Cholesterol often gets a bad rap. While there is such a thing as “bad” cholesterol, “good” cholesterol is actually important for heart health. The key, as with all aspects of health, is balance.
Another name for “bad” cholesterol is low-density lipoprotein (LDL). “Good” cholesterol is formally known as high-density lipoprotein (HDL).
When your LDL cholesterol level is high, you might need medical treatment in the form of statins. However, due to the possible side effects, you may also be wondering about alternative treatments, such as niacin (vitamin B-3).
There are a variety of causes that can lead to high cholesterol. Some of these are out of our control and determined by genetics, and some are lifestyle choices that we can change.
Different factors that can cause or increase your risk of high cholesterol include:
- having a family history of high cholesterol
- eating an unhealthy diet high in unsaturated fats and cholesterol
- lack of exercise
- having other illnesses, such as diabetes
- taking certain medications, including steroids and progestin
- being obese
- age (as you get older, your cholesterol level tends to rise)
- gender (LDL cholesterol rises more easily in women, though they tend to have lower “bad” cholesterol until around the age of 55)
Too much LDL cholesterol can increase your risk for heart disease. At the same time, too little HDL cholesterol can lead to the same effect. This is because HDL is responsible for removing the bad cholesterol from the blood and taking it back to the liver to be disposed, preventing the buildup of plaque in the arteries.
According to the National Institutes of Health, your ideal cholesterol levels are:
- Total cholesterol: less than 200 mg/dL
- LDL cholesterol: less than 100 mg/dL
- HDL cholesterol: 60 mg/dL or higher
Contrary to popular belief, high cholesterol isn’t caused by poor dietary choices alone. In fact, cholesterol is made in the liver. From there, it is circulated throughout the rest of the body. Thus, it can be problematic if your liver produces too much cholesterol.
In such cases, a healthy diet and regular exercise won’t be enough to control your levels. You may need statins, otherwise known as HMG-CoA reductase inhibitors, to balance the problem. Statins block the enzyme that the liver uses to make cholesterol. Statins are primarily used to help lower LDL cholesterol. They don’t increase heart-healthy HDL.
Another benefit of statins is their ability to eliminate arterial cholesterol buildup. This may reduce the risk of a heart attack, which is why statins are often prescribed to those with a high risk of heart disease.
Examples of statins include:
- atorvastatin (Lipitor)
- simvastatin (Zocor)
- fluvastatin (Lescol, Lescol XL)
- lovastatin (Mevacor, Altoprev)
Certain groups of patients are more likely to be prescribed statins than others. Women are less likely to be prescribed statins than men. The four groups most likely to be prescribed statins are:
- people who already have heart disease
- people 40 to 75 years old with type 2 diabetes
- people 40 to 75 years old who have a high risk of 10-year heart disease
- people with an exceptionally high level of LDL cholesterol
Utilizing statins are often considered to be a lifetime commitment. In many cases, you’ll have to make intense and substantial lifestyle changes in order to no longer need the medication to lower your cholesterol. Cholesterol levels will increase if you stop taking the medication, keeping you on it indefinitely in many cases.
Normally, niacin is derived from foods like chicken and tuna. It helps your body use energy from food as well as promotes healthy eyes, hair, and skin. It also supports good digestion and your nervous system.
Niacin is most commonly used in people who have high cholesterol but can’t take statins. Niacin should not be used by people with liver disease, stomach ulcers, or active bleeding. It is sometimes used in people who have already had a heart attack. Doctors are currently debating whether niacin should be used in patients who have a high risk of heart disease.
Niacin can also be used to boost your HDL cholesterol levels and decrease your levels of triglycerides, a type of fat that increases your risk of heart disease. The Mayo Clinic estimates that taking niacin supplements may increase HDL levels by 30 percent or more. However, the amount of niacin needed to have this effect is much higher than the amount normally found in the diet. At these high levels, there can be some undesirable side effects, so be sure to talk to your doctor before beginning to take high doses of niacin.
Niacin is widely available in vitamin stores, as well as in the supplement section of drugstores. Some doctors recommend prescription forms for those who may benefit from high doses.
It is common for doctors to prescribe more than one cholesterol medication. For instance, statins are sometimes taken with bile acid binding resins to help lower triglyceride levels.
To date, niacin is the only supplement that shows real promise in helping cholesterol, but it can’t decrease LDL cholesterol like statins can. Niacin is the preferable choice only if conventional medications aren’t well-tolerated.
The jury is out when it comes to combining statins with niacin. Not only can it be dangerous, but the Mayo Clinic reports that there is little evidence that combining niacin with statin medications offers any real benefits. In April 2016, the Food and Drug Administration (FDA) rescinded its prior approval of Advicor and Simcor, two drugs that combine niacin with statins.
While statins may be beneficial in cholesterol control, there are a few possible side effects. These include:
- abdominal discomfort
- constipation or diarrhea
- nausea or vomiting
- skin flushing
- muscle weakness
- memory loss
Such side effects are usually temporary when you first start the medication. Those at greatest risk for experiencing side effects from statins include people who are already taking other medications, people 65 years and older, people with small frames, and women. Having kidney or liver disease and drinking too much alcohol also increase your risk.
Niacin carries the risk of overdose, which can cause the following complications:
- high blood sugar
- internal bleeding
- liver damage
- upset stomach
Another safety issue with niacin is that some supplements may be tainted with unknown ingredients. This can increase the risk for drug interaction, especially if you’re taking other medications for cholesterol.
Lifestyle changes are certainly the preferred method for cholesterol control. The problem is that sometimes high cholesterol can’t be lowered through healthy habits alone.
Choosing between statins and niacin depends greatly on where your own levels stand, as well as the methods you have tried thus far. You should see changes within two to four weeks of taking statins or niacin.
For those who aren’t interested in taking statins or niacin or are unable to, there are a few alternative medications available. These include:
- PCSK9 inhibitors. This medication works by inhibiting a protein called PCSK9, which regulates how the liver clears out cholesterol. By binding to the protein, you lower cholesterol. This medication was effective in lowering cholesterol in several studies. Common side effects involved swelling or rash on the infection site, muscle pain, and in a small number of patients, eye problems. Around 1 percent of participants experienced memory impairment or confusion.
- Red yeast rice. Considered a natural medication, red yeast rice is a traditional Chinese medicine used to lower cholesterol. It contains several ingredients thought to help lower cholesterol, such as monacolin K. Monacolin K is a compound that is similar to lovastatin. Though natural, studies about red yeast rice’s long-term safety have not been conducted, and the results are unclear. It’s not currently approved by the FDA.
It’s not safe to stop taking statins for the sake of trying a more “natural” treatment. Make sure you do your research and discuss all methods of treatment with your doctor, both conventional and natural.
You asked, we answered
- I am interested in taking statins, but I am hesitant to make a lifelong commitment to a drug. What advice can you provide?
Taking a statin is not a magic cure. Eating a healthy diet, moderate exercise, and maintaining a healthy weight are still very important lifestyle choices. Statins have been shown to be safe and effective for most people and may help them live longer, healthier lives.- Alan Carter, PharmD