High Cholesterol

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Treatment

Treatment for high cholesterol depends on which lipid is high. The focus here is on management of high LDL ("bad") cholesterol levels. In some cases, LDL cholesterol can be lowered without medication (nonpharmacological therapy), and in other cases, medication (pharmacological therapy) is necessary.

Nonpharmacological Therapy
Standard nonpharmacological therapy consists primarily of modifying diet and lifestyle. This therapy may modestly reduce LDL cholesterol, but is not likely to lower the LDL cholesterol level more than about 30 mg/dL.

In patients without atherosclerosis who have modestly elevated LDL cholesterol levels, treatment with medication is not urgent, and an initial 6–12 month trial of nonpharmacological therapy may be advised. If the LDL cholesterol falls to an acceptable level within this time, the patient can continue with this treatment only. If the level remains high, however, pharmacological therapy should be initiated.

Lifestyle changes that may lower LDL cholesterol levels include the following:

• Diet. Minimize cholesterol and fat intake, especially saturated fat, which raises cholesterol levels more than any other substance. Cholesterol and saturated fats are found primarily in foods derived from animals, such as meats and dairy products. Dietary guidelines for reducing cholesterol and fat consumption:
  1. Eat lean fish, poultry, and meat. Remove the skin from chicken and trim the fat from beef before cooking.
  2. Avoid commercially prepared and processed food (e.g., cakes, cookies) and breaded fried foods.
  3. Increase the intake of fruits, vegetables, breads, cereals, rice, legumes (e.g., beans, peas), and pasta.
  4. Use skim or 1% milk.
  5. Eat no more than 2 egg yolks (or whole eggs) per week.
  6. Use cooking oils that are high in unsaturated fat (e.g., corn, olive, canola, safflower oils)
  7. Use soft margarine, which contains less saturated fat than butter.

• Weight loss. Losing a modest amount of weight (even 5-10 lbs.) can double the reduction in LDL levels achieved through an improved diet. Weight loss should be gradual.
• Exercise. Exercise can decrease LDL levels and increase HDL levels. For example, taking a brisk 30-minute walk 3-4 times a week can positively impact cholesterol levels. Patients with chest pain and/or known or suspected heart disease should talk to their physician before beginning any exercise program.

The Food and Drug Administration (FDA) recently approved two cholesterol-lowering margarine products (Benecol® and Take Control®). These margarines contain plant-derived substances that can decrease the absorption of cholesterol in the digestive tract and may reduce cholesterol by about 7–10%. They should not be used instead of drug therapy, but may be added to a nonpharmacological treatment plan for high cholesterol.

Pharmacological Therapy (Medication)
The introduction of HMG-CoA reductase inhibitors (statins) has significantly advanced the treatment of hypercholesterolemia. Statins can reduce LDL cholesterol levels by 20–40% and, at maximum doses, they can lower levels by 40–50%. They also can modestly increase HDL ("good") cholesterol levels, usually by about 5–10%.

These medications are usually well tolerated, have few side effects, and are taken once or twice a day. Because the body produces cholesterol primarily during the night, these medicines usually are taken after dinner or during the evening. Higher doses can be split and taken once in the morning and once in the evening.

Commonly prescribed statins include the following:

• Atorvastatin (Lipitor®)
• Fluvastatin (Lescol®)
• Lovastatin (Mevacol®)
• Pravastatin (Pravachol®)
• Rosuvastatin calcium (Crestor®)
• Simvastatin (Zocor®)

Rare side effects associated with statins include mild inflammation of the liver, muscle inflammation, pain, and weakness. Inflammation of the liver can be detected by liver function tests, which usually are performed once or twice during the first several months of therapy and periodically (e.g., twice a year) thereafter. Patients who experience severe muscle pain or weakness or any uncomfortable side effect should speak with their physician.

Lipitor® has been combined with the blood pressure-lowering drug Norvasc® to treat patients with high cholesterol and high blood pressure. This combination drug, which is called Caduet®, offers the convenience of taking only one medication to control both conditions.

Other cholesterol-lowering medications can be used alone, or combined with a statin, to reduce cholesterol to an acceptable level. Combining medications may increase the risk for liver and/or muscle inflammation.

Other medications include the following:

• Cholestyramine (LoCHOLEST®, Questran®)
• Colestipol (Colestid®)
• Fenofibrate (Tricor®)
• Fluvastatin (Lescol®)
• Gemfibrozzil (Lopid®)
• Niacin (Niacinol®, Niacor®, Nicolar®, Slo-Niacin®)

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