Treating High Cholesterol
TREATING HIGH CHOLESTEROL
Cardiovascular disease is the #1 cause of death for men and women in the United
States. It accounts for 1/3 of every death in the US.
Cholesterol is an important component of the cell walls in all cells of body and can be
used to make hormones or bile acid to help digest food.
High cholesterol can cause formation and accumulation of plaque deposits in the
arteries. When plaque builds up, it can cause hardening of the arteries (atherosclerosis)
in the heart, brain, kidneys and peripheral arteries. This increases the risk for
atherosclerosis cardiovascular disease (ASCVD) which can lead to heart disease, heart
attacks and strokes.
There are 2 important reasons to manage cholesterol. One is to reduce ASCVD risk and
the other is to reduce pancreatitis risk.
Cholesterol levels can be determined by blood screening for fasting lipid profile. The
National Institutes of Health (NIH) recommends all adults have their cholesterol levels
checked at least once every five (5) years unless you are deemed at “higher risk”.
o High density lipoprotein (HDL): “good cholesterol” works to remove excess
cholesterol and triglycerides in blood back to the liver.
o Low density lipoprotein (LDL): “bad cholesterol” contributes to fatty buildup in
o Triglycerides: 500mg/dL or higher is an indication of a high level of triglycerides
(hypertriglyceridemia). This is not a common form of high cholesterol, but it has
increased risk of pancreatitis. 8 out of 10 individuals with high triglycerides are
overweight or obese. Triglycerides are markedly affected by body weight and
body fat distribution. Triglycerides can often be managed by non-pharmacologic
approaches such as diet and exercise.
o Total cholesterol: 240mg/dL or higher is an indication of hypercholesterolemia
or high cholesterol. Treatment is by lowering LDL to reduce ASCVD risk.
Diet: can reduce triglycerides by 20-50% and lower cholesterol
o Focus on dietary pattern, rather than individual dietary components. Smoking
and alcohol intake is not recommended.
o Reduce daily intake of saturated fat (<7% of total calories) and cholesterol
(<200mg daily). This includes animal products such as meat, poultry, fish, eggs,
butter, cheese and milk. Plant foods do not contain cholesterol. Incorporating
lots of fruit, vegetables, nuts, seeds, cereal, beans can have a meaningful impact
on your health.
o Limit intake of trans fats (bakery shortening, stick margarine)
o Increase soluble fiber intake (psyllium, oat bran, beta-glucan, kojac
glucomannan). Soluble fibers form vicious solutions in water and can absorb
cholesterol and bile acid in the intestines. Insoluble fibers are used for
constipation. Some fiber are both insoluble and soluble such as psyllium.
Weight management: a mere 5-10% reduction in weight can reduce triglycerides by
20%. Aim to exercise for 30-60 minutes a day. Walking is a great form of exercise that
also has low impact on the joints.
Niacin (vitamin B3) dosed 1-3 grams/day can reduce LDL cholesterol by 10-20%, reduce
triglycerides by 20-50%, and raise HDL cholesterol levels by 15-35%. Niacin can cause
flushing of skin and gastrointestinal symptoms such as nausea, indigestion, gas,
vomiting, diarrhea. Ways to improve tolerability include: avoiding spicy or hot food or
drinks with dose, avoiding alcohol, taking the drug with food and aspirin 81-325mg 30
minutes before dose. Niacin IR is the most effective formulation of niacin and is
available OTC. It is dosed initially at 250mg after evening meals, increasing over several
weeks to 1-3 grams per day, split into two (2) to three (3) doses daily. Niaspan (niacin
ER) is a prescription product and is much less effective, but better tolerated. Slo-niacin
(niacin SR) is not recommended due to potential liver damage risk. No-flush niacin
(inositol hexaniacinate) is not recommended because there is no free drug.
Omega-3 fatty acids (fish oil) dosed 2-4 grams/day (EPA + DHA) can reduce triglycerides
by 20-50%. A good rule of thumb: 1 gram of omega-3 fatty acids lowers triglycerides by
5-10%. DHA fatty acids may increase LDL levels; Vascepa (Rx only) is the only product
without DHA. There is a lot of variation and risk of contamination in OTC supplements.
OTC products may need up to 16 capsules per day vs. prescription products need up to 4
capsules per day. You can also try eating more foods high in omega-3 fatty acids:
flaxseed oil, hempseed oil, coconut oil, fish, grass-fed animal products, walnuts.
Folic acid (vitamin B9) dosed 1mg per day can regulate cholesterol balance in the body,
decrease triglycerides, and your risk of stroke and heart disease. The human body can
not make folic acid and require it from dietary sources. Folate (natural form of folic
acid) is found in leafy greens, beans, and citrus foods. In the United States, most grain
products are also fortified with folic acid. Folic acid is especially important in pregnant
women and folate deficiency anemia.
Red rice yeast is a traditional Chinese culinary and medicinal product. It contains
monacolin K, a lovastatin-like ingredient. This is a controversial supplement as OTC
products are not standardized, yeast strains vary and there may be little or no
monacolin K. Some red yeast rice products contain a contaminant called citrinin, which
can cause kidney failure.
Soy: may moderately decrease total cholesterol and LDL levels.
Garlic: may reduce total blood cholesterol and LDL cholesterol with garlic use over 4-12
weeks. Use with caution with bleeding disorders.
Statins are the #1 most prescribed treatment for hypercholesterolemia as they have the
most strong and consistent evidence supporting ASCVD risk reduction vs. non-statin
drugs. Statins can reduce LDL by 18-55%, reduce triglycerides by 10-30%, and increase
HDL. The most common side effect from statins is muscle pain. Statin drugs include
Crestor (rosuvastatin), Lipitor (atorvastatin), Zocor (simvastatin), Pravachol
(pravastatin), Mevacor (lovastatin), Livalo (pitavastatin), Lescol (fluvastatin)
Bile acid sequestrants such as cholestyramine powder, Welchol (colesevelam), and
colestipol powder can lower LDL by 15-30%, however, they can increase triglycerides by
0-30%. In addition, they have a high pill burden, must be taken with every meal, and
have numerous GI side effects and drug interactions.
Fibrates such as fenofibrate and gemfibrozil can reduce triglycerides by 30-50%. They
are the 1 st line drug therapy when treating hypertriglyceridemia.
Zetia (ezetimibe) can reduce LDL by 18% and triglycerides by 5-10%.
PCSK9 inhibitors are the newest class of cholesterol lowering drugs. They can reduce
LDL by 40-60%. These are typically reserved as last line therapy and are rather costly.