Who Should Be Treated
In a sense, everyone. That’s because no cholesterol level is too good. But people with unhealthy levels should work hard to improve, while those with ideal results can afford to relax a bit. Table 1 shows the goals established by the Expert Panel on Detection, Evaluation, and Treatment of High Blood Cholesterol in Adults.
Cholesterol is a crucial determinant of cardiovascular health, but it’s only one. In fact, smoking is even more dangerous than unhealthy cholesterol levels, and high blood pressure, diabetes, and lack of exercise are nearly as harmful. Because each risk factor adds to the harm of others, people with the most risk need the most vigorous treatment. Table 2 shows how an individual’s risk profile influences the choice of therapy.
Prescription Drugs For Cholesterol And Triglycerides
From statins like Lipitor to PCSK9 inhibitors like Repatha to niacin and beyond, several kinds of medications are regularly prescribed to treat high cholesterol and triglyceride levels.
Which is most appropriate for you depends on several factors, but its likely your healthcare provider will want you to begin taking prescription medication if diet and exercise are not enough to lower your levels, or if your risk for cardiovascular disease is particularly elevated.
This article will help you learn about the possible prescription options your healthcare provider might suggest so you can take an active role in your treatment discussions and decisions.
Mechanism Accounting For The Statin Induced Lipid Effects
Statins are competitive inhibitors of HMG-CoA reductase, which leads to a decrease in cholesterol synthesis in the liver. This inhibition of hepatic cholesterol synthesis results in a decrease in cholesterol in the endoplasmic reticulum resulting in the movement of sterol regulatory element binding proteins from the endoplasmic reticulum to the golgi where they are cleaved by proteases into active transcription factors . The SREBPs then translocate to the nucleus where they increase the expression of a number of genes including HMG-CoA reductase and, most importantly, the LDL receptor . The increased expression of HMG-CoA reductase restores hepatic cholesterol synthesis towards normal while the increased expression of the LDL receptor results in an increase in the number of LDL receptors on the plasma membrane of hepatocytes leading to the accelerated clearance of apolipoprotein B and E containing lipoproteins . The increased clearance of LDL and VLDL accounts for the reduction in plasma LDL-C and triglyceride levels. In patients with a total absence of LDL receptors statin therapy is not very effective in lowering LDL-C levels.
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Drugs That Work In Your Intestines
What they are: Your doctor may call these âbile acid resinâ drugs or âbile acid sequestrants.â The work inside your intestines. They attach to bile from the liver and keep it from being absorbed back into your blood. Bile is made largely from cholesterol, so these drugs whittle down the body’s supply of cholesterol.
A different type of drug, ezetimibe , lowers âbadâ LDL cholesterol by blocking cholesterol absorption in your small intestine. Studies have found that in people who have had a heart attack, it can make a small cut in the risk of heart âevents,â such as another heart attack, when you also take a statin.
Side effects: For bile acid drugs, the most common side effects are constipation, gas, and upset stomach. For ezetimibe, the most common ones include muscle or back pain, diarrhea, and abdominal pain.
What Are The Side Effects Of Fibrates
The side effects of fibrates include nausea, stomach upset, and sometimes diarrhea. Fibrates can irritate the liver. The liver irritation usually is mild and reversible, but it occasionally can be severe enough to require stopping the drug.
Fibrates can cause gallstones when used for several years.
Fibrates can increase the effectiveness of blood thinners, such as warfarin , when both medications are used together. Thus, the dose of warfarin should be adjusted to avoid over-thinning of the blood which can lead to excessive bleeding.
Fibrates can cause muscle damage particularly when taken together with statin medications. Gemfibrozil interferes with the breakdown of certain statins , resulting in higher statin blood levels, and hence a higher likelihood of muscle toxicity from the statin. Doctors generally avoid combining a statin with fibrates because of concern over the higher risk of muscle damage with the combination. Gemfibrozil should not be combined with simvastatin and if combined with lovastatin the dose of lovastatin should not exceed 20 mg daily. However, fenofibrate does not interfere with the breakdown of statins and should be the safer fibrate to use if it is necessary to use a fibrate with a statin. Furthermore, pravastatin seems to have fewer muscle toxic effects than the other statins when combined with fibrates, but the risk still exists.
