Which cholesterol medication is right for you?

Do you have high cholesterol? Exercising more, quitting smoking and changing your diet could be enough to lower your bad cholesterol. But if that doesn’t do the trick, your doctor will likely prescribe a cholesterol-lowering medication.

There are 8 basic types of cholesterol medication. Statins are the most common — they’re prescribed to 93% of all people taking a cholesterol medication. Statins have been around for more than 30 years. They work well to help reduce low-density lipoprotein (LDL) cholesterol — aka “bad” cholesterol. High-density lipoprotein (HDL), the other type of cholesterol, is often called “good” cholesterol. Statins also work to improve HDL.

Why LDL cholesterol is a problem

Cholesterol is a waxy substance that travels through your bloodstream. Your body needs cholesterol to build healthy cells, according to the Mayo Clinic. But high levels of LDL cholesterol can stick to the walls of your arteries, narrowing them. That increases your likelihood of a heart attack or stroke.

Sometimes a statin is all it takes to get your LDL cholesterol into a healthy range (below 100 mg/dL). But some people may have to take another cholesterol-lowering medication in addition to a statin. And some people, such as women who are pregnant or breastfeeding, should not take statins at all.

The most common cholesterol medications

There’s a good chance your doctor will start by prescribing you a statin. Then they’ll monitor your cholesterol levels to see how well the statin is working. But there are also other cholesterol medications — including a few newer options. Here’s how statins and other medications work and who they work best for.

Statins

What they are: Statins lower your LDL cholesterol by blocking an enzyme that the liver needs to make cholesterol. They’ve been proven to work well at lowering LDL cholesterol and reducing your risk of a heart attack or stroke, says Avni J. Patel, PharmD. She’s an assistant professor of pharmacy practice at Wilkes University Nesbitt School of Pharmacy in Wilkes-Barre, Pennsylvania.

There are 7 types of statins. They all work to achieve similar results, but your doctor may choose a particular one over the others. That decision is typically based on cost, side effects and ease of use, as well as whether the statin interacts with any other medications you’re currently taking. Some common statins include:

• Lipitor^® (Atorvastatin)
• Crestor^® (Rosuvastatin)
• Zocor^® (Simvastatin)

Who they’re best for: Statins are usually the first-line treatment, unless the patient is pregnant or breastfeeding, says Inna Lukyanovsky, PharmD. She’s a functional medicine practitioner in Manalapan, New Jersey. Statins are mainly recommended for people who have high cholesterol (LDL above 190 mg/dL) that can’t be reduced by lifestyle changes. Also good candidates: People between the ages of 40 and 75 with an LDL of at least 70mg/dL who also have diabetes or a high risk of heart disease.

Statins are especially recommended for those who have had a heart attack or stroke, or for those with peripheral artery disease.

Potential side effects: Statins can sometimes cause mild side effects, such as constipation, headache, nausea or diarrhea. Between 5% and 30% of people taking a statin may experience muscle pain or weakness. Your doctor can often help manage this by changing to a different statin or lowering the dose, Patel says.

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Cholesterol absorption inhibitors

What they are: Cholesterol absorption inhibitors are a class of medication called ezetimibe. After statins, they are the most commonly prescribed kind of cholesterol-lowering medication. Ezetimibe works by stopping the small intestine from absorbing cholesterol so that you have less cholesterol in your body.

Who they’re best for: Cholesterol absorption inhibitors are usually for people who are already taking the highest dose of a statin but still need to lower their LDL cholesterol, Patel says. Often, that’s people who have a history of atherosclerotic cardiovascular disease or inherited high cholesterol.

Potential side effects: Diarrhea, fatigue and joint pain.

PCSK9 inhibitors

What they are: PCSK9 inhibitors are a new type of cholesterol-lowering medication. They work by stopping a protein called PCSK9 from breaking down LDL cholesterol receptors in your body. These receptors help clear away bad cholesterol, so the more you have of them, the better. The PCSK9 inhibitors that have been approved by the U.S. Food and Drug Administration are:

• Praluent^® (alirocumab)
• Repatha^® (evolocumab)

Who they’re best for: PCSK9 inhibitors are often prescribed to people whose cholesterol levels are still high after trying other treatments (such as statins and lifestyle changes). This includes people who have a high risk of heart disease even after taking other medications and those with inherited high cholesterol. PCSK9 inhibitors can be combined with a statin. They can be highly effective for some people — potentially cutting your risk of a heart attack by almost one-third, according to the Cleveland Clinic. The downside is that they’re expensive and have to be given by injection.

