Treatment and Management
Options
If you're diagnosed with high cholesterol, you'll
start treatment once your doctor has received
your complete medical history, and you've undergone
a physical examination and blood workup. After
your treatment begins, you'll need to come in
for regular blood tests, blood pressure measurements,
and weight checks. Your doctor will also check
on your diet and exercise.
Depending on your progress, you and your doctor
might decide to try one or more treatment options:
Lifestyle Changes
Your lifestyle -- what you eat and drink, how
much you exercise, and habits such as smoking
-- can contribute directly to high cholesterol
and heart disease. Conversely, positive lifestyle
changes can help lower your cholesterol.
Talk to your doctor about what steps you can
take to lower your cholesterol and your risk
of heart disease. He or she may recommend:
• Diet
• Exercise
• Stress reduction
Diet
Eating healthy can lower your cholesterol, help you lose weight and lower your
risk of developing heart disease. In fact, research has shown that lowering
the cholesterol and saturated fat in your diet can help lower your total
blood cholesterol and LDL levels
up to 15% (amount varies). The best way to determine the cholesterol and
fat content of the food you eat is to read
food labels.
Your physician or a registered dietitian can
also help you choose the best
foods to eat. One's diet needs to be higher
in fruits and vegetables (5 servings per day)
and higher in fiber (bread, cereals, fruits and
vegetables). Consider replacing butter with olive
oil. Eat fatty fish twice per week (salmon, mackerel).
Exercise
According to the American Heart Association® Aerobic exercise can help
you control your cholesterol, as well as lower your blood pressure and increase
your physical fitness, energy, and self-esteem. It can also keep the weight
off and increase HDL. Each person's
fitness needs are different. Your needs will depend on your age, current health
and health goals, so be sure to talk to your doctor before beginning any exercise
program.
Most adults should accumulate 30 minutes or
more of moderate to intense physical activity
on most days of the week. You can do a few short
bouts of exercise that add up to a daily total
of 30 minutes or more. If your goal is weight
loss, you should exercise a total of at least
180 minutes each week.
Choose a sensible and fun exercise routine,
so you'll stick with it. Even daily living activities,
such as daily chores, can count! In order for
a workout to be qualified as "aerobic," it needs
to elevate your heart rate for more than 10 minutes
at a time.
Stress reduction
Reducing and controlling stress is important
for good health, but especially important for
people with high cholesterol and heart disease.
When under stress for long periods of time, the
body reacts by constricting blood vessels, making
circulation more difficult.
Many people turn to excessive amounts of alcohol,
drugs and smoking to cope with stress, but these
unhealthy choices backfire, because they actually
increase the body's physical response to stress.
Healthy ways to reduce stress include relaxation
exercises, meditation, time management and a
flexible attitude. If you feel stressed, try
to figure out why and make changes where you
can. Sometimes it helps to discuss your feelings
with a health care provider, spiritual adviser
or psychologist.
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Medications
When
lifestyle changes alone don't lower your cholesterol,
your doctor's next step will be to prescribe
a cholesterol-lowering medication, such as:
No matter what medication you are taking, it's
important to see your doctor regularly so he
or she can monitor its safety and effectiveness.
Bile Acid Sequestrents
Bile acid sequestrants help lower total cholesterol
and LDL,
yet has minimal effect on HDL.
They enhance your body's natural ability to cleanse
excess cholesterol from your gut by binding with bile
acids in your intestine to form a complex
that's then excreted in your stool. Bile acid
sequestrants are not absorbed into your system.
These agents can be used either alone for people
with mild elevations of cholesterol or more frequently
in combination with other drugs. Colestid® (Colestipol),
available in powder or tablet form, and Questran® (Cholestyramine),
available only in powder, are both brand-name
bile acid sequestrants. WelChol® (Colesevelam),
available only in pill form, is taken once to
twice per day. It is as effective as other resins
but with much fewer gastrointestinal side effects.
The most frequent side effects include:
• constipation
• bloating
• gas
• nausea
• heartburn
• rash
Fibric Acid Derivatives
Fibric acid derivatives help lower triglycerides.
Limiting your intake of alcohol, fruit juices,
regular soft drinks and simple sugars such as
cookies and cake, in combination with fibrates
can help lower triglyerides further. Fibric acid
derivatives may also moderately increase HDL by
10-15%. Fibrates however are not LDL lowering
drugs.
Side effects are usually mild, but most frequently
include:
• diarrhea
• nausea
• stomach pain
• gas
• muscle pains
• liver damage
• heartburn
You should be able to adjust to the side effects
over time, but if you have concerns, be sure
to talk to your doctor about them.
Fibric acid derivatives may also interact with
other types of medications, most importantly statins,
which increases the risk of muscle damage. If
you have diabetes, your oral antidiabetic medication
or insulin may need to be adjusted. These medications
can also affect the anticoagulant effects
of Coumadin® (Warfarin), which is often prescribed
as a blood thinner, so if you're taking this
medication, your doctor may adjust your dosage.
