Medicines for People with Cholesterol Problems
by Phillip Treadwell, PharmD

This article will focus on cholesterol problems other than elevated triglyceride levels. The major problems that can occur with cholesterol are a high LDL or bad cholesterol, a low HDL or good cholesterol, and a combination of these two problems. There are a few drugs available to help with these problems and each has its distinct role. Hopefully, this article will give you some insights into the advantages and disadvantages of each of these agents.

The major class of medicines for cholesterol problems is the statins or HMG COA reductase inhibitors. Some members of this class have definitive clinical studies that prove that people who have cholesterol problems are less likely to die if they take them. This class includes: simvastatin (Zocor®), pravastatin (Pravachol®), atorvastatin (Lipitor®), lovastatin (Mevacor®) and fluvastatin (Lescol®). These agents are best for lowering elevated LDL, but may give some help with low HDL. However, these agents do have some disadvantages. They can rarely cause muscle damage that can be painful, or even lead to kidney damage. This may be more likely to occur in people who exercise vigorously. Serious liver damage is another rare side effect of these agents.

Another major class of cholesterol drugs is the bile acid sequestrants. Examples are colesevelam (Welchol®) and cholestyramine (Questran®). These drugs lower LDL to a somewhat lesser extent than statins. They may also help raise HDL slightly. However, they can actually raise triglyceride levels in the blood. They are not absorbed into the bloodstream, but, instead, bind cholesterol precursors in the intestines and prevent their absorption. Since they are not systemically absorbed, they generally do not cause problems outside the intestines. The major drawbacks of these agents are that they are bulky and hard to take. You must either drink a glass of moderately palatable liquid or swallow many large pills to get in the necessary dose. These agents can also cause intestinal obstruction if taken with an inadequate amount of water.

Niacin is a good all around cholesterol lowering agent. It can improve LDL and HDL cholesterol and lower triglycerides significantly (better than statins, less than fibrates). An important issue with niacin is product selection. High doses of sustained release niacin can cause severe liver damage in a large percentage of people taking it. Therefore, if you take niacin in high doses - 500mg per day or more - you should either select immediate release nicotinic acid (not niacinamide) or Niaspan®. Niaspan is a prescription product which is only available through your physician. Immediate release niacin is inexpensive, but must be taken three times per day. It can also cause an uncomfortable flushing sensation in most people who take it. Niaspan costs more but causes less flushing. Taking an aspirin 30 minutes before you take niacin can help with flushing symptoms. Niacin should not be used in high doses without the supervision of a physician.

Fibrates include gemfibrozil (Lopid®) and fenofibrate (Tricor®). These are the best agents for lowering triglycerides in the blood. They are good at improving HDL cholesterol, but are not as helpful with high LDL. Gemfibrozil is cheap, but fenofibrate is not. Fenofibrate is more potent than gemfibrozil for most people and fenofibrate can be taken once a day, while gemfibrozil must be taken twice a day. Both of these agents can cause severe interactions with some other cholesterol lowering drugs.

The thing to remember about cholesterol medicines is that, even though they have a number of side effects, many of them are proven to save lives. Careful selection of agents for a specific patient is vital to maximize benefit and minimize risk. Please talk to your physician or pharmacist about these medicines if you have any questions. Click here for information on cholesterol lowering foods.

 

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