What can you do about it?
Think of cholesterol as a "vital sign," similar to blood pressure, and high cholesterol as a leading risk factor for heart disease
Know your cholesterol numbers
Know your cholesterol goal
Use every visit with your healthcare professional to help reach your goal by discussing cholesterol management and other risk factors, and, if necessary, take steps to get treated
Drug therapy can be considered for patients who, in spite of adequate dietary therapy, regular physical activity and weight loss, need further treatment for elevated blood cholesterol levels. The guidelines for those who qualify are:
|
|
LDL Level |
Goal |
|
Without coronary heart disease and with fewer than two risk factors |
190 mg/dL or higher* |
160 mg/dL or lower |
|
Without coronary heart disease and with two or more risk factors |
160 mg/dL or higher |
130 mg/dL or lower |
|
With coronary
heart disease |
130 mg/dL or higher** |
100 mg/dL or lower |
*In men less than 35 years of age and premenopausal women with LDL cholesterol levels of 190 to 219 mg/dL, drug therapy should be delayed except in high-risk patients such as those with diabetes.
**In coronary heart
disease patients with LDL cholesterol levels of 100 to 129 mg/dL, the physician
should exercise clinical judgment in deciding whether to initiate drug
treatment.
In some cases, a physician may decide that using cholesterol-lowering drugs at
lower LDL cholesterol levels is justified. On the other hand, drug therapy may
not be appropriate for some patients who meet the above criteria. This may be
true for elderly patients.
The presence of other coronary heart disease risk factors influences the use of cholesterol-lowering drugs:
Age — This includes men 45 years or older, women 55 years or older OR who have premature menopause without estrogen replacement therapy.
Family history — This includes anyone having a father, brother or son with a history of coronary heart disease before age 55, or a mother, sister or daughter with coronary heart disease before age 65.
Smoking — This includes anyone who smokes or who lives and works every day around people who smoke.
High blood pressure — This includes anyone with a blood pressure of 140/90 mm Hg or higher, measured on two or more occasions.
HDL cholesterol — This includes anyone with an HDL cholesterol level of less than 35 mg/dL.
Diabetes — This includes anyone with a fasting blood sugar of 126 mg/dL or higher.
What
drugs are most commonly used to treat high cholesterol?
The drugs of first choice for elevated LDL cholesterol are the bile acid
sequestrants — cholestyramine and colestipol — and nicotinic acid (niacin).
These have been shown to reduce the risk for coronary heart disease in
controlled clinical trials. Both classes of drugs appear to be free of serious
side effects, but both can have troublesome side effects and require
considerable patient education to achieve adherence. Nicotinic acid is preferred
in patients with triglyceride levels exceeding 250 mg/dL because bile acid
sequestrants tend to raise triglyceride levels.
Another class of drugs for lowering LDL is the HMG CoA reductase inhibitors, e.g., lovastatin, pravastatin and simvastatin. Statin drugs are very effective for lowering LDL cholesterol levels and have few immediate short-term side effects.
They are easy to administer, have high patient acceptance and have few drug-drug interactions.
Patients who are pregnant, have active or chronic liver disease, or those allergic to statins shouldn’t use statin drugs.
The most common side effects are gastrointestinal, including constipation and abdominal pain and cramps. These symptoms are usually mild to severe and generally subside as therapy continues.
Long-term safety data (longer than five years) should be available in the next one to two years. Clinical trials are in progress.
What
other drugs are available to treat high cholesterol?
Other available drugs are gemfibrozil, probucol and clofibrate.
Gemfibrozil and clofibrate are most effective for lowering elevated triglyceride
levels. They moderately reduce LDL cholesterol levels in hypercholesterolemic
patients, but the FDA hasn’t approved them for this purpose. Probucol also
moderately lowers LDL levels. It has received FDA approval for this purpose.
If a patient doesn’t respond adequately to single drug therapy, combined drug therapy should be considered to further lower LDL cholesterol levels. For patients with severe hypercholesterolemia, combining a bile acid sequestrant with either nicotinic acid or lovastatin has the potential to markedly lower LDL cholesterol. For hypercholesterolemic patients with elevated triglycerides, nicotinic acid or gemfibrozil should be considered as one agent for combined therapy.
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