After that, they’ll likely monitor your levels every 3 to 12 months, depending on how well you’re doing. These evaluations will focus on the amount you’ve reduced your LDL levels, rather than the levels themselves, the AHA notes. The percentage reduction in LDL cholesterol will give your doctor a snapshot of how your new treatment is working.
5. Do Cholesterol Medications Have Side Effects?
Muscle pain may be the most common side effect of statins, Schulman says. This pain may range from mild soreness, tiredness, or weakness in your muscles to severe pain that makes your daily activities difficult, according to Mayo Clinic.
That said, research hasn’t yet clearly tied muscle symptoms to statins, and doctors emphasize the cardiovascular benefits of these medications. One review found that there isn’t any strong evidence to show that statins can cause muscle pain. And in another review, the study authors noted that while statins were found to cause some mostly mild pain in participants, the risk of muscle symptoms was small, compared with the cardiovascular benefits that would be gained.
In very few cases, statins may cause a muscle-damaging condition called rhabdomyolysis or increase inflammation in the liver. In addition, most statins include a U.S. Food and Drug Administration (FDA) warning on their labels indicating that the drugs may cause memory loss or confusion. In some older adults — 85 and up — the risk of memory loss may outweigh any health effects associated with high cholesterol, Schulman says. For them, Schulman recommends a lower statin dose or an alternative drug.
Finally, statins may also increase blood sugar levels in people with diabetes, according to the CDC. The risk of these side effects is generally low and varies from person to person, so you should talk to your doctor about whether the benefits of taking these drugs — lowering cholesterol and helping prevent heart attack and stroke — make the risks worthwhile.
Non-statin drugs generally have gastrointestinal-related side effects, such as nausea, vomiting, upset stomach, gas, and constipation, as well as muscle pain and headaches. In general, the risk of these side effects is very low, Mayo Clinic says. In addition, if you’re pregnant or planning to become pregnant, talk to your doctor about whether it’s safe to continue taking your cholesterol-lowering medication.
6. Can I Stop Taking Cholesterol Medication Once My LDL Level Comes Down?
Once your doctor prescribes a statin, you’ll likely be on the drug for the rest of your life, according to Cleveland Clinic, because your LDL would likely rise within a few weeks of stopping the medication. If you’re experiencing side effects, your doctor may adjust your dose or switch you to another statin or medication. “Studies suggest that you can still get about 70 percent of the cholesterol-lowering benefits of statins even if you take them only two or three times per week, instead of daily,” Schulman explains.
One study found that taking statins intermittently, from alternating days to once a week, was still effective in lowering LDL. If you have or develop other health conditions, such as liver disease, that make statin use risky, your doctor may prescribe an alternative, such as injectable PCSK9 inhibitors, which are administered with a small needle every two weeks. These drugs are expensive but work well in people who can’t tolerate statins, Schulman says. Still, you and your doctor will need to work out a plan for discontinuing statin treatment safely. You should never stop taking medication without talking to your doctor.
7. Can Other Medications, Supplements, or Foods Interfere With Cholesterol Medication?
Some medications may cause statins to not work as well or rise to harmful levels in your blood, the AHA says. But, just because you’re on one of these medications doesn’t mean you can’t take a statin. Instead, your doctor may want to monitor you more frequently or lower your statin dose, Schulman explains. Examples of drugs that may interfere with statins, according to the AHA, include antibiotics and antifungals used to treat infections; prescription and over-the-counter antacids; high blood pressure medications; and oral contraceptives. If you’re taking any of these, be sure to tell your doctor before starting a statin.
Grapefruit and grapefruit juice can also have negative effects on some statins, Schulman notes. Generally, this can be avoided by not consuming the fruit or its juice at the same time you take your statin dose.
8. Do I Still Need to Exercise and Watch My Diet if I’m Taking Cholesterol Medication?
The short answer is yes. You’ll still need to exercise regularly and eat a heart-healthy diet rich in fruits, vegetables, whole grains, and lean protein and low in saturated and trans fats, even while taking medication to lower LDL, the AHA says. Other lifestyle changes that can help lower cholesterol include quitting smoking and losing excess weight.
9. Can Complementary Therapies Help Manage High Cholesterol?
According to Mayo Clinic, there are few natural products that have been shown to lower cholesterol, but some supplements may also be helpful. Just as omega-3 fatty acid–based drugs can help treat high cholesterol, so, too, can over-the-counter supplements containing this nutrient.
Foods such as salmon are also an excellent source of omega-3s. In addition, red yeast rice supplements may also lower LDL and total cholesterol, Schulman says. In fact, it contains a compound similar to what’s found in prescription statins. “A lot of people use red yeast rice because they don’t want to take a statin, but they’re basically taking a statin anyway,” he notes. “People who can tolerate red yeast rice, in terms of any side effects, can often tolerate statins.”
The only disadvantage of using supplements containing omega-3s or red yeast rice is that these products aren’t regulated by the FDA. “So, you have no idea how much of them you’re actually taking,” Schulman adds. You should always talk to your doctor before trying a supplement or other complementary therapy, to ensure it’s safe for you.
10. Might My Treatment Plan Change if I Experience a Complication, Such As a Heart Attack?
In general, cholesterol-lowering drugs lower your risk of heart attack or stroke, but they don’t eliminate it, according to the AHA. If you have a heart attack or stroke while taking statins, it’s possible the drugs alone aren’t working well enough to control your cholesterol. Or, you may have developed another health condition that increases your risk of heart disease, such as high blood pressure or type 2 diabetes. Either way, it’s likely that if your overall health changes, your doctor will want to reevaluate your treatment plan and either adjust your statin dose or change the medication you’re taking, Schulman says.