If you have high cholesterol, you may need to take medication to lower it. A variety of medications are used to treat high cholesterol in different ways. Some increase “good” HDL cholesterol or lower “bad” LDL cholesterol—or both—and some reduce triglyceride levels. 

Typically, when you’re diagnosed with high cholesterol, your doctor will give you time—usually about three months—to try and lower your cholesterol naturally. You can lower your cholesterol by eating a healthy diet, exercising regularly, and reducing your stress.

If your cholesterol is still high after your time is up, your doctor will likely recommend cholesterol medication. In some cases, the causes of high cholesterol include genetic factors that you can’t overcome through lifestyle changes. High cholesterol leads to plaque buildup in the arteries, narrowing them and slowing or blocking blood flow. Narrowed arteries due to plaque buildup is known as atherosclerosis, and it’s a major risk for heart attack, stroke, and ischemic heart diseases, which are characterized by poor blood flow.

Another way your doctor will determine whether cholesterol drugs are right for you is by using the Altherosclerotic Cardiovascular Disease (ASCVD) Risk Calculator. The ASCVD risk calculator measures your 10-year risk for coronary artery disease, stroke, and heart attack based on factors like your age, blood pressure, cholesterol levels, and health conditions like diabetes. If your assessment shows a risk of 7.5 percent or higher, your doctor will recommend cholesterol-lowering drugs. While you can take the ASCVD risk assessment online, it might be most helpful to take it with your doctor, who can walk you through what the results mean and help you determine the best next steps. 

Here, we look at the most commonly prescribed medications to treat high cholesterol and reduce your risk for heart disease.

Statins

Statin drugs are typically the first choice of medications to lower your cholesterol, and they’re the most commonly prescribed medication to reduce your heart attack and stroke risk if you have a high ASCVD score or you’ve already had a heart attack or stroke. Statins slow down the liver’s production of cholesterol and improve the ability of the liver to remove LDL cholesterol that’s already in the blood. Statins have a proven track record for reducing the risk for heart attacks and strokes. 

Statin brand names

  • Atorvastatin (Lipitor)
  • Fluvastatin (Lescol)
  • Lovastatin
  • Pitavastatin (Livalo)
  • Pravastatin (Pravachol)
  • Rosuvastatin calcium (Crestor)
  • Simvastatin (Zocor)

Risks and side effects of taking statin medications

In general, statin drugs are very well tolerated. They may produce muscle-related problems and increase the risk of developing diabetes, although the risk of serious side effects and complications is extremely low. 

Statins occasionally lead to increased enzymes in the liver that indicate inflammation. In mild cases, you can continue taking the statin, but in severe cases, your doctor will recommend trying a different statin drug.

You may have an increased risk of side effects related to statin drugs if you:

  • Take multiple cholesterol medications
  • Are female
  • Have a smaller body frame
  • Are over the age of 80
  • Have liver or kidney disease 
  • Drink too much alcohol
  • Have hypothyroidism or neuromuscular disorders like ALS

While some of the side effects of statins are bothersome, the risk of life-threatening complications is extremely low. The effectiveness of statins for lowering heart attack and stroke risk generally outweigh the risks of taking them. 

Special considerations for taking statins

Grapefruits and grapefruit juice contain chemicals that may interfere with the enzymes that break down statins in your digestive system. Although you don’t need to banish these from your diet, talk to your doctor about how much grapefruit in your diet is safe. 

Many drugs interact with statins, including some medications for irregular heart rhythms, HIV medications known as protease inhibitors, some antibiotic and antifungal drugs, and some immunosuppressant medications. 

Bile acid sequestrant drugs

Also known as bile acid-binding agents, bile acid sequestrant drugs prevent bile acid in your stomach from being absorbed into your blood. This tricks your liver into making more bile, which requires it to use cholesterol in your blood, effectively lowering blood cholesterol levels and reducing your risk of heart disease, heart attack, and stroke.

Bile acid sequestrants are safe for children and women who may become pregnant. They’re most helpful for people with elevated “bad” LDL cholesterol. They can be combined with statins or niacin for even better cholesterol-lowering effects—especially in people with extremely high LDL cholesterol or in those who can’t take statin drugs.

