Medically Reviewed

High Cholesterol Treatment, Explained

If you have high cholesterol, treatment may involve a combination of lifestyle changes and medications. Here’s what to know.

Updated Jul 15, 2024

By

Wyatt Myers

Medical ReviewerAvinainder Singh, MBBS, MMSc

Our Experts: Suzanne Steinbaum, M.D.; Eric Brandt, M.D.; Eduardo Hernandez, M.D.

Suzanne Steinbaum, M.D.Director of Women’s Cardiovascular Prevention, Health and Wellness Mount Sinai Hospital New York, NY

Eric Brandt, M.D.Cardiologist and Lipidologist Michigan Medicine Frankel Cardiovascular Center Ann Arbor, MI

Eduardo Hernandez, M.D.Attending Cardiologist and Assistant Professor of Medicine Texas Heart Medical Group and Medical Director of Diagnostic Heart Center of St. Luke’s, Baylor College of Medicine Houston, TX

Symptoms of high cholesterol aren’t always visible, so it can be a massive surprise when your doctor suddenly tells you that you have it (or that your levels are borderline).

Cholesterol is the fatty, waxy substance that’s produced by the liver and moves through the bloodstream. It helps your body build cells, as well as produce needed vitamins and hormones.

If you’re wondering what a diagnosis of high cholesterol means for you, know there are a variety of treatments your doctor might recommend you try. These can range from minor to major lifestyle changes, to taking certain medications to help keep your cholesterol in check. We break down treatment for high cholesterol and all that’s involved so that you can take smart steps toward better health.

High cholesterol itself isn’t something you “cure” in the traditional sense, but it’s very manageable. It’s more about controlling it through lifestyle changes and sometimes medications. Lifestyle changes like a healthy diet, regular exercise, and not smoking can significantly lower cholesterol levels. Medications like statins can also help control cholesterol levels. So, while you may not permanently eradicate high cholesterol, you can effectively manage it to reduce the associated health risks. Regular monitoring and adjustments are usually necessary to maintain healthy cholesterol levels over time.

A variety of approaches and can nudge numbers into a healthy change. Your doctor will likely start with the least aggressive treatment first—recommending tweaks to your daily way of living. One huge bonus: These are the same principles that are known to be good for anyone wanting to live a long, healthy life. From upgrading your diet to getting more exercise, these are a few of the things you may discuss.

Limit Saturated Fats

Foods high in saturated fat have the greatest impact on raising cholesterol levels, according to the Mayo Clinic in Rochester, MN. Saturated fat is primarily found in red and processed meats, full-fat dairy, and a few plant-based foods:

• Beef

• Butter

• Cheese

• Coconut oil

• Cream

• Lamb

• Palm oil

• Pork

• Poultry with the skin

• Salami and other cured deli meats

• Some baked goods and fried foods

• Whole or 2 percent dairy

It’s best to cap your saturated fat intake to 5 to 6% of your daily calories, according to the American Heart Association. That amounts to 13 grams of saturated fat per day on a 2,000-calorie diet.

Curb Trans Fat

Trans fats, which used to be plentiful in packaged foods like cookies, crackers, and margarine under the ingredient name “partially hydrogenated oil,” are a major contributor to high cholesterol. Although the U.S. Food and Drug Administration has banned its widespread use in packaged foods, trace amounts of trans fats are still permitted. The package label can state “0 trans fat” even when the food has up to 0.5 grams per serving, and those potential amounts of trans fat can add up, so check ingredient lists.

Trans fats may still be found in the following types of foods:

• Baked goods

• Fried foods

• Frozen pizza

• Microwave popcorn

• Non dairy coffee creamer

• Refrigerated dough

• Shortening

• Stick margarine

The goal is to get your intake of trans fats as close to zero as possible.

