Treatment of High Cholesterol: A Primer
What good does treatment of high cholesterol do?
It’s really worthwhile. A little work can make a big difference. Consider just these two simple but reliable rules:
- Every 1% reduction in your cholesterol level lowers your risk 2%.
- Each increase of 1 mg/dL (not percent) of your good cholesterol decreases your risk 2-3%.
When and how should high cholesterol be treated?
It depends on a number of factors, most importantly:
- The level of cholesterol
- The "type" of cholesterol which is elevated, most commonly the LDL and HDL
- Other lipids, such as triglycerides
- Whether the patient already has manifest arteriosclerosis, such as a heart attack, stroke, or other evidence of blocked vessels
- Whether the patient has other risk factors for developing arteriosclerosis such as smoking, high blood pressure, diabetes, or a family history of early arteriosclerosis.
The principles of treatment are:
- Establish the accuracy of the measurements. More than one blood test is generally required, and fasting samples are necessary if screening values are high
- Screen for other factors or diseases which may be causing high cholesterol levels.
- Diet (this is not a misprint . . . it’s very important)
- Medications may be required, and are covered later in this section.
Can you tell me a good diet?
We’ll do our best . . . follow the link . . . Low Fat Diet
But I follow my low-fat diet really closely. Why is my cholesterol still high?
It is a shame that some people try so hard, yet never get desired results. It is really important to realize that the nature of some people’s problem with cholesterol is one that simply does not completely normalize even with the best of diets. Many patients have a defect in the enzymes in the liver that regulate cholesterol properly. In addition to diet and exercise, they may require medications to help achieve more optimal cholesterol levels.
What about statins?
Statins (HMG CoA reductase agents) are really exciting agents which have changed the landscape of treating high cholesterol and arteriosclerosis. We now have agents that not only will significantly decrease the levels of cholesterol, but furthermore have been proven to lower mortality in patients with coronary artery disease and stroke. Let’s be realistic: they’re not for everyone. But they are extremely effective for the many, many patients with high cholesterol.
Statins work by inhibiting the most important step of the production of cholesterol by the liver. In addition, this stimulates the formation of receptors that remove bad cholesterol from the circulation. There are several agents available:
These are listed in order of increasing potency. Drug companies make strenuous attempts to differentiate themselves from the other agents, but there are no "head-to-head" comparisons. Not everyone needs the most potent agents, and often the least expensive are also the least effective. The key point here is that patients who require therapy with these agents worry about getting on one of them, and be treated to obtain the desired cholesterol level, rather than worry "which agent is best". They are all very good if used in the proper dosage.
This class of drugs come at a substantial cost to the consumer, usually between $50-90 per month. One should do some "phone shopping" or other shopping around to find the best price, since many of these are "loss leaders" at some pharmacies.
The results of several recent studies are impressive, however.
The Scandinavian Simvastatin Survival Study – investigated over 4000 patients who had a heart attack, showing a 40 % reduction in deaths over about 5 years in patients treated with Zocor.
In patients who had undergone heart bypass surgery, lovastatin was shown to reduce blocked bypass grafts by about one-third.
The "West of Scotland" study showed a reduction in mortality in people who had no previous events such as a heart attack or bypass surgery. These were just folks with modest elevations of cholesterol in the range of 250 mg/dL. The incidence of first heart attacks was reduced by about 31%, death by 32%, and mortality from any cause by 22%.
Most recently, a study examining multiple published trials comprising approximately 29,000 patients showed a 29% risk of stroke, 28% reduction in cardiovascular deaths, and 22% reduction in overall mortality. This confirms the decrease in the incidence of blockage of vessels to the brain as well as to the heart.
There seems to be a great deal of concern regarding the toxicities of these agents. Many years ago, when Mevacor was first released, the requirements for follow-up for possible toxicities were substantial, and kept many people off this class of medications. Millions of patient-years of experience have since taken place, and it is clear that the incidence of serious side effects is quite low. Manufacturer recommendations differ and have changed over the last several years. All do recommend initial evaluation of simple blood tests that indicate liver damage, and periodic follow-up of these studies, particularly if they are noted to be elevated. Occasionally, other side effects are noted by patients, and dosages may have to be revised, but overall they are a well tolerated group. Who shouldn’t use these agents? Patients with active or chronic liver disease, and women of childbearing age unless contraception is fully satisfactory.
