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Understanding Cholesterol and the Medications to Control it


A Cholesterol Primer

Total Cholesterol
All of the different types added together. The goal is to keep it under 200.

HDL Cholesterol
The good stuff, the more the better. The best value is as far above 35 as possible.

LDL Cholesterol
The bad stuff, the less the better. The best value is under 80, but at least under 130.

Triglycerides
This is the chemical that carries the other half of cholesterol (free fatty acids). Conflicting evidence of causing heart attacks or strokes. Very high levels are associated with pancreatitis. Ideal levels are less than 160.


Cholesterol-We all have it, but the experts say too much is bad for our health.

Why do we have cholesterol in our bodies? It is a building block for most of the hormones, such as estrogen, testosterone, and thyroid. It is also a protective cover for our nerves. Our bodies attach wastes to choleserol, flushing them through the liver.

Although some study results don't match up well together, most of those studies that were looking for why people had heart attacks and strokes found high cholesterol, low good HDL, and high bad LDL cholesterol.

There are other conditions besides cholesterol that increase the chances for early heart attacks and strokes. These include diabetes, high blood pressure, family history, and cigarette smoking. Each one increase heart attack and stroke risk by itself, and the risks are multiplied (not added) as the other conditions occur.

Normal levels of cholesterol in people that do not eat food from animals is about 150. Newborns have normal levels of 53 to 135, but adults who have this low level of cholesterol should be checked for liver disease-that is where cholesterol is made. It can also be very low in malnutrition, and much higher in pregnancy and if the ovaries are removed.

During the 1990s, Heart Disease experts recommended treatment for people whose total cholesterol was over 240, HDL was less than 30, and LDL was higher than 130.

Early in 2001, a panel of experts recommended starting treatment for patients with cholesterol problems at lower levels, because newer studies showed that people with an LDL level of 80 or less do not have heart attacks.

If your blood tests for cholesterol show a higher risk for heart attacks and stroke, what can you do to lower the bad LDL, raise the good HDL, or lower the total cholesterol?

As we have heard again and again, we can lower the amount of cholesterol and saturated fats that we eat. For some people, this works well by itself.

But for others, changing the diet has little effect. These people were born with lazy enzymes in the liver, and need the help of medicines.

Medicines for Cholesterol Problems

There are five different types of medicine used to treat cholesterol problems. There are many other types of medicines that cause cholesterol levels to go a little lower: ace inhibitors, erythromycin, MOA inhibitors, and the nitrates used for angina.

1. The first is fish oil from fresh water fish or synthetic omega-3 fatty acids as a capsule. This medication does not lower the bad LDL, but may increase the good HDL cholesterol. Note that fish oil or synthetic fatty acid also act as a blood thinner, like aspirin, and so could possibly cause stomach or nose bleeding.

2. A class of medicine used to both lower the bad LDL and increase the good HDL is Niacin (Nicotinic Acid), a B vitamin. The side effects can be troubling: flushing, itching, stomach pains, blurred vision, fatigue, increased blood sugar and uric acid (the chemical in gout), liver damage, and very rarely, dry eyes or darkened areas of skin.

Despite all of these potential side effects, many people can tolerate this drug without problems, especially if they take one aspirin (325 mg) or one Motrin (Ibuprofen) 200 mg an hour before taking the niacin. Liver damage with long term use was a problem in the past, but is now rare when it was found to happen only with high doses greater than 2,000 mg per day. One particular formulation that is over the counter and seems to be better tolerated is Niaspan.

3. The third class of medicine that was once commonly used is bile acid sequestrants (Questran, Colestid, Welchol, and others). This type of drug was used because mostly because there was no other medicine then that could lower cholesterol reliably. Bile acid is comes from the liver and is stored in the gall bladder. The gall bladder releases the bile acid into the lower stomach if fatty food is eaten. The bile acids are mostly cholesterol, and after helping to break up fats, are reabsorbed further on in the intestine.