There are two fibrates: Tricor® (Fenofibrate)
and Lopid® (Gemfibrozil). If you're taking
a fibric acid derivative and miss a dose, don't
double up on the next dose.
Fish Oil
Concentrated fish oil capsules contain the omega-3-fatty
acids eicosapentanoic acid (EPA) and docosahexanoic
acid (DHA). Both EPA and DHA can reduce triglycerides by
10-30% depending on the dose.
Fish oils are most often used in combination
therapy with fibrates or niacin to
further reduce triglycerides.
Fish oils need to be taken 3 times a day with
meals and can give patients a mild upset stomach.
One way to avoid this is to gradually increase
your dosage according to your doctor's recommendations.
HMG Co-A Reductase Inhibitors (Statins)
Doctors prescribe HMG Co-A reductase
inhibitors (statins) primarily to lower LDL,
but they might also decrease triglycerides and
slightly raise HDL.
In general statins decrease LDL by 20-50% depending
on dosage. Statins can modestly reduce reduce
triglycerides by 10-20% and have minimal effect
on HDL, raising it by 5-10%.
Statins should rarely be the first line agents
to reduce triglycerides or raise HDL. These medications
work by blocking an enzyme the
body uses to make cholesterol, so the body actually
manufactures less cholesterol.
There are a variety of HMG Co-A reductase inhibitors:
• atorvastatin (brand name Lipitor®)
• fluvastatin (brand name Lescol®)
• lovastatin (brand name Mevacor®)
• pravastatin (brand name Pravachol®)
• simvastatin (brand name Zocor®)
These medications carry with them two rare,
but serious side effects: muscle pain and liver
disease. Common side effects include upset stomach,
nausea, and diarrhea. Your doctor will monitor
your progress closely. Be sure to keep all your
scheduled appointments and talk to him or her
about any concerns you may have.
Niacin Therapy
In large doses, niacin -- vitamin B3 --
can lower total cholesterol, LDL and triglycerides.
Niacin regardless of the form used will reduce
triglycerides by 20-40% on average while reducing LDL by
5-25% and raising HDL by
15-35% depending on dosage. Although a very small
amount of niacin is present in some foods --
especially leafy green vegetables -- it would
be practically impossible to eat enough to lower
your cholesterol.
Niacin comes in two different forms:
- Immediate-release
- Extended-release
Immediate-release niacin --
which you must take 3 times a day -- is safe
and effective, but causes flushing or itching
of the skin, which can be uncomfortable. Flushing
is the body's response to niacin, and it's not
a danger sign or an allergic response. In most
cases, your body will adjust to the niacin over
time and won't flush even when you increase your
dosage.
Extended-release niacin,
also known as Niaspan®, is taken once a day
and available by a doctor's prescription. You
take it at bedtime with a low-fat snack and the
dose is gradually increased each month to avoid
side-effects.
Over the counter slow release niacin is also
available. One product in particular, Slo-Niacin
is taken twice daily and has been shown to be
effective in improving cholesterol and reducing
atherosclerotic plaque size when added to a statin
drug in patients with established heart disease.
Over the counter Inosital Hexanicotinate is available
and marketed as “no flush niacin”,
but has not been thoroughly studied yet and currently
cannot be recommended.
Whatever form of niacin you're taking, remember
that although flushing is bothersome, it isn't
dangerous and will decrease over time. To decrease
this unpleasant side effect, try these tips:
- After getting your doctor's approval to do
so, gradually increase the dose and take it
with a little bit of food.
- Don't take niacin with any hot drink or alcohol,
which can worsen flushing.
- Avoid spicy foods and monosodium glutamate
(MSG), a common food additive.
- Try to avoid hot showers, saunas and steam
showers, which will all make you more aware
of any flushing you may experience.
If you find the flushing intolerable, talk to
your doctor before switching brands or stopping
your niacin. And, as with any medication, it's
important you see your doctor regularly so he
or she can monitor your progress. Be sure to
call your health care provider right away if
you have persistent abdominal pain, nausea or
fatigue after starting any kind of niacin therapy.
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LDL Apheresis
LDL apheresis is an aggressive and sometimes
lifesaving procedure for people with severe hypercholesterolemia.
Your doctor may recommend this procedure if
your cholesterol remains dangerously high despite
lifestyle changes and combination cholesterol
lowering medication.
During LDL apheresis, the patient's blood
is separated into cells and plasma, then the
plasma is diverted over a column containing
a material that locks onto the LDL cholesterol
and safely removes it without removing the HDL cholesterol.
The plasma is then returned to the patient.
Because the results are temporary, LDL apheresis
is not a cure, and it needs to be repeated
regularly. Back
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Reviewed by: Philippe
Szapary, MD
Last updated: September 2001
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