What about niacin?
Niacin has the appeal of being "natural". It is a vitamin which lowers cholesterol and triglycerides. It also raises the good cholesterol, HDL. However, its effects are only modest, lowering the total cholesterol in the range of ___% in most people, while the statins noted above can lower levels up to 50%. This may however be "just right" for some people. It has the disadvantages of causing a substantial amount of "flushing" of the skin (which can be minimized as outlined below), and requiring multiple doses per day.
Flushing can be minimized by using a gradually increasing schedule, and taking it with food. One aspirin or coated aspirin can be taken prior to taking Niacin (as long as you've not been told not to take aspirin for other reasons). Antacids can be used if heartburn or indigestion occur.
A reasonable schedule for increasing the dosage of niacin is:
50 mg three times a day for 1 week . . .
100 mg three times a day for 1 week . . .
250 mg three times a day for 1 week . . .
500 mg three times a week for 1 week . . .
then 1000 mg three times a day for 1 month . . .
. . . then repeat the blood test for cholesterol and triglyceride levels.
Other things to remember:
- Niacin can cause liver problems.
- Niacinamide, Nicotinamide or long-acting niacin preparations should not be substituted without specific instructions.
- These agents should not be continued if "statins" (see above) are prescribed, unless you are specifically instructed to do so.
- Patients with active stomach ulcers, arthritis caused from gout, diabetes, or asthma need to be aware that niacin can worsen these conditions.
I’ve heard of Lopid. What is it used for?
Lopid (chemical name "gemfibrozil") is an agent of the fibric acid class used to lower fats in the blood. It is particularly effective in lowering triglycerides, and less effective in lowering "bad" LDL cholesterol. It modestly increases "good" HDL cholesterol.
It has been largely supplanted by the statins, both because the statins lower total cholesterol much more impressively, as well as the fact that Lopid has not been shown to decrease mortality in large trials as have the statins. It still has uses however in selected cases, particularly patients with high triglycerides.
Caution is required to use this agent in addition to statins, since there is a significant increase in the incidence of muscle inflammation which may be quite severe. This combination needs close medical supervision.
What about other agents that aren’t absorbed?
Other agents used to treat cholesterol include the "bile acid sequestrants", "cholestyramine" and "colestipol". These are appealing also because they are not absorbed, simply staying in the intestines and absorbing bile and not allowing it to be reabsorbed. By removing bile acids which are made from cholesterol, the liver is forced to use some of its cholesterol to make new bile acids. It is usually taken as a powder mixed with a beverage such as water or juice.
Their effects are modest, leading to only about 10% reduction in cholesterol levels (20-25% reductions can be accomplished at the highest doses, but these are not often tolerated). Furthermore, they are not well tolerated, with many patients reporting bloating, constipation, intestinal gas, and nausea.
You should also be aware that these agents, some of which are available over the counter, may also cause:
- Increased levels of triglycerides, sometimes to dangerous levels
- Alterations in absorption of other medications
- Decreased absorption of fat-soluble vitamins
My doctor said my estrogen replacement is good for my cholesterol. Is this true?
Yes, it is true. Estrogen decreases bad cholesterol and increases good cholesterol. This is one of its many mechanisms to lower mortality from atherosclerosis by about 50%. This is despite a tendency to increase triglyceride levels, often to a pretty marked degree.
Negative effects include possible increased risks of endometrial or breast cancer. This controversial area has occasioned many studies with most showing a benefit to those women who took replacement hormones. There are enough factors in play that discussion with your physician is a good idea.
What about machines that can lower cholesterol?
There are people with a specific disorder of the metabolism of cholesterol who just simply cannot get their cholesterol down with diets or medications. This is an exaggerated situation of what most people experience. However, while in the "average case" an agent such a statin can increase the activity of the enzymes and receptors in the liver, there simply are not any receptors to influence in these folks. They therefore require a machine to filter the blood and remove the offending cholesterol. The Liposorber is the most current model in use for the approximately 7,000 Americans with this particular disorder. This is complex, expensive, not without risk, and certainly not for most of us.
What about gene therapy?
In another sort of "believe-it-or-not" therapy, patients have undergone removal of part of their liver. Cells were then "transfected" with the gene for normal reception and removal of LDL. The cells were then put back in the patient’s liver. Improved cholesterol levels were noted. Again, this is not for the majority of us who have such receptors, even if they aren’t quite perfect.
