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The Lowdown on Cholesterol-Lowering Medications

Figuring out which to use depends on what your needs are

SUNDAY, June 9, 2002 (HealthDayNews) -- You can hardly turn on a TV or flip through your favorite magazine without seeing an ad for at least one of the widely touted cholesterol-lowering drugs.

Indeed, although most doctors advise diet, weight loss and exercise as the first line of defense against cholesterol problems, for many people medication becomes the necessary alternative, particularly for those at high risk of heart disease.

But how do you know if you really need medication? And if you do, which of the many cholesterol-lowering drugs are right for you?

Before you can answer that question, it's important to know a little something about what cholesterol is and how it affects our health.

"Cholesterol is a kind of waxy compound that is both made in the body and found in foods," says Dr. Dan Fisher, clinical assistant professor of cardiology at New York University Medical Center.

About 85 percent of the cholesterol circulating in our blood is made naturally in the body by the liver, says Fisher. The remainder comes from the foods we eat -- primarily fats found in poultry, beef, seafood and dairy products.

You may have also heard the terms "good" and "bad" cholesterol. The so-called "bad" cholesterol, also known as LDL (low density lipoprotein) is what causes blood vessels to "clog." This occurs when these tiny, waxy particles begin sticking to vessel walls, narrowing the pathway by which blood flows through the body.

"When blockages form in the vessels leading to the heart, your risk of heart attack increases dramatically," says Dr. LeRoy Rabbani, director of Cardiac Intensive Care at Columbia Presbyterian Medical Center in New York City. Likewise, when those blockages occur in a vessel leading to the brain, a stroke can occur.

The job of the "good" cholesterol, known as HDL (high density lipoprotein), is to act as a kind of "drain cleaner," says Rabbani, helping to pull the "bad" cholesterol from the bloodstream.

The goal, both doctors say, is to keep HDL cholesterol high, while reducing LDL cholesterol.

One way to do that is by reducing the amount of cholesterol-rich, high saturated fat foods you eat. Doing so can "effectively lower cholesterol by as much as 20 percent in some people," says Rabbani.

However, when LDL cholesterol levels rise too high and HDL levels drop too low, or if your risk of heart attack is high, then medication usually becomes necessary, Rabbani and Fisher say.

Which one you choose, however, depends somewhat on the specific goals you are trying to accomplish -- raising your HDL, lowering your LDL, or a combination of both.

According to Fisher and Rabbani, the four types of cholesterol-lowering medications available today are:

  • Statin drugs, also known as HMG-CoA reductase inhibitors. They include medications such as Lovastatin (brand name, Mevacor), Simvastatin (Zocor) and the newest, Atorvastatin (Lipitor). They work primarily in the liver to reduce the amount of cholesterol being made. Their main goal is to reduce LDL, and can do so by as much as 40 percent.
  • Resin drugs, which include the medications Cholestyramine (Questran) and Colestipol (Colestid). They work by encouraging the liver to produce more of a substance called bile acid that binds with cholesterol, keeping it from circulating in the blood. These drugs also work primarily on LDL cholesterol.
  • The B vitamin Niacin -- in therapeutic doses. The main job of niacin is to lower the levels of triglycerides, another type of blood fat that can contribute to cholesterol-related damage. It can also lower LDL and increase HDL. So, it becomes a kind of all-around heart-healthy medication.
  • Fibrate drugs, including the medications Gemfibrozil (Lopid) and Fenofibrate (Tricor). They work primarily by lowering triglyceride levels and increasing HDL levels. They have little direct effect on LDL cholesterol.

Sometimes, a combination of drugs becomes necessary. Commonly prescribed duos include statins with fibrates, or statins with niacin, Rabbani says.

While combining drugs increases the risk of some side effects, including potentially fatal muscle weakness, Rabbani says the complication is rare, and can usually be detected long before any permanent or life-threatening damage occurs.

It's also important to note that each of the drugs works differently and all have different molecular structures. So, if one isn't doing the job, or if side effects become intolerable, you should feel comfortable about trying a different drug, even within the same category, Fisher says.

What To Do

To learn more about how cholesterol works in the body and which drugs and diet regimens work best, visit the National Heart, Lung, and Blood Institute's National Cholesterol Education Program.

How do you know when your cholesterol levels are too high? Check the American Heart Association for the latest advice. The AHA also offers recipes for low-fat and low-cholesterol meals.

SOURCES: Interviews with Dan Fisher, M.D., associate professor of cardiology, New York University Medical Center, New York City; LeRoy Rabbani, M.D., director of Cardiac Intensive Care, Columbia Presbyterian Medical Center, New York City
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