How Are Elevated Cholesterol and Triglycerides Treated?
Formal guidelines like the ATP III recommendations usually stress lifestyle changes as the primary method of reducing elevated cholesterol and triglyceride levels. These lifestyle changes primarily consist of diet, exercise, and weight loss.Recommended dietary changes include incorporating low total fat, low saturated fat, low dietary cholesterol, and increased starch and fiber. Physical activity should ideally consist of at least 20 minutes of aerobic exercise, three to five times per week, but in fact any increase in physical activity is helpful. Patients who are obese can often significantly reduce their LDL cholesterol and triglyceride levels by losing weight.
Cholesterol levels should be re-measured 3-6 months after undertaking these lifestyle-based efforts at improving lipid levels. If lipid levels are still not satisfactory, drug therapy should then be considered.
What Drugs Are Used to Treat Cholesterol and Triglycerides?
Drugs used to treat cholesterol and triglyceride levels fall into five major categories:Bile acid binding resins: Cholestyramine prevents the cholesterol in bile (the digestive product secreted from the gallbladder) from being reabsorbed into the bloodstream in the gut, so the cholesterol is excreted in the stool. Side effects include intestinal gas and gallstones, which significantly limits their usefulness. Cholestyramine can also cause a decrease in the absorption of other drugs you may be taking, as well as certain vitamin deficiencies. In addition, cholestyramine can can occasionally cause an increase in triglyceride levels.
Niacin: Niacin is one of the B vitamins. When used in large doses and in the correct form, it can significantly reduce LDL cholesterol and increase HDL cholesterol. Its major side effects include skin flushing and severe itching, along with gastrointestinal disturbances; it can cause liver disease in some formulations. Nicacin is very effective, but because of side effects, it often tends to be poorly tolerated. Using niacin appropriately and safely to treat lipid levels can be tricky and potentially dangerous, and in general should be done under a doctor's supervision.
Fibric acid derivatives: The chief benefits of the fibric acid derivatives, gemfibrozil and clofibrate, are that they can lower triglyceride levels and (very modestly) increase HDL cholesterol levels. Their ability to reduce LDL cholesterol is much more modest. Their side effects include nausea, vomiting, abdominal pain and gallstones. The frequency of these side effects often limit their usefulness.
Ezitimibe: Ezitimibe is a unique anti-cholesterol drug that works by reducing the absorption of dietary cholesterol by the gut. Ezitimibe is marketed as Zetia, and in combination with a statin drug as Vytorin. Ezitimibe significantly reduces LDL cholesterol levels. However, this drug has been the subject of much controversy since 2008, when the ENHANCE trial suggested that (despite the successful reduction in cholesterol with ezitimibe), patients treated with this drug may have had more rapid progression of atherosclerosis. It is currently used by most doctors only when adequate cholesterol levels cannot be achieved with other measures.
Statins: The statin drugs inhibit the liver enzyme HMG-CoA reductase, which significantly reduces the production of cholesterol by the liver. These drugs almost always produce a substantial reduction in LDL cholesterol, with a modest decrease in triglycerides, and a modest increase in HDL cholesterol. They tend to be well-tolerated in general, but can cause elevations in liver enzymes, and a muscle disorder which can be severe in rare cases. The muscle disorder (myopathy) is particularly likely when statins are used in combination with gemfibrozil.
Finally, there are some non-prescription approaches to reducing cholesterol that may sometimes be effective.
Of all these drug choices, the statins are not only generally more effective than drugs in other categories, they also tend to be much better tolerated. Furthermore, evidence is accumulating that the aggressive use of statins can slow the progression of coronary artery disease, and can stabilize coronary artery plaques (which can reduce the risk of acute coronary syndrome (ACS)).
Treating Abnormal Lipids - Summary
The most common approach to the treatment of abnormal lipid levels can be summarized as follows: First, dietary changes, weight loss, and exercise are tried. If that fails (human nature being what it is), then most doctors will try statins. If statins fail, or if they are not tolerated, an agent from another class of the lipid-lowering drugs can be tried.Sources:
Third report of the National Cholesterol Education Program (NCEP) Expert Panel on detection, evaluation, and treatment of high blood cholesterol in adults (Adult Treatment Panel III). Circulation 2002; 106:3143.
Gould, AL, Rossouw, JE, Santanello, NC, et al. Cholesterol reduction yields clinical benefit: Impact of statin trials. Circulation 1998; 97:946.
D'Agostino RB, Sr, Grundy, S, Sullivan, et al. Validation of the Framingham Coronary Heart Disease Prediction Scores: Results of a Multiple Ethnic Groups Investigation. JAMA 2001; 286:180.