I’ve heard that a couple of drinks of alcohol a day will help my cholesterol. Is this true?
It is true that modest alcohol ingestion will raise the "good" (HDL) cholesterol. It appears that the equivalent of one or two ounces can raise the level by 5-10%. Red wine may provide some additional benefit, as can some dark beers.
It is important to realize that alcohol is the most abused drug worldwide, and particularly in the United States. It will probably kill far more people from its multiple negative health effects (including traffic accidents) than it helps with this modest improvement in cholesterol. I find it very hard to recommend that people begin drinking alcohol for this side effect, but it allows us to drink with less guilt. You may try to prefer red wines and dark beers.
What was the big stir about fish oil capsules a few years ago?
Fish oil is still being talked about, although as with so many things, a lot of the hype has worn off. The benefits of eating fish may stem in part from eating less red meat and therefore less saturated fat. However, omega-3 polyunsaturated fatty acids (PUFA’s) may lower other harmful fats in many cases. These particular fats are found in many fish, particularly salmon, halibut, mackerel and herring. Even shrimp, which is a controversial item on the healthy heart menu, has a substantial amount of these compounds.
PUFA’s do make platelets less "sticky". However, they may depress the immune system as well. The amount of fish that is required to lead to substantial drops in cholesterol would require the ingestion of 1-3 pounds of fish per day, an amount the average American is unlikely to eat. Fish oil capsules can supply the 6-15 grams of fish oil necessary to make a difference.
It is not yet time to recommend fish oil capsules as a general measure for preventing arteriosclerosis, particularly with concerns regarding their effect on the immune system long-term. However, a diet rich in fish can clearly be very healthful, and is recommended.
I’ve heard that chromium can lower my cholesterol. What about it?
Chromium is an element that gained notoriety first with diabetes. It is a cofactor for insulin, and there must be enough of it around for insulin to work. It has a similar but lesser role in cholesterol metabolism. IF, and I stress IF, a person has a deficiency of chromium, which is very unusual, supplementing chromium would help. However, most of us have all of the chromium we need, and in that case taking more has never been shown to do any significant good.
Excess chromium is excreted, and it would be difficult to become toxic, so some people would say "why not take it?" This is hard to argue with. If you do have a high cholesterol problem though, don’t let taking substances such as chromium give you a false sense of "taking care of the problem". Furthermore, all of our budgets are tight . . . make sure you’re getting something for your investment.
How can I raise my HDL?
As opposed to lowering your bad cholesterol, it is sometimes more difficult to raise your good cholesterol levels. Most efforts that will lower the bad cholesterol 30% will only increase the good HDL cholesterol 5%. However, remember that even this modest improvement is magnified by the improved ratio of bad to good cholesterol.
Low HDL is considered a separate risk factor for developing arteriosclerosis. That is, even if the total cholesterol is okay, people with a low HDL have a definite increase in their risk of developing disease. It can be addressed by:
- Regular exercise.
- Stopping smoking not only lowers the risk of heart disease directly, but also will generally result in an increase in the HDL.
- It is true that an ounce or so of alcohol, particularly red wine will raise HDL.
My triglycerides are high. How can that be treated?
If treatment is needed for high triglycerides (hypertriglyceridemia), the principles are similar to that for high cholesterol. That is:
- Reverse any medical conditions or change medication which may be worsening the problem.
- Low fat diet (this is even more important than with high cholesterol)
- Maintain ideal body weight (this is particularly important)
- Exercise regularly (this is particularly important, too)
- Avoid alcohol
- Avoid simple sugars
- Obtain good control of diabetes if present
- Use drug therapy if indicated. Niacin and gemfibrozil are particularly effective when triglyceride elevation is the only abnormality present.
Guggul for Lower Cholesterol
Cholesterol and Green Tea
Omega-3 Oils and Cholesterol Levels
Policosanol effects on Cholesterol Levels
Natural Alternatives to Statins
Omega 3 Fish Oils and Cholesterol
High Cholesterol Risks: Atherosclerosis
Cholesterol Lowering Foods
Beta Sitosterol for Cholesterol Health
Cholesterol and Triglycerides
Treatment of High Cholesterol
Lovastatin Effect on Cholesterol