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Managing Diabetes Magazine - diabetes

Keep Cholesterol in Check
Using cholesterol-lowering medications

If you have diabetes, your risk of heart attack and stroke is higher. When cholesterol levels are also high, cardiovascular (heart and blood vessel) problems become even more likely. Fortunately, high cholesterol is one risk factor you can take steps to control. Improving your diet and increasing exercise are the two most important and cost-effective ways to fight it.

Limiting your intake of foods high in saturated and trans fat and cholesterol is an essential step in guarding against heart disease. Regular exercise also helps to check cholesterol. However, lifestyle changes may not be enough to reduce cholesterol to a healthy level. In this case, cholesterol medications may be added to your therapy. Without these medications, many more people would suffer harm from cardiovascular disease, including heart attacks and stroke.

To understand the cholesterol medications now available, you need to know about different types of cholesterol.

LDL carries cholesterol from the liver to the various body cells. However, on the way, it can be left on the walls of major arteries. Over time, this slowly narrows and may block the blood vessel. Fatty deposits built up in the blood vessels of the heart can lead to a heart attack. When they build up in blood vessels leading to the brain, they can cause a stroke. Depending on your level of risk for these complications, your doctor will want to decrease your LDL to certain targets. Be aware that the risk factor table does not include all possible scenarios and treatment goals can vary depending on your medical history.

Understanding good and bad cholesterol

Total cholesterol can be broken down into two types of ‘good’ and ‘bad’ cholesterol.

HDL (high density lipoprotein)
‘Good’ cholesterol Keep it high (H = High)
LDL (low-density lipoprotein) ‘Bad’ cholesterol Keep it low (L = Low)

HDL carries cholesterol back to the liver to be broken down and removed from the body. It helps rid the body of fatty deposits threatening to block important blood vessels.

Your doctor may also discuss triglycerides, another type of fat found in the blood. A high triglyceride level also puts you at risk of cardiovascular disease. As with cholesterol, if lifestyle changes do not work well enough, triglycerides can be reduced by medications. Recent research suggests that other substances, such as lipoprotein, may also play a role in preventing heart disease. However, reducing LDL to its target level is typically the primary goal. Your doctor will decide if focusing on the other types of cholesterol is right for you.

Once you begin cholesterol medication, your doctor must check the effects regularly. One test, the lipid profile, examines different types of fats in your blood (LDL and HDL cholesterol, and triglycerides). This blood test is usually done after you have taken your new medication for four to six weeks. The results show whether it is working properly. As well, possible side effects can be identified at this time. After this first blood test, your doctor should continue checking your cholesterol therapy every four to six months.

Assessing Blood Cholesterol Levels

When to treat
Low Risk Intermediate RIsk High Risk
LDL (low-density lipoprotein) When LDL is greater than 5.0 mmol/L When LDL is greater than 3.5 mmol/L Always
Source: 2016 Canadian Cardiovascular Society Guidelines

Risk factors for heart disease

Action can be taken to reduce risk



Atherosclerosis (hardening of the arteries)  
Previous heart attack  
Previous stroke  
Previous bypass surgery  
Previous angioplasty (surgery on blood vessels)  
High blood pressure  
Family history of angina, heart attack or stroke  
Age - male older than 45, female older than 55  
Angina (heart pain)  
Inactive lifestyle  
Peripheral vascular disease (trouble with blood flow in the vessels to the hands, legs and feet)  
High blood cholesterol levels  

If your doctor has prescribed this medication, taking it is necessary to stay healthy. You are likely to continue with it for many years, even a lifetime. Lowering your cholesterol level is a long-term commitment. It improves your chances of living longer and enjoying a better quality of life.

The choice of medication depends on three things:

  • which part of your lipid profile requires treatment
  • which medications were previously effective or ineffective
  • your tolerance of possible side effects.

The following information about common cholesterol medications is by no means a complete list. Learn as much as you can about these medications, and approach your doctor or pharmacist with questions.

Statins (HMG-CoA reductase inhibitors)

Statins (HMG-CoA reductase inhibitors)
available in Canada
Generic name Brand name
atorvastatin Lipitor
fluvastatin sodium Lescol
lovastatin Mevacor
pravastatin Pravachol
simvastatin Zocor
rosuvastatin Crestor

These medications are most commonly used to reduce cholesterol levels. They are often called statins, as their generic names end in ‘statin.’ Statins are usually the most effective choice for lowering LDL cholesterol. For those with very high LDL levels, a statin is usually the first medication chosen.

Cholesterol made by the liver accounts for a large portion of the cholesterol in the body. Statins lower cholesterol production in the liver. As the liver is thought to make most of its cholesterol during the night, some statins are meant to be taken close to bedtime. This maximizes their effect during peak production of cholesterol.

Statins are relatively safe and side effects are uncommon. However, sometimes they do affect liver function. For this reason, liver function tests should be done regularly. If the liver is being affected, that medication will usually be stopped and another one chosen. Effects on the liver are usually reversible. Another, rarer side effect of statins involves the muscles and is called myopathy. If your muscles become painful, tender or weak, report this to your doctor right away.

