High Cholesterol
How is it treated?
Treatment of high cholesterol is aimed at lowering the low-density lipoproteins (LDL) or "bad cholesterol," lowering triglyceride levels, and increasing the high-density lipoproteins (HDL) or "good cholesterol." Decreasing total cholesterol by 10% can result in a 30% reduction in coronary heart disease incidence. For every 1% decrease in LDL (bad cholesterol levels), heart disease rates drop 2%. On the other hand, for every 1% decrease in HDL, there is a 2 to 3% increase in the risk of heart disease.
A low fat/low cholesterol diet and exercise are essential in helping to lower cholesterol and to maintain low cholesterol levels. While drug therapy is often needed to lower cholesterol, diet and exercise are additionally recommended to help the drug therapy lower and control cholesterol levels. Patients with established cardiac disease and multiple risk factors (metabolic syndrome, diabetes, or smoking) are sometimes given more intense lifestyle changes. To learn more about diet and exercise, click on the "Helping Yourself" section above.
The decision to start a patient with dietary therapy or drug therapy is usually based on a patient's LDL cholesterol levels, presence of heart disease, and risk factors. Your doctor should calculate your "10-year risk" (also known as a ?Framingham Risk?) for developing heart disease and use that risk estimation to decide if and when to start cholesterol-lowering therapy either through dietary modifications or medications.
Your goal LDL level will also depend on the above-mentioned factors. The following table illustrates guidelines that will aid your health care provider in making these decisions.
|
Patient Category |
LDL Level |
LDL Goal |
| Without heart disease and with less than 2 risk factors |
LDL greater than 160 mg/dL start diet therapy + exercise
LDL greater than 190 mg/dL start drug therapy (160 to 189 mg/dL: LDL-lowering drug optional) |
less than 160 mg/dL |
| Without heart disease and with 2 or more risk factors with a 10- year risk less than 10%* |
LDL greater than 130 mg/dL start diet therapy + exercise
LDL greater than 160 mg/dL start drug therapy |
less than 130 mg/dL |
| Without heart disease and with 2 or more risk factors with a 10- year risk 10 to 20%* |
LDL greater than 130 mg/dL start diet therapy + exercise
LDL greater than 130 mg/dL start drug therapy (LDL 100 to 129 mg/dL: drug therapy optional) |
less than 130 mg/dL (optional goal: less than 100 mg/dL) |
| With heart disease |
LDL greater than 100 mg/dL start diet therapy + exercise
LDL greater than 100 mg/dL start drug therapy(LDL less than 100 mg/dL: drug therapy optional) |
less than 100 mg/dL(optional goal: less than 70 mg/dL**) |
| With Type 2 Diabetes Mellitus |
LDL greater than 100 mg/dL start diet therapy + exercise
LDL greater than 100 mg/dL start drug therapy(LDL less than 100 mg/dL: drug therapy optional) |
less than 100 mg/dL(optional goal: less than 70 mg/dL**) |
*10-year risk calculators are available at on DrugDigest under the ?Interactive Tools? tab.
**In patients that are ?very high risk? (those with established heart disease and multiple major risk factors including diabetes, metabolic syndrome, and current smokers), a more aggressive LDL goal of less than 70 mg/dL may be encouraged
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Drug Therapy
For the initial drug treatment of hypercholesterolemia, HMG-CoA reductase inhibitors (also called "statins") are often used because of their effectiveness and low incidence of side effects. Currently, six statin drugs are available. The choice of which to use will depend on how much cholesterol reduction you need, doctor's preference, and prescription insurance benefits. Studies have shown that certain high risk patients, such as those with diabetes, benefit from cholesterol lowering therapy with statins. To learn more about how the statins compare to each other, visit our "Compare Drugs" section.
Other drug classes that may be used to treat hypercholesterolemia include bile acid resins, nicotinic acid, fibric acid derivatives, and cholesterol absorption inhibitors. Some of these drugs can be used in combination if a further reduction in cholesterol is needed.
If you specifically have elevated triglyceride levels, a fibric acid derivative or niacin may be most effective for you. Both medications work by decreasing the liver's production of triglycerides. Additionally, fibric acid derivatives (or "fibrates") such as gemfibrozil also increase HDL-C (good cholesterol) production.
Bile acid resins are mainly used in young adults with hypercholesterolemia or in combination with another cholesterol-lowering medication. These drugs interact with several medications including carbamazepine, gemfibrozil, and thyroid medication as well as several blood pressure medicines and antibiotics. These medications should be administered at least 1 to 4 hours before or 4 to 6 hours after these cholesterol lowering agents. Please evaluate your medication list on our Drug Interaction Checker.
Cholesterol absorption inhibitors are a new class of cholesterol lowering agents and work together with statins to lower cholesterol. This class of drugs works to lower blood cholesterol levels by absorbing excess cholesterol (from foods) in the intestines and thus blocking cholesterol's entry into the bloodstream. In a study published by the Mayo Clinic in May 2005, it was found that the addition of Zetia (a cholesterol absorption inhibitor) to statin therapy may cause a further reduction in a patient?s cholesterol levels. It is thought that this reduction may be the result of the two drugs working together but at different areas of the cholesterol production pathway. In fact, one pharmacy manufacturer combined Zetia with a commonly used statin known as Zocor. This combination product is called Vytorin. However, as with any medications it is recommended that you ask your doctor if this drug or combination of drugs is appropriate for you.
To learn more about these drug classes, click on the links below.
Drug classes used to treat High Cholesterol Antilipemic Agents Bile Acid Resins Cholesterol Absorption Inhibitors Combination HMG-CoA Reductase and Cholesterol Absorption Inhibitors Fibric Acid Derivatives HMG-CoA Reductase Inhibitors
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How is it treated?