The bile acid sequestrants bind the cholesterol, and stop it from being reabsorbed. Instead, it goes out in the stool. These medicines can lower the bad cholesterol by 20%, increase the good HDL, but also can raise the triglycerides.


The side effects have to do with increasing the cholesterol in the stools: constipation is frequent, and heartburn, nausea, bloating, and passing gas are not uncommon. They all tend to disappear over time. The side effects are less when the medicine is taken just before meals or if dietary fiber is increased (fruits, vegetable, whole grains, nuts and fiber supplements.)

4. The fourth class of cholesterol modifying medicine are the fibrates. They are easy to take pills or capsules.

The fibrates lower triglycerides and increase HDL levels. They may also decrease LDL levels. If the person has high triglycerides levels, the fibrates may increase LDL levels as the triglycerides levels go down.

Studies of patients on fibrates have shown contradictory results. Heart attacks are less for patients on fibrates than is expected with the lower level of cholesterol and increased HDL levels. But no study has shown significant reduction in deaths with persons with hyperlipidemia using fibrates. In contrast, both Niacin and Bile Acid Sequestrants have shown less heart attacks and deaths by their use when compared with sugar pills.

Side effects are few and rare. They make diabetic and anticoagulant medicines stronger. Gall bladder attacks, liver damage, and muscle pain can occur rarely. There is an unusual disease that is very rare, called rhabdomyolysis, that causes severe and chronic muscle pain. Because it can occur more frequently if both fibrates and statins discussed below are taken together, they should not be combined at the same time.

5. The last class, and currently the most common to be prescribed for hyperlipidemias are the statins. Also known as the HMG-CoA Reductase Inhibitors for the liver enzyme they inhibit, the statins reduce Triglycerides, increase HDLs up to 15%, and are the most effective of all the classes in lowering LDLs.

Studies that compare one of these drugs to a sugar pill have shown remarkable benefits. In people who already have had heart vessel blockage, the statins were found to reduce death from all causes, reduce death from heart attacks, and cause new heart attacks to be milder. Strokes occur much less often also.

When started within two days of a heart attack, statins seem to prevent some future heart attacks or make them milder. For those who have not ever had a heart attack, they greatly reduced the chances of one occurring in the future.

But it gets better. They reduce age related bone thinning (osteoporosis) in rats, and may reduce the risk of fractures in the elderly. In men, regular use seems to reduce their chances of getting diabetes.

Side effects are rare, and if they occur, may go away just by using another statin. Mild stomach upset and muscle pain can occur. Severe muscle pain and weakness have been seen, with very rare kidney damage. These side effects seem to happen more often in people with preexisting liver or kidney damage, serious infections, low thyroid hormone levels, or advanced age.

Chances of a statin causing liver damage are also rare, but greatly increase with drinking a lot of alcohol. Fatigue and erection problems have been reported with higher doses. There seems to be no increase in cancer in people taking statins.

Side effects can occur much more frequently if certain drugs are used at the same time. These include Sporanox, Nizoral, erythromycin, Biaxin, Sandimmune, Serzone and HIV drugs. Grapefruit juice should not be used within hours of taking a dose of a statin. Finally, as mentioned earlier, side effects are seen more frequently when fibrates are also taken with a statin, and so should be avoided.

Conclusion

Low total cholesterol, high HDL cholesterol, and low LDL cholesterol levels are proven to reduce the number of heart attacks, strokes, and some cancers. Talk to your health care provider soon about checking your cholesterol levels.

You may find your levels are just right. If not, only minor changes in eating and exercise habits may bring your levels into a safe range. If that doesn't work, there are now safe and easy-to-take medications. Bring your cholesertol levels into the recommended limits to increase the chances of a long and healthy life, even if you take other risks: smoking. alcohol, or being really overweight


Author is Jack Kircher, PA. Last revision date: 24 September, 2001.