Bile acid sequestrant brand names

  • Cholestyramine (Prevalite)
  • Colesevelam (WelChol)
  • Colestipol (Colestid)

Side effects and risks of taking bile acid sequestrants

Bile acid sequestrants effectively lower cholesterol without any serious side effects. The most common side effect is constipation, which you can combat with stool softeners. Other possible effects of these medications include diarrhea, gas and bloating, nausea, heartburn, and muscle aches. 

Special considerations for taking bile acid sequestrants

If you have certain health conditions, bile acid sequestrants are not for you. These include:

  • Gallbladder or liver problems
  • High triglyceride levels
  • Heart, kidney, or thyroid conditions 

Bile acid sequestrants may affect how other medications and vitamins are absorbed in the body. Many people on these medications take a multivitamin, but talk to your doctor about whether a multivitamin is necessary for you.

PCSK9 inhibitors

PCSK9 is a protein found in liver cells that prevent the cells from removing excess cholesterol. PCSK9 inhibitors bind to and deactivate PCSK9, lowering LDL cholesterol and significantly reducing the risk of heart attack and stroke. Research shows PCSK9 inhibitors can decrease LDL cholesterol by 45 to 70 percent. They also reduce triglycerides and increase “good” HDL cholesterol by eight to 10 percent. 

PCSK9 inhibitors are administered by injection every two to four weeks. Your doctor will teach you how to inject them yourself into your arm, stomach, or thigh. 

Most people with high cholesterol don’t need PCSK9 inhibitors, and the FDA has approved them only for people who have genetic high cholesterol, known as familial hypercholesterolemia, or who have serious heart disease—including those who have had a heart attack or stroke.

PCSK9 inhibitor brand names

  • Alirocumab (Praluent)
  • Evolocumab (Repatha)

Side effects and risks associated with PCSK9 inhibitors

Side effects of PCSK9 inhibitors are typically mild and include back pain and cold or flu symptoms. You may experience redness or pain around the injection site. In rare cases, these medications can cause an allergic reaction, causing a rash, facial swelling, or trouble breathing. These are medical emergencies that require immediate attention. 

Special considerations for taking PCSK9 inhibitors

These medications can be taken on their own or along with a statin drug. While PCSK9 inhibitors are far more expensive than other cholesterol medications, they have a powerful effect on cholesterol levels and reducing the risk of cardiovascular events. If your insurance doesn’t cover enough of the cost to make PCSK9 affordable for you, your doctor can help you apply for a patient assistance program to reduce your cost. 

ATP citrate lyase (ACL) inhibitors

ACL inhibitors are cholesterol-lowering drugs that block the production of cholesterol in the liver. They’re typically used with statins and lifestyle modifications to lower LDL cholesterol in people who have atherosclerosis cardiovascular disease (ASCVD) or familial heterozygous hypercholesterolemia, a genetic cause of high cholesterol. 

ACL inhibitors were approved by the FDA in 2020 to lower cholesterol.

ALC inhibitor brand names

  • Bempedoic (Nexletol)
  • Bempedoic acid and ezetimibe (Nexlizet)

Risks and side effects of taking ACL inhibitors

Common side effects of ACL inhibitors include:

  • Abdominal or joint pain
  • Severe dizziness
  • Flu-like symptoms
  • Muscle pain or spasms
  • Itching and swelling of the face, throat, or tongue
  • Trouble breathing 
  • Backache

Serious side effects may include:

  • High levels of uric acid in the blood
  • Irregular, fast heartbeats in the upper chambers of the heart (atrial fibrillation, or A-fib)
  • Increased liver enzymes
  • Difficulty urinating
  • Severe pain, redness, or swelling of the joints
  • Damage to tendons, such as bruising after a tendon injury or hearing a snap or pop in the tendon area
  • Decreased white blood cell counts

Special considerations for taking ACL inhibitors

You shouldn’t become pregnant while taking ACL inhibitors, and if you’ve ever had gout, tendon problems, or liver or kidney disease, your doctor may not recommend this medication. 

Niacin

Niacin is a B-vitamin that can help lower cholesterol when taken in larger doses as prescribed by your doctor. Niacin helps increase good cholesterol, reduce bad cholesterol, and lower triglyceride levels. It may be prescribed along with a statin to boost its effects. While niacin is available as an over-the-counter vitamin supplement, taking these supplements without consulting your doctor could have serious side effects. 

