Statins: Considered the go-to drugs for cholesterol management, statins work their magic by limiting the amount of cholesterol the liver produces. These drugs—Lipitor (atorvastatin), Zocor (simvastatin), Mevacor (lovastatin), and Crestor (rosuvastatin)—block the enzyme needed to make new cholesterol while the liver absorbs and disposes of the LDL (bad) cholesterol already present in the bloodstream. All told, statins can reduce total and LDL cholesterol levels by 20% to 60% and lower the risk for heart attack and stroke by about 30%. But as powerful as they are—statins also help lower triglycerides and modestly raise HDL (good) cholesterol—they have no impact on the cholesterol we ingest, which is why having a prescription in hand is not a visit-the-drive-thru-free card. "Without prudent dieting, taking a statin is like bailing out a sinking rowboat without plugging the hole," says Dr. Granato.
New research suggests statins may protect people whose cholesterol levels are normal but have high levels of C-reactive protein, or CRP, a sign of artery inflammation (which can trigger heart attacks and stroke). If your LDL level is borderline high and you have some other risk factors, your doctor may want to do a blood test to check your CRP to determine if you should start taking a statin. Otherwise, the negatives associated with statins probably outweigh any benefits of taking the drug for someone with normal cholesterol.
Drawbacks: Statins can get your cholesterol into a healthy range but you'll need to keep taking them forever to stay there. Plus, you're committed to yearly or twice-yearly blood tests to ensure the statins don't damage your liver or break down muscle cells, a condition called rhabdomyolysis. (Minor muscle soreness affects about 5% of people taking statins, but in rare instances the destruction of muscle tissue leads to fatal kidney failure.)
In addition, statins don't mix well with grapefruit, grapefruit juice, or certain drugs, like many antibiotics and the blood-thinner warfarin. Finally, alcohol intake must be watched, since it too is eliminated through the liver.
Cholesterol Absorption Blocker: When you can't take statins, either because you have liver damage or can't tolerate the side effects, or if you're already on a statin but need to nudge your cholesterol down further, your doctor may prescribe Zetia (ezetimibe), a cholesterol absorption blocker. It stops the cholesterol you ingest from being absorbed through your intestines. Used with a statin, this may knock your LDL down another 15% to 25%.
Drawbacks: Ezetimibe lowers cholesterol, but it's not clear it prevents heart attack or stroke. "Unlike statins, it doesn't seem to protect against life-threatening events," says Dr. Granato.
Niacin: This B vitamin is one of the few drugs that effectively raise HDL cholesterol. It primarily prevents the liver from removing good HDL from the bloodstream, so levels stay high. Used alone, niacin can raise HDL between 15% and 35%; when paired with a statin, HDL may increase 50%. It's also helpful for lowering LDL and triglycerides.
Drawbacks: Taking over-the-counter niacin at high doses (1,000 milligrams or more daily) can cause some unpleasant side effects, like flushing, nausea, dizziness, and stomach upset. Niaspan (extended-release niacin), available by prescription, may reduce some of these symptoms. It still needs to be used judiciously and under supervision of a doctor who can monitor your liver function. High doses can cause liver toxicity, increase blood sugar levels in diabetics and, when paired with statins, raise the risk for the muscle destruction that can lead to kidney failure. A better way to raise HDL is by exercising and quitting smoking, says Pamela Douglas, M.D., cardiologist and professor of medicine at Duke University Medical Center in Durham, North Carolina.
Fibrates: When people have diabetes, which can automatically double, even quadruple, the risk for heart attack or stroke, fibrates are often partnered with statins to provide some extra protection. Fibrates are used to reduce cholesterol and triglyceride levels in the blood. The most commonly prescribed include Lopid (gemfibrozil) and TriCor (fenofibrate). In particular, fibrates help boost HDL, which tends to be lower in diabetics, by raising it about 10% to 20%. And they have the opposite effect on triglycerides, which are often higher in those with diabetes, by lowering them 20% to 30%.
Drawbacks: Stomach upset and an increased risk for gallstones are common with fibrates. Pairing fibrates with statins can also increase the risk for rhabdomyolysis.