If a healthful diet, regular exercise, and weight loss do not bring your total cholesterol or LDL levels down to your target, your doctor may prescribe a cholesterol-lowering medication, or a combination of more than one. You also may need to take these drugs if you have even mod- erately high cholesterol and also have a medical condition such as heart disease, thyroid disease (hypothyroidism), diabetes, or kidney disease. Your doctor will consider your age and family history as well as your risk status (see box, page 21) to determine what target cholesterol level is appropriate for you, and whether drugs are needed.
If you are at high risk or very high risk, your doctor may recommend drugs to lower your LDL cholesterol aggressively, to less than 70 mg/dL. If you are at moderate risk, drugs will probably be recom- mended if your LDL is higher than 130. On the other hand, drug ther- apy is not necessarily appropriate for everyone—for example, for frail elderly people who have high cholesterol levels but who do not have heart disease or diabetes.
It is important to discuss your medical history and lifestyle with your doctor before you begin taking cholesterol-lowering medications. Tell him or her about any other medications, vitamins, or herbal supple- ments you are taking. (Some drugs can interact with one another in a harmful way.) You and your doctor will also need to talk about what other illnesses you have, particularly if you have had liver problems, diabetes, gout, ulcers, or kidney or gallbladder disease, because some cholesterol-lowering medications can make these problems worse.

There are ?ve main types of cholesterol-lowering drugs, each with a different method of action in your body.
• Statins (or HMG CoA reductase inhibitors). The most com- monly prescribed cholesterol-lowering drugs are statins, which block the activity of an enzyme (HMG CoA reductase) in your body that helps you make cholesterol. As your cholesterol produc- tion slows down, your liver makes more LDL receptors. These receptors attract LDL particles in your blood and further lower your LDL levels. In addition to lowering cholesterol levels, statins may have other positive effects such as reducing in?ammation and improving the working of the cells that line the blood vessels. Many people can take statins without dif?culty, but the drugs can cause side effects in some people such as constipation, abdominal pain, or cramps. These side effects are likely to lessen or disappear the longer you take the drug. Statins are usually taken at bedtime, because the body produces more cholesterol in the evening. If you develop any muscle cramps or muscle weakness, alert your physi- cian because this might represent a more serious side effect. Mus- cle aches affect both sides of the body and commonly occur in large muscle groups such as those in the shoulders and the thighs. While taking statins, you need to have a blood test periodically to make sure your liver is not being affected by the drugs. Examples of statins include lovastatin, pravastatin, simvastatin, atorvastatin, and rosuvastatin.

• Bile acid sequestrants (or resins). Your liver uses cholesterol to produce bile, an acid involved in the digestive process. These drugs bind chemically to bile in the intestine, preventing the bile from being reabsorbed; the bile is subsequently eliminated from the body in the stool. Your liver responds by using more choles- terol, which is a building block of bile, to make more bile. As a result, less cholesterol is left to enter your bloodstream. Bile acid sequestrants may have side effects such as constipation, stomach bloating, upset stomach, or heartburn. Examples of bile acid sequestrants are cholestyramine, colestipol, and colesevelam.

• Nicotinic acid (niacin). This product is a form of vitamin B that slows the liver’s production of certain components of LDL. It also can lower triglycerides and raise HDL. Possible side effects of nicotinic acid include ?ushing, upset stomach, a gout attack, or abnormal heart rhythms. The ?ushing can be reduced by taking an aspirin 30 minutes before taking the nicotinic acid. If niacin is prescribed, it should be started at low doses and increased gradu- ally. Alcohol should not be consumed for two hours after taking niacin because of a possible increase in ?ushing. Episodes of ?ush- ing may be curbed with a chewable adult-dose aspirin or liquid ibuprofen (like aspirin, a nonsteroidal in?ammatory product).

• Fibric acid derivatives (or fibrates). These drugs inhibit the production of the particles that may contain triglycerides and also stimulate enzymes that break down fats. Fibric acid derivatives may be prescribed to lower your triglycerides. They can cause side effects such as upset stomach, vomiting, gas, or headache, and they may increase the risk of gallstones. Examples of ?brates include gem?brozil and feno?brate.

• Cholesterol absorption inhibitors. This is a newer class of drugs that inhibits the uptake of cholesterol by the small intestine. Eze- timibe is the ?rst drug developed in this category, and it can be given with any statin. Currently, the statin drug simvastatin is manufac- tured with ezetimibe in a combination pill. Ezetimibe is often pre- scribed for people with high cholesterol levels who cannot take a statin. Side effects may include stomach pain, feeling tired, or aller- gic reactions such as swelling in your throat. Inform your doctor promptly if these side effects occur.

You may not have any side effects at all from your medications, or you may experience some that are not mentioned here. Be sure to tell your doctor immediately if you think you might be experiencing side effects from the drugs you are taking. But don’t stop taking them without checking with your doctor ?rst; going off medication abruptly can make your condition worse. These drugs should not be used during pregnancy (with the exception of bile acid sequestrants) because the effects on developing fetuses are not yet known.