Heart disease kills nearly a million Americans a year, and cholesterol-lowering medications are frequently prescribed to individuals at high risk. Yet one study found that about 14 percent of patients never filled their prescriptions and 13 percent never took the drugs they brought home. Over a five-year period, only 26 percent of patients took their medicine regularly.
Doctors, of course, don’t take the prescription of cholesterol-lowering medications lightly. When cholesterol is high, the patient is usually advised to first make lifestyle changes–a lower fat diet, exercise and weight loss. Even after the drugs are started, diet and exercise are still considered important components of treatment. The medications generally produce more dramatic changes than can be accomplished by most individuals through lifestyle changes alone. But they are not magic.
The role of cholesterol as a risk factor for heart disease was established several decades ago. The National Cholesterol Education Project recommends that total cholesterol should be lower than 200 milligrams/deciliter and LDL for those without high risk, less than 130 mg/dL. HDL, the good cholesterol, should be greater than 40 mg/dL, and triglycerides, under 150 mg/dL.
In practice, doctors look at a patient’s cholesterol profile in the context of other risk factors such as smoking, high blood pressure, family history, obesity and a diagnosis of diabetes. If your overall risk of having a heart attack or stroke is low to moderate, your doctor may not prescribe cholesterol-lowering medications until the numbers on your test become extreme. On the other hand, some individuals considered very high risk (such as those who have suffered a previous heart attack or persons with diabetes) may be asked to get LDL under 100 or even lower.
To produce the desired effects with the fewest desirable side effects, doctors can choose one or more medications from several types available.
STATINS such as Crestor, Lipitor, Lescol, Mevacor, Pravachol and Zocor are the most effective and the most frequently prescribed drugs for lowering total and LDL cholesterol. They work by slowing the production of cholesterol in the liver and increasing the liver’s ability to remove cholesterol already in the blood.
One statin, Baycol, was taken off the market because it was linked to kidney failure and severe muscle inflammation. These effects can occur, although they’re rare, with other statins so it’s important for a doctor to monitor treatment. Unusual or unexplained muscle aches or brown urine–a sign of muscle inflammation–should be reported immediately.
BILE ACID SEQUESTRANTS include Questran, Questran Light, LoCholest, Prevalite, WelChol and Colestid. They have a record established over 30 years of use and are capable of lowering LDL by 10 to 20 percent. For a greater effect, they are often used in combination with statins.
CHOLESTEROL ABSORPTION INHIBITORS such as Zetia and Vytorin work by blocking the absorption of cholesterol from the small intestine. These are the newest class of lipid-lowering drug, first approved in 2002. They are useful for persons who cannot take a statin or cannot tolerate a high enough dose. A pill containing both Zocor and Vytorin has been found to lower LDL by as much as 60 percent.
FIBRATES are usually indicated for persons with extremely high levels of triglycerides (500 mg/dL or higher). These drugs include Lopid, Lofibra and Tricor.
NIACIN is usually the best choice for raising abnormally low levels of HDL cholesterol. It can also lower triglycerides and LDL. To produce these effects, relatively large doses of niacin are needed. And while some preparations are available without a prescription, they should be used only under a doctor’s direct supervision.
Three landmark studies published between 1994 and 1996 established that cholesterol-lowering medications were effective in reducing the number of heart attacks, strokes and heart-related deaths. Many of these drugs are now among the most widely prescribed in the country, and there’s good reason for patients to take full advantage of the benefits they offer.
Michelle Herbert Thomas, PharmD, CDE
Clinical Director