Niacin brand names

  • Niaspan
  • Niacor

Risks and side effects of niacin

Mild side effects associated with niacin may include:

  • Flushing and redness in the face or neck
  • Diarrhea
  • Upset stomach
  • Headache
  • Skin rash

Serious side effects may include:

  • Liver damage
  • Severe muscle pain or weakness
  • Changes in heartbeat rhythms
  • Changes in blood pressure
  • Severe flushing or skin rash
  • Glucose intolerance
  • Vision changes
  • Gout

Special considerations for taking Niacin

Some brands of prescription niacin need to be taken with a snack or meal. Drinking alcohol and hot drinks may increase flushing, so you should avoid these. While you’re taking niacin, you should eat a low-fat diet.

Fibrates

Fibrates are prescribed to adults for hypertriglyceridemia, or isolated increases in triglyceride levels. They may also help increase your “good” HDL cholesterol. Certain fibrates are sometimes used as a secondary treatment to lower LDL cholesterol if it’s not well-controlled on a statin alone.

Fibrate brands

  • Fenofibrate (TriCor)
  • Gemfibrozil (Lopid)

Risks and side effects of taking fibrates

Side effects of fibrates may include:

  • Headaches
  • Constipation
  • Diarrhea
  • Stomach pain
  • Dizziness

Serious side effects may include:

  • Abdominal pain
  • Muscle pain or weakness
  • Yellowing of the skin
  • Skin rash

Special considerations for taking fibrates

People who have liver, gallbladder, or kidney conditions shouldn’t take fibrates. Before starting fibrate therapy, you’ll need to start a cholesterol-lowering diet.

Omega-3s

Omega-3 fatty acids are found naturally in fatty fish and many types of nuts, and they’re essential for good heart health. Omega-3 prescriptions lower high triglyceride levels. Triglyceride levels above 200 mg/dL are considered elevated, but at this time, prescriptions for omega-3 fatty acids are approved by the FDA only for people who have very high triglycerides—above 500 mg/dL. Research shows that omega-3 prescription medications can reduce triglycerides by 20 to 30 percent, and they may increase “good” HDL cholesterol. Omega-3 prescriptions can be taken with statin medications.

Omega-3 prescription brands

  • Epanova
  • Lovaza
  • Omtryg
  • Vascepa

Risks and side effects of omega-3 prescriptions

While prescription strength omega-3s can lower triglycerides and increase HDL cholesterol levels, they may also raise your “bad” LDL cholesterol. Your doctor will consider a range of factors when deciding whether omega-3 is right for you, including whether you’re pregnant or breastfeeding, take blood thinners, or have an allergy to fish or shellfish.

Side effects of prescription omega-3s vary by brand and may include:

  • Stomach pain
  • Nausea
  • Diarrhea
  • Burping
  • Unpleasant taste in the mouth
  • Joint pain

Special considerations for taking omega-3s

Prescription omega-3s may affect the blood’s ability to clot, so if you take blood thinners, such as warfarin or NSAIDs like aspirin or ibuprofen, you’ll need to take extra precautions to avoid injury. Although omega-3 supplements are available over the counter, these are not the same as prescription omega-3s, and you should talk to your doctor before taking them.

FAQs about cholesterol medications

Do you have to stay on statin cholesterol medication forever?

Not necessarily. You can stop taking a statin under the supervision of your doctor, but if you have a history or elevated risk of heart attack or stroke, taking statins for the rest of your life can reduce your risk of high cholesterol, heart attack, and stroke by as much as 50 percent

Do you have to change your lifestyle if you’re on cholesterol medication?

Ideally, yes. Medications help lower cholesterol and reduce your risk of heart disease, heart attack, and stroke—but they’re not magical, and they work far better when combined with a healthy lifestyle that includes regular exercise, healthy food, and stress management.

What does my doctor need to know in order to prescribe the right medication for me?

Before prescribing cholesterol-lowering medication, your doctor will consider a wide range of factors, including your cholesterol levels, ASCVD score, lifestyle, and medical and family histories. It’s important to tell your doctor about all medications and supplements you’re taking, since some may interact negatively with certain cholesterol-lowering drugs. Also, be honest about your alcohol and drug use, including smoking.

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