When Your Cholesterol Treatment Isn't Working


Controlling high cholesterol can be a challenge. Piedmont Healthcare Cardiologist Bukola Olubi, MD, explains how she guides her patients through the treatment process.

A key part of my job as a cardiologist is helping patients realize how dangerous high cholesterol is in terms of its contribution to the number one killer of Americans, which is heart disease, followed by stroke. It is so important to reduce your cholesterol to prevent this risk.

High cholesterol can be caused by a variety of factors, including your family history, but it’s primarily based on what you eat. Your body makes all the cholesterol it needs, so any extra cholesterol you have comes from your diet. And if you eat too much saturated fat and other fatty foods, then you’re likely to have elevated cholesterol levels. Some of my patients have high cholesterol due to genetic factors; they have what’s called familial hypercholesterolemia.

We have lots of options for lowering high cholesterol, including lifestyle changes and various medications, but some patients need to try several different things to finally find something that works.

Usually the first line of treatment is a medication called a statin. Statins are known to be the most effective drug we have right now for prevention of coronary artery disease, heart attacks, and strokes. Currently, there are several statins available to lower cholesterol:

Although statins are the first-line treatment, it’s not uncommon for my patients to experience side effects with statins that may be intolerable. Statins can cause muscle aches, digestive problems, and other side effects that lead my patients to look for alternatives.

If you’re on the highest dose of statin you can tolerate and your cholesterol levels are still high, then I’ll add something else, like a cholesterol absorption inhibitor. Right now, the only cholesterol absorption inhibitor on the market is ezetimibe (Zetia). I might combine ezetimibe with the statin and see if we’re able to reach your goal numbers that way.

I might also try bile-acid-binding resins, also known as bile acid sequestrants. Currently, the Food and Drug Administration (FDA) has approved a few bile-acid-binding resins to treat high cholesterol:

  • Cholestyramine (Prevalite, Questran)

  • Colesevelam (Welchol)

  • Colestipol (Colestid)

Another alternative to statins is a class of drugs called PCSK9 inhibitors. They have been shown to lower cholesterol by as much as 70%, which is quite impressive. The FDA has approved two PCSK9 inhibitors so far:

  • Alirocumab (Praluent)

  • Evolocumab (Repatha)

Candidates for PCSK9 inhibitors must have tried the maximally-tolerated dose of statins before insurance companies will cover them. But for those patients who try everything but still can’t get cholesterol down, and for those patients who have hypercholesterolemia, PCSK9 inhibitors can be an effective choice.
Fortunately, there are many options available if your current cholesterol treatment isn’t doing the trick. The most important thing I try to convey to my patients is that their cholesterol medications certainly won’t work if they’re not taking them. If the side effects of statins or other drugs are intolerable, don’t just stop taking them; call your doctor and discuss different options that may work for you to get your cholesterol down to a healthy level.

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THIS CONTENT DOES NOT PROVIDE MEDICAL ADVICE. This content is provided for informational purposes and reflects the opinions of the author. It is not a substitute for professional medical advice, diagnosis or treatment. Always seek the advice of a qualified healthcare professional regarding your health. If you think you may have a medical emergency, contact your doctor immediately or call 911.