Nearly 74 million Americans have high cholesterol, according to the Centers for Disease Control and Prevention. However, fewer than half are receiving treatment for it. This puts them at a higher risk for heart attack and stroke. While exercise and a healthy diet can often help manage cholesterol levels, sometimes medication is needed.
Two types of medications prescribed to treat high cholesterol include statins and PCSK9 inhibitors. Statins are a popular treatment that have been available since the 1980s. PCSK9 inhibitors, on the other hand, are a new type of cholesterol drug. They were approved by the Food and Drug Administration in 2015.
When you and your doctor are deciding on a cholesterol drug for you, you may consider factors such as side effects, cost, and effectiveness. Read on to learn more about these drugs and how the two types compare.
Statins are one of the most common types of medications used to help lower cholesterol. If you have high cholesterol or other cardiovascular risks, your doctor may suggest that you begin taking a statin. They’re often used as a first-line treatment for high cholesterol. This means they’re the first treatment your doctor may suggest.
How they work
Statins work by blocking a substance called HMG-CoA reductase. This is a compound your liver needs to make cholesterol. Blocking this substance reduces the amount of cholesterol your liver makes. Statins also work by helping your body reabsorb any cholesterol that has gathered on the walls of your blood vessels. To learn more, read about how statins work.
Statins come in the form of tablets or capsules that you take by mouth. There are many kinds of statins available in the United States today. They include:
- atorvastatin (Lipitor)
- fluvastatin (Lescol)
- lovastatin (Altoprev)
- pravastatin (Pravachol)
- rosuvastatin (Crestor)
- simvastatin (Zocor)
- pitavastatin (Livalo)
Statins can be prescribed for many people with high cholesterol, but PCSK9 inhibitors are typically prescribed only for certain types of people. Because statins have been around much longer, we know more about how effective they are. PCSK9 inhibitors are newer and so have less long-term safety data.
Also, PCSK9 inhibitors are very expensive compared to statins.
PCSK9 inhibitors are given by injection only. There are only two PCSK9 Inhibitors available today in the United States: Praluent (alirocumab) and Repatha (evolocumab).
When they’re prescribed
The American College of Cardiology recommends that you and your doctor consider a PCSK9 inhibitor only if:
- you are considered high risk for a cardiovascular problem and your cholesterol is not controlled with statins or other cholesterol-lowering drugs
- you have a genetic condition called familial hypercholesterolemia, which involves extremely high cholesterol levels
In either of these cases, PCSK9 inhibitors are typically prescribed after two types of medication haven’t helped lower your cholesterol levels. For instance, your doctor may first prescribe a statin. If that doesn’t lower your cholesterol levels enough, your doctor may suggest ezetimibe (Zetia) or drugs called bile acid resins. Examples of these include cholestyramine (Locholest), colesevelam (Welchol), or colestipol (Colestid).
If your cholesterol levels are still too high after this second type of medication, then your doctor may suggest a PCSK9 inhibitor.
How they work
PCSK9 inhibitors can be used in addition to or instead of statins. These drugs work differently. PCSK9 inhibitors target a protein in the liver called proprotein convertase subtilisin kexin 9, or PCSK9. By reducing the amount of PCSK9 in your body, PCSK9 inhibitors allow your body to remove cholesterol more efficiently.
Statins and PCSK9 inhibitors can each cause mild and more serious side effects, and the effects are different between the drugs.
|Mild side effects||• muscle and joint pain|
• stomach pain
|• swelling at the injection site|
• pain in your limbs or muscles
|Serious side effects||• liver damage|
• increased blood glucose levels
• higher risk of type 2 diabetes
• cognitive (mental) problems
• muscle damage leading to rhabdomyolysis
• liver problems
• kidney problems
Statins have been shown to lower cholesterol in many people. They have been used since the 1980s and their effects have been studied in thousands of people who take statins to prevent heart attack and stroke.
In contrast, PCSK9 inhibitors were recently approved, so the long-term safety data is not as good. Yet PCSK9 inhibitors are highly effective for some people. One study showed that alirocumab reduced cholesterol levels by 61 percent. It also reduced the likelihood of cardiovascular events such as heart attack and stroke. Another study found similar results with evolocumab.
Statins are available in brand-name and generic forms. Generics generally cost less than brand versions, so statins can be inexpensive.
PCSK9 inhibitors are new, so they don’t have generic versions available yet. For this reason, they’re more expensive than statins. The cost of PCSK9 inhibitors can be over $14,000 per year. In addition, to have this cost covered by your insurance, you must fall into one of the two categories recommended for using PCSK9 inhibitors. If you don’t fit into one of those categories, you would likely have to pay for a PCSK9 inhibitor yourself.
Statins and PCSK9 inhibitors are important drug options in the treatment of high cholesterol levels. While both types of drugs help lower cholesterol levels, there are some key differences. The table below outlines these differences at a glance.
|Drug form||tablets taken by mouth||injection only|
|Prescribed for||people with high cholesterol levels||people with high cholesterol levels who meet two key criteria|
|Most common side effects||muscle pain, headache, and digestive problems||injection-site swelling, limb or muscle pain, and tiredness|
|Generic availability||generics available||no generics available|
Talk to your doctor
If you have high cholesterol and think either of these types of drugs might be right for you, your first step should be to talk to your doctor. They can tell you more about these drugs and your other treatment options. Some questions to discuss with your doctor might be:
- Is medication the next step for me in managing my high cholesterol?
- Do I meet the two criteria for people who can be prescribed PCSK9 inhibitors?
- Should I talk with a lipid specialist?
- Should I start an exercise plan to help manage my cholesterol?
- Can you refer me to a registered dietitian to help me manage my diet?