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What Are The Risks Of Taking Fiber
- Side effects. Fiber does not have serious side effects. At high levels, it can cause bloating, cramping, gas, and perhaps worsening constipation. Drinking more water â 2 liters a day â may help.
- Interactions. If you take any regular medications, talk to a doctor before you start using a fiber supplement. It may block the absorption of some drugs.
- Risks. Rarely, fiber supplements have caused intestinal blockages. If you have any chronic disease, talk to a doctor before you start using a fiber supplement. The sugar and salt in some supplements, particularly powders, might be risky for people with diabetes or high blood pressure. People with diabetes may want to choose a sugar-free powder or another form of fiber. Blond psyllium is the most common type of fiber supplement on the market.
Effect Of Statin Therapy On Clinical Outcomes
A large number of studies using a variety of statins in diverse patient populations have shown that statin therapy reduces atherosclerotic cardiovascular disease. The Cholesterol Treatment Trialists have published meta-analyses derived from individual subject data. Their first publication included data from 14 trials with over 90,000 subjects . There was a 12% reduction in all-cause mortality in the statin treated subjects, which was mainly due to a 19% reduction in coronary heart disease deaths. Non-vascular causes of death were similar in the statin and placebo groups indicating that statin therapy and lowering LDL-C did not increase the risk of death from other causes such as cancer, respiratory disease, etc. Of particular note there was a 23% decrease in major coronary events per 1 mmol/L reduction in LDL-C. Decreases in other vascular outcomes including non-fatal MI, coronary heart disease death, vascular surgery, and stroke were also reduced by 20-25% per 1 mmol/L reduction in LDL-C. Additionally, analysis of these studies demonstrated that the greater the reduction in absolute LDL-C levels the greater the decrease in cardiovascular events. For example, while a 40mg/dl decrease in LDL-C will reduce coronary events by approximately 20%, an 80mg/dl decrease in LDL-C will reduce events by approximately 40%. These results support aggressive lipid lowering with statin therapy.
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Be Mindful Of What You Put In Your Coffee
Though the research is mixed on whether coffee itself can raise your cholesterol levels, researchers do know that saturated fat increases your cholesterol levels. And saturated fat can be found in a lot of things we put in coffee. Here are a few to avoid or enjoy sparingly.
- Cream and half-n-half. The classic coffee lighteners made with whole-fat milk have high levels of saturated fat, which has been shown to increase levels of LDL cholesterol. More cholesterol-friendly choices include nonfat or low-fat options or plant-based milks with no saturated fat.
- Sweet coffee drinks. Those frothy, sugary coffee concoctions popping up at more and more coffee shops have more in common with a milkshake than a cup of coffee and, besides packing in a lot of sugar, may contain ingredients high in saturated fat. Ask about ingredients before you indulge.
- Bulletproof coffee. Popular with fans of the ketogenic diet, bulletproof coffee is a breakfast substitute that calls for adding butter and coconut oil into your daily cup of joe. Both have high levels of saturated fat and there have been several case reports of people who regularly drink bulletproof coffee having sharp rises in their LDL cholesterol.
The bottom line for coffee and cholesterol is the same as many foods and beverages: Enjoy it in moderation, be mindful of how it is made, and know what ingredients are going into it.
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Mechanism Accounting For The Omega
While not the primary mechanism for the decrease in plasma TGs, studies have shown that omega-3-fatty acids may increase the clearance of TG rich lipoproteins . Post heparin lipoprotein lipase activity is not increased by omega-3-fatty acid administration but the lipolytic activity of non-stimulated plasma is enhanced . Additionally, apolipoprotein C-III levels are decreased with omega-3-fatty acid administration which could also contribute to an increase in the clearance of TG rich lipoproteins .
The increase in LDL-C levels that occurs in patients with marked hypertriglyceridemia treated with omega-3-fatty acids is thought to be due to the enhanced conversion of VLDL to LDL .
