New Options for Decreasing Bad Cholesterol
Judi Ebbert, PhD, MPH, RN | Sept 20, 2016 Nov 20, 2016
Good vs. bad cholesterol
Cholesterol supports healthy cells and builds hormones and vitamins, but eating too many saturated fats causes the liver to overproduce cholesterol. “Good” cholesterol (HDL) carries cholesterol to the liver for removal from the body. “Bad” cholesterol (LDL) enters the bloodstream and forms deposits in arterial walls, increasing risk for a heart attack or stroke.
Know your numbers!
A blood test detects cholesterol levels. High LDL requires lifestyle changes such as eating less saturated fat, getting more exercise, and losing weight. A personal or family history of heart disease and diabetes may signal the need for lifestyle changes and medication. Finding the right regimen may involve trial and error, and that’s okay. The goal is low LDL and optimal quality of life.
Statins are the drug of choice because they work well. In addition, there is a growing array of non-statin alternatives. The American College of Cardiology (ACC) and American Heart Association (AHA) reviewed randomized clinical trials on non-statins. In 2016 they published a report on the use of non-statin therapies. The following frames explain statins and non-statin alternatives.
Statins stop the liver from making cholesterol, which makes it pull LDL from the bloodstream. Statins also reduce arterial inflammation and stabilize plaques. Approved statins include at least seven types—all have “statin” in their names, like lovastatin and pravastatin. Side effects may include memory loss, high blood sugar, type 2 diabetes, and muscle pain. Liver injury is possible but very rare.
This non-statin medication inhibits the action of a specific protein, reducing the amount of cholesterol absorption in the small intestine. Ezetimibe can be taken alone or with a statin. Adverse effects may include upper respiratory infection, diarrhea, joint pain, sinusitis, and pain in hands and feet. If taken with a statin, side effects may include cold-like symptoms and muscle pain.
PCSK9 is an enzyme that blocks the receptors that pull LDL out of blood. Remember that oil (LDL) and water (blood) don’t mix. PCSK9 inhibitors, which allow receptors to pull LDL from blood, include evolocumab and alirocumab. They are given alone or with statins. Adverse effects may include cold-like symptoms, upper respiratory infection, influenza, injection site reactions, and back pain.
Bile Acid Sequestrants (Binders)
Bile-acid binders prevent them from going into the bloodstream. As bile acids decrease, the liver generates more LDL receptors, which pull LDL out of the bloodstream. Cholestyramine, colestipol, and colesevelam are given as an adjunct to improved diet and exercise, and the last may be used with a statin. Possible adverse effects are constipation, indigestion, and nausea.
Mipomersen is injected weekly in persons with confirmed familial hypercholesterolemia (HoFH). This drug targets a protein encoded by the APOB gene. Adverse effects may include injection site reactions, flu-like symptoms, nausea, headache, and elevated ALT, which can indicate liver injury. Mipomersen is available only to those with confirmed HoFH.
Lomitapide is an adjunct to a low-fat diet for persons with HoFH. The drug inhibits microsomal triglyceride transfer protein (MTP/MTTP), blocking components needed to make cholesterol. The result is less LDL in the bloodstream. Side effects may include diarrhea, nausea, vomiting, indigestion, and abdominal pain. Lomitapide is available only to those with confirmed HoFH.
Niacin (vitamin B3)
Niacin is an essential nutrient that can boost good HDL cholesterol and lower triglycerides, another blood fat of concern. Niacin does little to lower bad LDL cholesterol. It is given with statins to achieve ideal levels of HDL, LDL, and triglycerides. Side effects include itching, flushing, and stomach upset. Too much niacin can cause liver problems, high blood sugar, and hormone changes.
Phyto means plant, and sterol is a type of steroid. Phytosterols can lower LDL levels. The FDA reports that 2 grams per day can reduce LDL. Sources include plants, unrefined plant-derived lecithin, nuts, seeds, legumes, wheat germ, whole grains, fruits, and vegetables. Note that too many phytosterols may cause bloating, diarrhea, and constipation.
Where do you start?
See a board-certified doctor to obtain cholesterol levels and determine risk for heart attack and stroke. The exam will include blood work and personal and family history. The doctor’s visit is the best time to ask questions, so make a list ahead of time and take notes during the consultation. Take medicine as directed. If side effects occur, tell your doctor before stopping the medication.
What’s the take-away?
High LDL increases risk for heart attack and stroke. Cholesterol levels are measured by a simple blood test. When LDL exceeds the normal range, it’s important to partner with a doctor to devise a strategic plan for lifestyle changes and, if necessary, medication. Cholesterol-lowering agents, particularly those that target LDL, have come a long way, giving people more options than in the past!