Alternatives to Statins for Lowering Cholesterol

Thomas H. Lee, MD

Q: I've tried all of the statin drugs to lower my cholesterol but each one has caused severe muscle pain. Are there any non-statin medications I could try using to lower my cholesterol?

A: Have you tried niacin yet?

Niacin is an excellent drug for reducing cardiac risk in almost every way -- it lowers harmful LDL cholesterol, raises beneficial HDL, and reduces cardiac complications. One reason it plays second fiddle to statins is that it causes side effects like itching and flushing in many people. These side effects can often be minimized or even eliminated by taking an aspirin before niacin, by gradually building up the dose, or by taking the intermediate-release type called Niaspan, which is available by prescription only.

Two other drugs that may be used in place of a statin are ezetimibe (Zetia) and colesevelam (Welchol).

Both of these medications work in the intestines, rather than the bloodstream, and so are less likely than statins to cause side effects. Ezetimibe blocks cholesterol in food from crossing the intestinal wall and getting into the bloodstream. Colesevelam grabs cholesterol-rich bile acids in the intestine and locks them into a watery goo that is excreted in the stool.

Ezetimibe has been controversial since trials showed it adds little to cardiac protection. Colesevelam might be a good choice if you have diabetes because it lowers blood sugar as well as cholesterol.

What you eat can help lower cholesterol.

Switching from an average American diet to a Mediterranean-type diet can lower cholesterol and blood pressure. Researchers at the University of Toronto created what they called a "dietary portfolio of cholesterol-lowering foods" that included margarine enriched with plant sterols; oats, barley, psyllium, okra, and eggplant, all rich in soluble fiber; soy protein; and whole almonds. A diet emphasizing these foods substantially lowered LDL, triglycerides, and blood pressure, and did not harm HDL. Eating nuts can modestly lower cholesterol.

Fish oil and garlic have long been touted as cholesterol reducers, but meta-analyses of clinical trials show they have little effect on cholesterol. Substances that do lower cholesterol are plant sterols and stanols. They have been added to margarine (Benecol, Promise, others), orange juice, granola bars, chocolate, and other foods. They are also available as plain, no-calorie pills.

Thomas H. Lee, M.D., is the chief executive officer for Partners Community HealthCare Inc. He is a professor of medicine at Harvard Medical School. Dr. Lee is an internist and cardiologist at Brigham and Women's Hospital, Boston, Massachusetts.

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