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What Causes High Cholesterol And Why Is It Harmful
People with high cholesterol or triglycerides have abnormally high levels of fats in their blood. Cholesterol is produced in the liver and is used by cells throughout the body. Its found in fatty foods such as eggs, red meat and cheese. Triglycerides are the result of extra calories stored in the body when not used for energy. Theyre produced by the liver but also come from some foods including red meat, dairy, refined carbohydrates or sugars and alcohol.
Low-density lipoprotein is known as the bad cholesterol because it can result in a buildup of plaque known as atherosclerosis, which leads to blockages in your blood vessels and increases your risk for heart disease or stroke.
In general, LDL below 100 milligrams/deciliter is considered good. However, recent studies show that LDL levels below 30-50 mg/dL are even more effective in preventing heart disease. Triglyceride levels less than 150 mg/dL are considered good, although less than 100 is ideal.
Why Should You Treat High Cholesterol
Most people with high cholesterol wont experience any adverse symptoms at first. This might make you think you dont need to worry about your cholesterol levels, but this isnt the case.
Untreated high cholesterol puts you at increased risk of significant health problems, some of which can be fatal. These complications include :
- Coronary artery disease
- High blood pressure
Clinical trials have shown that if you and your provider decide to use a cholesterol-lowering medication, you can cut your risk of heart disease by as much as 2030% .
High cholesterol is often a lifelong condition, but it is usually easily managed through a heart-healthy diet, lifestyle changes, and cholesterol medications. Talk with your healthcare provider about when to have your cholesterol levels tested and whether starting on a cholesterol-lowering medication is right for you.
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How Can I Lower My Cholesterol
If the lifestyle changes alone do not lower your cholesterol enough, you may also need to take medicines. There are several types of cholesterol-lowering drugs available, including statins. If you take medicines to lower your cholesterol, you still should continue with the lifestyle changes.
Some people with familial hypercholesterolemia may receive a treatment called lipoprotein apheresis. This treatment uses a filtering machine to remove LDL cholesterol from the blood. Then the machine returns the rest of the blood back to the person.
NIH: National Heart, Lung, and Blood Institute
How Are Fats And Cholesterol Connected In Cats
Fats, including cholesterol, are carried in the blood in complex compounds that also contain protein: so-called lipoproteins.
These include triglycerides, cholesterol and phospholipid linked to apopproteins, which are manufactured in cells of the liver and intestines. Apolipoproteins are synthesized in the liver or in intestinal cells.
There are four major lipoprotein classes in cats, as follows:
Chylomicrons and Very low density lipoproteins carry triglycerides in the blood
Low density lipoproteins and High density lipoproteins carry cholesterol in the blood. In cats, HDL outnumbers LDL by 5:1, while in humans, LDL is the main carrier of cholesterol.
Many humans are aware of these abbreviations from their own blood test results, but its important to remember that the significance of abnormal levels is very different in humans compared to cats.
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Lifestyle Management For High Triglycerides
If your triglyceride levels fall into the borderline high category, says Jacoby, Its extremely likely that making lifestyle improvements alone will control your levels. Most often, people with moderate levels have metabolic problems, including prediabetes and diabetes, which also respond well to healthy lifestyle changes.
The AHA/ACC guidelines recommend the following lifestyle changes to lower levels:
- Reduce your body weight
- Reduce your carbohydrate consumption
- Eat omega-3 fatty acids
Combining a low-carb diet with exercise and fish oil is often enough to get control of your triglycerides, says Jacoby, and can have the additional benefit of addressing metabolic problems and reducing body weight. For the majority of people with moderate to severe elevations, triglyceride levels are very responsive to a heart-healthy lifestyle. Its worth trying to normalize through those changes and then move on to medications if lifestyle isnt sufficient, he says.
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Otc Supplements For The Management Of High Cholesterol
Emily M. Ambizas, PharmD, MPH, CGPAssociate Clinical ProfessorCollege of Pharmacy & Health SciencesQueens, New YorkClinical Specialist, Rite Aid PharmacyWhitestone, New York
US Pharm. 2017 42:8-11.