Enjoy Eggs, If You Want

Interestingly, eggs, which have the most dietary cholesterol of common foods and have long been the subject of debate around whether they’re healthy or unhealthy, don’t raise cholesterol levels — at least not for everyone. Current research has shown that for three out of four people, eating up to seven eggs a week will not increase the risk of heart disease. However, because studies are ongoing, the Mayo Clinic suggests limiting egg intake to around one large egg a day might be best. You can also remove the yolks and eat just the egg whites if you want the protein without cholesterol.

Eat More Omega-3s

Foods rich in omega-3 fatty acids—such as walnuts, flaxseeds, and fatty fish—have heart-healthy benefits. They can lower triglycerides, raise HDL cholesterol, reduce blood pressure, and reduce the risk of dying from heart disease, according to a recent analysis in the British Medical Journal.

Fish is a great protein source and the American Heart Association recommends eating two 3.5-ounce servings of fish every week. Fish high in omega-3 fatty acids include:

• Albacore tuna

• Herring

• Mackerel

• Salmon

• Sardines

Be sure to have your fish baked, grilled, or very lightly sautéed—not fried and/or breaded.

Fill Up on Fiber

Both soluble and insoluble fiber are all-stars for health, but soluble fiber is especially helpful for high cholesterol. Soluble fiber isn’t absorbed in the intestine, so it binds to LDL cholesterol there and removes it from the body as waste, according to the National Lipid Association. Getting 5 to 10 grams of soluble fiber a day, along with drinking plenty of water, can lower total and LDL cholesterol levels by as much as 11 points. Good choices for soluble fiber include:

• Apples

• Bananas

• Barley

• Beans

• Broccoli

• Brussels sprouts

• Carrots

• Green beans

• Oatmeal

• Pears

• Quinoa

• Sweet potatoes

Fuel Up on “Whole” Foods

Eating a healthy diet rich in vegetables, fruits, whole grains, and lean sources of protein rather than fatty, sugary, and processed foods helps with weight and overall health, along with improving cholesterol levels.

Making all of these dietary changes may seem like a tall order, but adopting even one small change at a time can make a big difference. Once you’ve mastered one healthy diet tweak, move on to the next. If you need help putting all this advice into action, ask your healthcare provider to recommend a registered dietitian that you can work with to reduce cholesterol levels even more.

Break a Sweat

Regular exercise is an excellent idea for everyone, but especially you have high cholesterol. Exercise not only lowers LDL cholesterol and triglycerides, it even raises levels of good HDL cholesterol — that’s the trifecta of cholesterol benefits. We still don’t know exactly how exercise works this magic, but it’s thought to increase certain enzymes that boost HDL cholesterol as well as prompting muscles to draw on fats for energy, lowering the amount of fats in the bloodstream, according to a study in Sports Medicine.

Aim for 150 minutes of moderate exercise or 75 minutes of vigorous exercise, spread across every week, but more minutes and/or more vigorous activity is even better, if you’re healthy enough to handle it. Talk to your health care provider about any concerns before undertaking an exercise program on your own. If you need a place to start, a daily walk still offers benefits. Add more challenging activities to your workout schedule as your stamina increases.

Lose a Little Weight

If you can successfully make the diet and exercise changes above, this third recommendation should come naturally (though not necessarily quickly). Carrying just a few extra pounds can contribute to high cholesterol, the Mayo Clinic notes, so map out a plan to reach the ideal weight for your height and frame. You can start by determining your body mass index (BMI) by using a BMI calculator.

If losing weight takes longer than you’d like, try not to get frustrated. Stay consistent in your food choices and exercise routine — eventually your patience will pay off. Think of your ideal weight as a long-term goal, one you can ultimately reach by aiming for small losses along the journey. Losing 5 to 10% of your body weight will start to lower total cholesterol, LDL cholesterol, triglyceride levels, and other risk factors for heart disease.

Cut Out Tobacco and Curb Alcohol

Smoking is bad in more ways than can be counted, but one definitive result is that it lowers levels of good HDL cholesterol, notes the Cleveland Clinic. How so? The oxidative stress caused by cigarette smoke has a negative effect on both the amount and function of HDL cholesterol, robbing it of its heart-protective quality. That’s yet another reason to look into a smoking cessation strategy.