Bile acid sequestrants

Fibrates (fibric acid derivatives) available in Canada
Generic name Brand name
bezafibrate Bezalip
fenofibrate Lipidil Micro
gemfibrozil Lopid

Bile acids are released by the gall bladder as you digest. Bile acid sequestrants are drugs that stay in your gut to absorb and remove bile acids after they are released. The body responds by making even more. Since bile acids are made from cholesterol, blood cholesterol levels are reduced.

Three bile acid sequestrants are available in Canada. The most commonly used is cholestyramine resin (Questran or Olestyr). The other two are colestipol hydrochloride (Colestid) and colesevelam (Lodalis). These medications may be used if your LDL cholesterol level is higher than what it should be, but not too high. For very high cholesterol levels, the statins will need to be used. Sometimes a bile acid sequestrant may be combined with statins.
Keep in mind that this type of drug can bind with and remove other medications or supplements (vitamins and minerals) you take. For this reason, space out the timing. If you do take anything else, time it at least one hour before or four to six hours after taking the bile acid sequestrant.

The most common side effect of this type of medication is constipation (trouble moving the bowels). It can be quite serious for some people. Other digestive system problems can also occur. As with any medication, bring any concerns up with your doctor or pharmacist.

If high triglyceride levels are the first concern, fibrates are the usual treatment. In some people, fibrates also lower LDL cholesterol and raise HDL cholesterol. However, fibrates do not always have a large effect on cholesterol levels. They are usually just used to help lower triglyceride levels.

If you use a fibrate, you must have your blood checked regularly. During the first year of therapy, blood cells should be checked to ensure there are no problems. Liver function tests should also be done regularly, as with statins.

Side effects from fibrates are uncommon. The most likely ones are digestive, and include nausea, vomiting and abdominal pain.

Niacin (nicotinic acid)

Niacin can lower LDL cholesterol, and increase HDL cholesterol. It can also reduce blood levels of triglycerides. As with bile acid sequestrants, niacin may be an option for people with mildly higher cholesterol levels. It is also useful when both LDL cholesterol and triglyceride levels are high. Although niacin is much cheaper than other prescription drugs used to reduce cholesterol, it is often not covered by drug plans.

Side effects often limit the use of niacin. It is not recommended for people with diabetes since it can elevate blood glucose levels. It is also not suggested for those suffering from gout. Niacin often causes the skin to flush and itch, but this side effect usually goes away over time. Gradually increasing the dose or using an extended release product often prevents flushing. However, avoid ‘long-acting’ products, as they are associated with reduced effectiveness and increased risk of liver damage. A dose of aspirin (ASA) one hour before taking niacin often helps reduce flushing. Talk to your doctor or pharmacist to see if it is safe for you to use ASA.

Niacin can have a toxic effect on the liver, so regular blood tests must be done. It can also upset the digestive system. People with diabetes should not use niacin unless it is recommended and guided by a doctor.

Cholesterol absorption inhibitor

Ezetimibe (Ezetrol) is used to reduce the amount of LDL in the blood. It may slightly reduce triglycerides and slightly increase HDL. This medication may be taken alone, or used with statins or certain fibrates. Side effects, although rare, include stomach pain, fatigue, and muscle soreness.
PCSK9 Inhibitor

Repatha (evolocumab) is a new class of medication for lowering cholesterol. It works by helping the liver’s ability to remove LDL from the blood. It may also increase HDL. Unlike the other cholesterol medications, Repatha is given as a subcutaneous injection, just below the surface of the skin, either biweekly or once monthly. This medication is intended to be used in addition to other therapies that lower LDL. Side effects are rare but may include injection site reactions, respiratory tract infection, back pain, muscle aches, and cough. Repatha is expensive which limits its use for most patients. Because it is relatively new, the majority of drug plans do not cover the cost at this time.

Although you cannot feel high cholesterol, it is critical that you take the medication prescribed to lower it every day. Cholesterol medications are not effective when taken every other day, or only a few days each month, or just occasionally. These medications are prescribed to reduce your chance of having a heart attack or stroke. It is all a matter of odds. When it comes to your health, you want the odds to be in your favor as much as possible. Take time to discuss your cholesterol treatment with your doctor or pharmacist.

FAMILY HEALTH is written with the assistance of:
College of Family Physicans of Canada
Alberta College of Family Physicians
FAMILY HEALTH is written with the assistance of:
College of Family Physicans of Canada
Alberta College of Family Physicians
While effort is made to reflect accepted medical knowledge and practice, articles in Family Health Online should not be relied upon for the treatment or management of any specified medical problem or concern and Family Health accepts no liability for reliance on the articles. For proper diagnosis and care, you should always consult your family physician promptly. © Copyright 2019, Family Health Magazine, a special publication of the Edmonton Journal, a division of Postmedia Network Inc., 10006 - 101 Street, Edmonton, AB T5J 0S1 [DI_MDab17]
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