Potential side effects: Muscle and back pain, swelling at the injection site, cold-like symptoms.

ACL inhibitors

What they are: There are 2 types of ACL inhibitors: Nexletol^® (bempedoic acid) and a combination of bempedoic acid and ezetimibe (brand name: Nexlizet^®). They work by lowering the amount of cholesterol the liver makes.

Who they’re best for: ACL inhibitors are an option for people who have a history of heart disease or who have inherited high cholesterol and may need more help lowering their bad cholesterol, Patel says. This medication can also be taken with a statin.

Potential side effects: Upper respiratory infection; stomach, muscle or back pain; tendon injuries.

Bile acid sequestrants

What they are: These medications work by causing the intestine to get rid of more cholesterol in your blood. They’re not usually meant to be used on their own. Examples include:

• Prevalite^® or Questran^® (cholestyramine)
• Colestid^® (Colestipol)

Who they’re best for: These are the only cholesterol-lowering medications that can be used during pregnancy. Bile acid sequestrants are usually considered for people who are already on the highest dose of a statin and ezetimibe and still need to lower their bad cholesterol, Patel says.

Potential side effects: “They’re an older class of medication, and they can have a lot of unpleasant side effects, such as gas, diarrhea and upset stomach,” Lukyanovsky says.

Niacin

What it is: Niacin is a B-complex vitamin supplement that’s available over the counter, but you’ll need a prescription for higher doses. It can raise your good cholesterol more than 30%, according to the Mayo Clinic. Research suggests it doesn’t reduce the risk of a heart attack or stroke, so it should usually be taken with a statin.

Who it’s best for: In rare cases, it can be taken on its own — such as if you don’t have high LDL cholesterol but have low good cholesterol and/or high triglycerides, Lukyanovsky says.

Potential side effects: Itching, tingling, headache, upset stomach and coughing. It can also raise blood sugar, which is why it should be prescribed cautiously if the patient has diabetes. Talk to your doctor to see if it’s right for you.

Fibrates

What they are: Fibrates are a medication that reduces how much very-low-density lipoprotein (VLDL) your liver makes. Fibrates also can increase your good HDL cholesterol. Unlike statins, fibrates haven’t been proven to reduce your risk of a heart attack or stroke. So if you’re at high risk of heart disease, you’ll most likely need to take fibrates with a statin.

Who they’re best for: These might be the best pick for people with elevated levels of VLDL proteins. VLDL proteins carry triglycerides (a type of fat in your blood) to other parts of the body. By limiting how much VLDL your body makes, fibrates lower your triglyceride levels.

Potential side effects: Stomach pain, constipation, diarrhea, dizziness, headaches and leg cramps. Some fibrates can also interact with blood thinners.

Omega-3 fatty acids

What they are: Often known as fish oils, omega-3 fatty acids are found in fatty fish, such as salmon, tuna and halibut. But it can be hard to get enough omega-3 fatty acids from food alone, so you might need to take a supplement. There’s strong evidence that regular doses of omega-3 fish oils or omega-3 fatty acids (2 grams, twice a day) can significantly lower blood triglyceride levels.

Who they’re best for: These are an effective and safe option for someone who suffers from hypertriglyceridemia (elevated triglyceride levels) in addition to high LDL cholesterol, according to the American Heart Association. They’re also a good pick for someone who wants to try a more natural approach to lowering their triglyceride levels.

Potential side effects: Rash, itching, belching and gas. Fish oils may also increase bleeding, and they might interfere with some medications.

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Additional sources
Cholesterol basics: Mayo Clinic (n.d.). “High Cholesterol”
PCSK9 inhibitors: Cleveland Clinic (2022). “PCSK9 Inhibitors”
Fibrates: Cleveland Clinic (2022). “Fibrates” 
Study on omega-3 fatty acids and triglycerides: Circulation (2019). “Omega-3 Fatty Acids for the Management of Hypertriglyceridemia: A Science Advisory from the American Heart Association”