The relationship between drinking and cholesterol levels is a little more complicated. Some research has shown that moderate alcohol consumption can actually give good HDL cholesterol levels a boost. Don’t look at this as permission to glug with abandon though. The suggested upper limits, even for those at peak health, are two drinks a day for men aged 65 and younger and one drink a day for women or men over 65, according to the Mayo Clinic.

Even small changes to your health can have a big impact over time. Don’t feel like you have to do everything from the list above at once. Just focus on one heart-healthy, cholesterol-lowering habit at a time. You and your doctor will see how your numbers change as a result.

When lifestyle changes alone are simply not effective enough for managing cholesterol levels, medications will be added to the plan. If you have a family history of high cholesterol or your levels are high or very high, they may be prescribed from the start along with lifestyle changes (which are still vital!).

Statins

A statin is usually the first cholesterol medication prescribed. Statins work by preventing excess cholesterol from forming in the liver in the first place. They have been shown to lower LDL cholesterol and triglycerides, raise HDL cholesterol, and reduce the risk of heart attack and stroke. According to the Jupiter Trial, which looked at the effects of statins in a group of more than 15,000 patients, statins lowered LDL cholesterol by as much as 50 percent, reduced the risk of heart attack by 54 percent, and lowered the risk of stroke by 48 percent.

Common statins include:

• Altoprev (lovastatin)

• Crestor (rosuvastatin)

• Lipitor (atorvastatin)

• Zocor (simvastatin)

Possible side effects of statins include:

• Constipation

• Diarrhea

• Increased blood sugar levels

• Muscle pain and soreness

• Nausea

• Stomach cramps

Symptoms are typically mild and go away over time.

Statins are not recommended for pregnant women or people with liver disease. It’s important to note that statins don’t work for everyone and may not be able to lower cholesterol levels enough—you might benefit from an additional medication.

Bile Acid Sequestrants

Also called bile acid resins, these lower cholesterol in a unique way. Bile is an acid produced by the liver, and is critical for digestion. When you take bile acid sequestrants, however, the medications bind to bile and render it ineffective. This causes the liver to use cholesterol to make more bile, thus keeping the excess cholesterol out of the bloodstream, and lowering cholesterol levels.

If you experience severe side effects from statins or don’t see a significant reduction in cholesterol from statins alone, your doctor might prescribe a bile acid sequestrant. These drugs lowered LDL cholesterol by more than 20 points and appeared to significantly lower the risk of heart disease, a 2015 review article of studies with more than 7,000 patients noted.

Bile acid sequestrants include:

• Colestid (colestipol)

• Prevalite (cholestyramine)

• Welchol (colesevelam)

Possible side effects include:

• Bloating

• Constipation

• Gas

• Heartburn

• Nausea

Cholesterol Absorption Inhibitors

These drugs prevent the small intestine from absorbing fats in the food you eat and releasing them into the bloodstream. The result? More cholesterol leaves the body as waste rather than returning to your bloodstream. CAIs have been shown to reduce LDL cholesterol by 18 to 25%. You may be prescribed a CAI along with a statin if the statin doesn’t lower your cholesterol to an acceptable level on its own. The most prescribed CAI is Zetia (ezetimibe).

Possible side effects include:

• Fatigue

• Muscle soreness

• Stomach pain

Some people develop a hypersensitivity to the medication and must discontinue it.

PCSK9 Inhibitors

This medication is for people with a genetic condition that causes very high LDL levels, as well as those with a history of heart disease. PCSK9 inhibitors work by binding to a protein in the liver and preventing the release of excess LDL cholesterol into the bloodstream. PCSK9 inhibitors are given by injection from your doctor every two to four weeks. Some research indicates that they can reduce LDL cholesterol by as much as 50 to 70%.