Cardiovascular disease remains the leading cause of mortality and morbidity in the United States, with coronary artery disease being the number-one cause of death.1 Dyslipidemia is a major contributor to the development of CAD and other forms of atherosclerosis individuals with high total cholesterol levels have about twice the risk for heart disease. Approximately 100 million adults in the U.S. have total cholesterol levels > 200 mg/dL , and almost 74 million have high levels of low-density lipoprotein cholesterol .2,3 Adults aged > 20 years should have their cholesterol measured at least once every 5 years.2
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What Are Risk Factors For High Triglycerides
Factors that may raise triglyceride levels include:
- Excessive alcohol use.
- American Academy of Family Physicians. High Cholesterol. Accessed 11/182/2021.
- American Heart Association. Cholesterol. Accessed 11/18/2021.
- Centers for Disease Control and Prevention. Getting Your Cholesterol Checked. Accessed 11/18/2021.
- Hormone Health Network. Triglycerides. Accessed 11/18/2021.
- MedlinePlus. Triglycerides Test. Accessed 11/18/2021.
- Merck Manual Consumer Version. Overview of Cholesterol and Lipid Fats. Accessed 11/18/2021.
- National Heart, Lung and Blood Institute. High Blood Triglycerides. Accessed 11/18/2021.
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What Qualifies As High Triglycerides
According to MedlinePlus , blood levels less than 150 mg/dL fall under the triglycerides normal range, while anything higherknown as hypertriglyceridemiacan increase risk for heart disease. Elevated triglycerides can also be a very early sign of diabetes, states Kristin Thomas, MD, a board-certified internist and co-founder of Foxhall Medicine in Washington, DC.
Extremely high triglyceridesblood levels over 500 mg/dLmay be due to a genetic disorder and can increase the risk of pancreatitis, along with heart disease, including atherosclerosis , Dr. Thomas, co-author of You Can Prevent A Stroke, explains. It can be seen alone or in association with many other conditions, as well, such as metabolic syndrome, hypothyroidism, fatty liver disease and kidney disease, Dr. Malaney says.
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How Do Statins Work
Statins work by slowing down the production of LDL-cholesterol in the liver, where its made. Because the liver isnt making so much cholesterol, it then takes cholesterol out of your blood to make bile with, so your blood cholesterol levels fall.
Statins slow down LDL-cholesterol production by blocking an enzyme called HMG-CoA-Reductase the medical name for statins is HMG-CoA Reductase inhibitors. Enzymes are proteins in the body which speed up normal processes. In this case, LDL production.
Statins can lower your triglycerides
As well as lowering your LDL-cholesterol, statins can lower your triglycerides too, and high triglycerides are linked to liver disease, heart disease and diabetes.
Statins can raise HDL cholesterol
Statins can sometimes raise your HDL-cholesterol the type of cholesterol which helps to clear the fat from of your arteries.
Effect Of Statins Therapy On Clinical Outcomes In Specific Patient Groups
The key issue is âwhich primary prevention patients should be treatedâ and this is still controversial. It should be noted that the higher the baseline risk the greater the absolute reduction in events with statin therapy. For example, in a high-risk patient with a 20% risk of developing a vascular event, a 25% risk reduction will result in a 15% risk of an event . In contrast in a low-risk patient with a 4% risk of developing a vascular event, a 25% risk reduction will result in a 3% risk . Thus, the absolute benefit of statin therapy over the short term will depend on the risk of developing cardiovascular disease.
Additionally, based on the Cholesterol Treatment Trialists results the reduction in cardiovascular events is dependent on the absolute decrease in LDL-C levels. Thus, the effect of statin treatment will be influenced by baseline LDL levels. For example, a 50% decrease in LDL is 80mg/dl if the starting LDL is 160mg/dl and only 40mg/dl if the starting LDL is 80mg/dl. Based on studies showing that a decrease in LDL of 1 mmol/L reduces cardiovascular events by ~20% the relative benefit of statin therapy will be greater in the patient with the starting LDL of 160mg/dl than in the patient with the starting LDL of 80mg/dl . Thus, decisions on treatment need to factor in both relative risk and baseline LDL levels.
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