Lifestyle and Cholesterol Levels

When is it time to use medication for high cholesterol, and what are the best choices?

For elevated triglycerides, I suggest a three-month commitment to reduce the sugar and simple starches in your diet. This means lowering consumption of foods like potatoes, white rice, pasta, and baked goods, and replacing them with smaller quantities of whole grains like brown rice, whole-wheat pasta, and bright-colored vegetables and fruits.

It also means cutting down on sugary drinks, like soda. If that doesn't lower your triglycerides below 150 mg/dl, it's time to think about medications-and that's in addition to your dietary modifications, not instead!

Niacin, one of the B vitamins, is an effective and appealing treatment for many people concerned about high triglycerides, because it is a fairly natural approach. Over-the-counter forms of niacin are usually not strong enough, so a high-dose prescription version is usually used.

The only problem is that such high doses often cause redness and sweating in the face and upper chest (called a flushing reaction). Using a slow-release form of niacin and taking some aspirin before each dose sometimes helps.

Fibrates are also useful for lowering triglycerides. The two most widely used are gemfibrozil and fenofibrate. The most common side effect is upset stomach, but most people aren't too bothered by that. Rarely, the fibrates can cause irritation of the liver, which gets better quickly when the medicine is stopped.

Statins also lower triglyceride levels, but not nearly as well as niacin and fibrates.

If a high LDL is your main problem, you should reduce your dietary fat intake. If that's not good enough after three months, then I suggest taking a statin.

There are several to choose from, and your doctor can help select the best one for you. Many people know that they have to avoid grapefruit when taking a statin, but there is one exception-pravastatin is not affected by grapefruit, although it is one of the weaker statins.

The most common side effects are irritation of the liver or muscles, but these problems happen to less than 1 in 1,000 people taking a statin, and resolve promptly when you stop taking it.

One of the most exciting things about statins is that, besides lowering your LDL level, they also appear to directly reduce the risk of heart attack and stroke. The specific reason for this is not yet understood. It is not known if any other methods of lowering cholesterol have the same kind of additional protective benefit.

If a statin plus dietary change still doesn't get you to your LDL goal, you might benefit from adding ezetemibe. This medicine blocks absorption of LDL cholesterol from your intestines.

It doesn't have much effect when used by itself, but ezetemibe is very powerful in combination with a statin, and almost never causes any side effects.

A few other medicines are occasionally prescribed to lower cholesterol, but these four (niacin, fibrates, statins and ezetimibe) are among the best and the most commonly used.

There are a few natural products advertised to lower cholesterol. The FDA issued a warning in August 2007 that two of the most common, red rice yeast and policosanol, often contain a cholesterol-lowering drug, lovastatin, as the main active ingredient. So you may be fooling yourself if you think these are safer than a prescribed statin just because they are "natural".

Garlic, fish oil, and a variety of other products are sometimes advertised as lowering cholesterol, too. My general attitude is that if an alternative product or natural substance is truly harmless, I have no objection to giving it a try. But always work with your doctor to monitor whether such products are really working and to make sure they aren't causing any side effects.

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