PCSK9 inhibitors include:

• Praluent (alirocumab)

• Repatha (evolocumab)

Possible side effects include:

• Hives

• Problems at the injection site

• Rash

• Swelling of nasal passages

Some people develop a hypersensitivity to the medication and must discontinue it.

Small Interfering RNA (siRNA) Therapy

This novel medication class for high cholesterol treatment uses RNA interference to increase the liver’s ability to remove harmful LDL cholesterol from the blood. It works by preventing the production of PCSK9 proteins that lead to the degradation of LDL receptors. Protecting these receptors allows for greater removal of LDL particles from the blood, thus lowering your level of “bad” cholesterol.

Recent studies have determined siRNA therapy to be safe and well-tolerated. Clinical trials found siRNA therapy reduced LDL cholesterol levels by approximately 50% in study participants.

Currently, the only siRNA therapy approved to treat high cholesterol is Leqvio (inclisiran). The medication is given by injection under the skin twice a year (after an initial three-month second dose). It is generally prescribed after other medications fail to deliver results. Your doctor may prescribe siRNA therapy is addition to statins to help you lower your high cholesterol.

Possible side effects include:

• Diarrhea

• Urinary tract infection

• Problems at the injection site, like swelling or redness

Triglyceride Medication

If you have high triglycerides in addition to high total cholesterol or high LDL cholesterol, or if only triglycerides are high, your doctor may prescribe a medication aimed at lowering triglycerides. These include fibrates, niacin, and prescription omega-3 fatty acids; all three have been shown to decrease triglycerides and possibly increase HDL cholesterol as well.

Fibrates

These medications lower levels of VLDL cholesterol (the source of triglycerides) produced by the liver. They also speed up its removal from the bloodstream. They’re effective and can reduce triglycerides by 25 to 50 percent, but you’ll need regular monitoring if you also take statins, as they can increase the risk for certain statins side effects. They’re not for people with liver, kidney, or gallbladder issues.

Fibrate medications include:

• Antara, Lipofen (fenofibrate)

• Lopid (gemfibrozil)

Possible side effects of prescription fibrates include:

• Headaches

• Nausea

Niacin

Prescription-strength niacin, one of the B vitamins, can reduce the liver’s production of both VLDL and LDL cholesterol and improve HDL. It can lower triglycerides 20-50%. However, it’s not meant for people with heart disease, diabetes, liver problems, or bleeding problems, among other medical conditions.

Niacin medications include:

• Niacor

• Niaspan

Possible side effects include:

• Flushing

• Increased blood sugar levels

• Itching

• Upset stomach

Prescription Omega-3 Fatty Acids

Omega-3s are available in over-the-counter supplements and prescription formulas, but only the prescription variety is regulated by the FDA. Over-the-counter omega-3 fatty acids, along with dietary changes, may be enough to help you control mildly high triglycerides, while prescription omega-3 fatty acids, which contain 4 grams of EPA or EPA and DHA, are FDA-approved for very high levels of triglycerides (above 500 mg/dL), though an American Heart Association advisory panel found them also effective for people with high levels, between 200-499 mg/dL. Prescription-strength omega-3s can cut triglyceride levels by up to 30%.

Prescription omega-3 fatty acids include:

• Lovaza

• Vascepa

Possible side effects include:

• Indigestion

• Bleeding

• Reduced blood sugar control

Bempedoic Acid

Taken orally, this medication is used to lower "bad" cholesterol in the blood. It is particularly useful for adults who have atherosclerotic cardiovascular disease (ASCVD) or heterozygous familial hypercholesterolemia (HeFH) and need additional lowering of LDL-C.

A prescription bempedoic acid includes:

• Nexletol

Possible side effects include:

• Muscle spasms

• Back pain

• Anemia

• Increased liver enzymes

There are two types of cholesterol, and they’re about as far apart as you can get:

HDL (high-density lipoprotein) and LDL (low-density lipoprotein)

• HDL is often referred to as “good” cholesterol. It grabs up LDL in the bloodstream and carries it back to the liver to be processed and removed as waste.

