Improving your diet and increasing exercise are the two most important and cost-effective ways you can fight high cholesterol. Limiting your intake of foods high in fat or cholesterol is an essential step in guarding against heart disease. Regular exercise also helps keep cholesterol in check. However, lifestyle changes may not always reduce cholesterol to a healthy level. If this is your situation, cholesterol medications may be added to your therapy. Without these drugs, many more people would suffer heart attacks, stroke and other harmful results of cardiovascular disease.
As part of understanding the cholesterol medications now available, you need to know about different types of cholesterol. Often when people talk about cholesterol levels in the blood, they are referring to total cholesterol. Total cholesterol can be broken down into LDL (low-density lipoprotein) and HDL (high-density lipoprotein). For an idea of what normal blood levels of cholesterol should be, see table 2.
The 'bad' cholesterol is the LDL cholesterol and the 'good' cholesterol is the HDL cholesterol. Remember, you want HDL to be high (H=high) and LDL to be low (L=low). LDL carries cholesterol from the liver to the various body cells. On the way, however, the LDL cholesterol can be left on the walls of important arteries. This slowly narrows the blood vessel, and in time may block it. When these fatty deposits build up in the blood vessels of the heart it can lead to a heart attack. HDL carries cholesterol back to the liver to be broken down and removed by the body. As result, HDL helps rid the body of the fatty deposits that threaten to block important blood vessels.
After looking at your blood test, your doctor may also discuss triglycerides, another type of fat found in the blood. A high triglyceride level is also a risk factor for cardiovascular disease. As with cholesterol, high triglycerides can be reduced by medications if lifestyle changes are not working well enough. Recent research suggests that other substances such as lipoprotein-a and homocysteine may also play a role in the prevention of heart disease.
Once you have started cholesterol medication, regular checks of your therapy by your doctor are important.
A lipid profile is usually done after you have taken your new medication for four to six weeks. This is to make sure that the medicine is working properly. A lipid profile looks at the different types of fats in your blood (LDL and HDL cholesterol, and triglycerides). You will also be checked for any side effects that your medication might be causing. After the first blood test your doctor will probably only need to check your cholesterol therapy every four to six months.
You are likely to continue with cholesterol medication for many years, or even a lifetime. Understanding your medicine and why it is necessary for your health is important. Lowering your cholesterol level is a long-term commitment. Doing so will give you a better chance to live longer and enjoy a better quality of life.
The choice of medication depends on three things. The first is which part of your lipid profile requires treatment. The medications previously found effective or ineffective for you and your tolerance of possible side effects will also be considered. The information about the more commonly used cholesterol medications which follows is by no means complete. Hopefully, it will encourage you to learn as much as you can. If you have any questions, do not hesitate to speak to your doctor or pharmacist.
The most commonly used medications to reduce cholesterol levels are the HMG-CoA reductase inhibitors. They are also referred to as the statins since all of their generic names end in 'statin.' These drugs include those listed in table 3. They are usually the most effective choice for lowering LDL cholesterol. For people with very high LDL levels, a statin will usually be the first drug chosen.
Statins work by decreasing cholesterol production in the liver. Cholesterol made by the liver accounts for a large portion of the cholesterol present in the body. It is believed that most cholesterol is made by the liver during the night. For this reason, statins should be taken close to bedtime so their effects are maximized during the liver's peak production of cholesterol.
Statins are relatively safe and side effects are uncommon. However, sometimes they can cause changes in liver function. For this reason, liver function tests should be done on a regular basis. If effects on the liver are observed, the drug will usually be stopped and another one chosen. Effects on the liver are usually reversible. Another even rarer side effect of statins is called myopathy, a muscle disorder. If you develop any muscle pain, tenderness or weakness, report it to your doctor right away.
Bile acids are made from the cholesterol in your blood. They are released by the gall bladder when you digest food. Bile acid sequestrants are drugs that stay in your gut and absorb and remove bile acids after they are released into the small intestine. The body responds by making even more bile acids. Since bile acids are made from cholesterol, blood cholesterol levels end up being decreased.
There are only two bile acid sequestrants available in Canada. The most commonly used is cholestyramine resin (Questran™). The other one is called colestipol hydrochloride (Colestid™). These drugs may be used when a patient's LDL cholesterol level is higher than what it should be, but not too high. For very high cholesterol levels other drugs (the statins) will need to be used. Sometimes a bile acid sequestrant may be combined with these other drugs.
The most important thing to remember is this type of drug can bind with and remove other drugs or supplements (vitamins and minerals) you may be taking. For this reason, no other medications or supplements should be taken within the same time frame as the bile acid sequestrant. If you do take other medications they must be taken at least one hour before or four hours after taking the bile acid sequestrant. The most common side effect of this type of drug is constipation (trouble moving the bowels). This can be quite serious for some people. The drug may also cause other digestive system problems. As with all medications, any concerns should always be brought up with your doctor or pharmacist.
Fibrates are usually used when elevated blood triglyceride levels are the first concern. The fibrates available in Canada are listed in table 4. In some patients, fibrates can also lower the LDL cholesterol and raise the HDL cholesterol. However, since fibrates do not always have a large effect on the cholesterol levels, they are usually just used to help lower triglyceride levels.
Patients who use a fibrate need to have their blood checked regularly. During the first year of therapy, blood cells should be checked to ensure there are no problems. As with statins, liver function tests should also be done on a regular basis. Side effects with fibrates are uncommon. The most likely problems a patient will have involve the digestive system. They include nausea, vomiting and abdominal pain.
Niacin can be used to decrease LDL cholesterol, and increase HDL cholesterol. It also can decrease blood levels of triglycerides. Like the bile acid sequestrants, niacin may be an option for people with mildly higher cholesterol levels. It is also useful when both LDL cholesterol and triglycerides are raised. It is much cheaper than the other prescription drugs used for reducing cholesterol, but is often not covered by drug plans.
Side effects can often limit the use of niacin. It is not generally recommended for people with diabetes since it can cause high blood sugar levels. It is also not suggested for people who suffer from gout. Niacin often causes a flushing and itching of the skin, which usually goes away over time. This flushing can often be prevented by gradually increasing the dose or by using a slow release product. A dose of aspirin (ASA) one hour before the niacin will also help reduce flushing. Niacin can cause liver toxic effects so regular blood tests should be done while taking it. Digestive system upset can also be a problem. People with diabetes should not use niacin unless recommended by, and under the guidance of, their doctor.
Although you cannot feel high cholesterol, it is important to take your cholesterol lowering medications every day. Cholesterol medicines are NOT effective if taken every other day, or for only a few days each month or just occasionally. Cholesterol lowering medications are prescribed to reduce your chance of having a heart attack or stroke. It's all a matter of odds and when it comes to your health, you want the odds to be as much in your favor as possible. Take time to discuss your cholesterol treatment with your doctor or pharmacist.