When Statins Aren’t Enough to Lower Cholesterol

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More than 100 million people in the United States struggle to keep their cholesterol in check. If a heart-healthy diet and regular exercise don’t achieve good control, doctors usually prescribe statin medications. They tend to be the first choice because they’re highly effective, but statins alone may not be enough for everyone. Fortunately, several medications can be added to statins for better cholesterol management.

Treating High Cholesterol: Why Statins Are a Great Start

Ideally, the level of LDL (“bad”) cholesterol in your blood should be below 100 mg/dL. Higher levels can lead to serious problems over time, including heart attack and stroke. Statins have been shown to reduce the liver’s production of cholesterol, lowering LDL (“bad”) cholesterol levels by up to 60%. That, in turn, lowers the risk of heart disease by up to 37% and the risk of stroke by up to 31%. If statins don’t get you to your goal at first, your doctor may recommend raising the dose or adding another type of medication.

Cholesterol and Statins: Add-On Therapies for Better Control

Statins don’t lower bad cholesterol enough for about half of the people who take them. Combining statins with another therapy is a common way to get better results. The four main types of add-on therapies are:

  • Bile acid sequestrants
  • Fibrates
  • Ezetimibe
  • Bempedoic acid

A bile acid sequestrant (BAS) works differently than statins. Instead of reducing the liver’s production of cholesterol directly, BSA resins bind to cholesterol-producing bile acids in your intestine, block them from entering your blood, and eliminate them as bodily waste. Essentially, the combination of a statin and a BAS attacks cholesterol in your body on two fronts, lowering bad cholesterol by up to 56%, about the same as some people achieve with statins alone. As an added bonus, a BAS may also help lower blood sugar, making it a popular choice for those who have both high cholesterol and diabetes. Examples include colestipol (Colestid) and colesevelam (Welchol).

Fibrates work more like statins in reducing the liver’s production of cholesterol, but they aren’t as effective taken alone. Fibrates are better than statins, however, at raising HDL (“good”) cholesterol levels, which helps clear bad cholesterol from your blood. Combining a statin with a fibrate covers two bases, lowering bad cholesterol by up to 46% while raising good cholesterol up to 34%. Taking some fibrates with statins can increase your risk of muscle damage, so your doctor will keep that in mind when choosing the right one for you. Common fibrates include gemfibrozil (Lopid) and fenofibrate (Tricor).

Ezetimibe (Zetia) is a newer medication that prevents cholesterol from being absorbed in your intestine, where it would then travel into your blood. Taken alone, ezetimibe lowers bad cholesterol by up to 18%. Taken with a statin, it lowers bad cholesterol up to 25%. There are drugs available that combine ezetimibe with statins, so you only need to take one pill.

Bempedoic acid (Nexletol) may be combined with statins for those at high risk of heart attack or stroke. It’s considered a targeted therapy, or biologic, because it works at the cellular level, blocking a specific enzyme the liver needs to make cholesterol. Bempedoic acid has been shown to lower bad cholesterol an additional 17% over statins alone in as little as 12 weeks.

Medication Plus Lifestyle Changes: It’s Never Too Late

It’s important to have regular conversations with your doctor about your treatment plan to monitor whether current medications are working as expected or a new direction is needed. Keep asking for help living heart-healthy as you go. Just because lifestyle changes alone have been unable to control your cholesterol doesn’t mean these changes aren’t worth making. Quitting smoking and losing weight can still reduce your risk of heart disease. Studies have shown that for every 1% you lower your cholesterol, you lower your risk of serious heart problems by 1%, too.

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Medical Reviewer: William C. Lloyd III, MD, FACS
Last Review Date: 2020 Aug 3
THIS TOOL DOES NOT PROVIDE MEDICAL ADVICE. It is intended for informational purposes only. It is not a substitute for professional medical advice, diagnosis or treatment. Never ignore professional medical advice in seeking treatment because of something you have read on the site. If you think you may have a medical emergency, immediately call your doctor or dial 911.
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