• LDL, the bad kind, can build up in artery walls if levels become too high. Eventually, this buildup can set the stage for heart disease, heart attack, or stroke.

A third type, very low-density lipoprotein (VLDL) cholesterol, carries triglycerides through the bloodstream. Triglycerides are fats derived almost entirely from the foods we eat. High levels of these fats in your bloodstream can cause problems similar to LDL cholesterol.

The routine blood test that checks for high cholesterol, called a lipid profile or lipid panel, reports your results as four components:

• Total cholesterol (the sum of your LDL, HDL, and 20% of your triglyceride level)

• LDL cholesterol

• HDL cholesterol

• Triglycerides

Doctors typically suggest keeping total cholesterol below 200 mg/dL and LDL cholesterol below 100 mg/dL, but if you have existing heart problems, your LDL cholesterol should be even lower—the goal is below 70 mg/dL. That’s because when levels are higher, those extra fats can start getting deposited in your arteries, causing blockages that could lead to heart disease, heart attack or stroke.

Here are the numerical ranges for each component. Your doctor interprets your numbers to determine if you have high cholesterol (or high triglycerides).

Total Cholesterol:

• Below 200 mg/dL is the goal.

• 200-239 mg/dL is borderline high = time to take action.

• 240 mg/dL and above is high = a comprehensive plan is a must.

LDL Cholesterol:

For people without heart disease or an elevated risk of developing heart disease:

• Below 100 mg/dL is optimal.

• 100-129 mg/dL is near optimal.

• 130-159 mg/dL is borderline high.

• 160-189 mg/dL is high.

• 190 mg/dL and above is very high.

For people with heart disease or coronary artery disease:

• Below 70 mg/dL is optimal.

• 70-99 mg/dL is near optimal.

• 100-159 mg/dL is high.

• 160 mg/dL and above is very high.

HDL Cholesterol:

• Below 40 mg/dL for men and below 50 mg/dL for women is considered poor.

• 40-59 mg/dL in men or 50-59 mg/dL in women is considered good.

• 60 mg/dL and above is ideal for everyone.

Triglycerides:

• Below 150 mg/dL is optimal.

• 150-199 mg/dL is borderline high.

• 200-499 mg/dL is high.

• 500 mg/dL and above is very high.

Your doctor will consider your medical history and gender along with your various numbers to determine whether you have high cholesterol and how to manage it.

Left unchecked, excess cholesterol not only continues to accumulate in the bloodstream, but also ultimately lines the walls of the arteries in the form of deposits called plaque.

These plaques can narrow the arteries and set the stage for life-threatening events, such as heart attack and stroke—especially when cholesterol levels range from borderline high to very high.

Though the goal of high cholesterol treatment is broadly to “lower cholesterol,” it’s more nuanced than that. While you want to lower total cholesterol levels as well as levels of bad LDL cholesterol and triglycerides, you also want to raise levels of good HDL cholesterol because it’s protective.

The best high cholesterol treatment for you will be based on a variety of personal factors. These include:

• Whether your cholesterol is borderline high, high, or very high

• Whether you have a personal or family history of high cholesterol and heart disease

• Your weight

• Whether you smoke

There’s not one solution for everyone. If your cholesterol is borderline high and you have no other risk factors, lifestyle changes alone may be enough to move the needle. If the lifestyle changes aren’t making the desired difference in your cholesterol levels, your doctor may begin recommending cholesterol medications.

If you have a strong family history of high cholesterol or have several risk factors for heart disease, your doctor may recommend a combination of medication and healthy lifestyle changes from the start.

While lowering high cholesterol can feel overwhelming, requiring you to adjust some of your daily habits, along with perhaps taking a new medication, know that small changes over time can have a profound effect on your numbers—and your entire health outlook. Adapt new habits one at a time, stay consistent, and check in with your doctor regularly to see what else might be needed. Eventually, your new way of living won’t feel like work, but rather simply your way of life.