Cholesterol levels in your body include:

  • high-density lipoproteins (HDL), known as the “good” cholesterol
  • low-density lipoproteins (LDL), known as the “bad” cholesterol
  • non-HDL cholesterol

You’ll receive a blood test known as a lipid panel to check your cholesterol levels. It will also include your triglyceride levels, which is another type of lipid (or fat) that’s found in your blood.

Having high cholesterol means you have high levels of LDL or non-HDL cholesterol, or both. These are risk factors for cardiovascular (heart) disease. Having high triglyceride levels is also a risk factor for cardiovascular disease.

Healthy diet and exercise are the first line in managing high cholesterol. However, management depends on the person.

Some people are able to use lifestyle modifications to lower LDL levels and increase HDL levels. They may also able to lower triglyceride levels with diet and exercise.

Others may struggle to manage high cholesterol with diet and exercise alone. This is especially true for people who have a strong family history of high cholesterol.

Medication is typically recommended when:

  • your cholesterol levels are high enough to increase your risk for cardiovascular disease (or you already had a cardiovascular event, such as a heart attack or stroke)
  • you have an LDL level greater than 190 milligrams per deciliter (mg/dL)
  • you have diabetes (which makes a person 2 to 4 times more likely to develop cardiovascular disease) or are otherwise considered high risk for cardiovascular disease, and you have an LDL level greater than 70 mg/dL

A doctor will calculate your cardiovascular disease risk score to show your risk for developing a heart attack or stroke over 10 years. If the score is greater than 5 percent, they’ll recommend a medication.

You can calculate your cardiovascular disease risk score online using the American College of Cardiology’s risk estimator.

Having a triglyceride level greater than 200 mg/dL also puts a person at higher risk for cardiovascular disease. A triglyceride level of greater than 885 mg/dL will prompt a doctor to prescribe a medication, because you would be at an additional increased risk for pancreatitis.

Some people have a very strong family history of high cholesterol, known as familial hypercholesterolemia. Lifestyle modifications may not be enough to lower their cholesterol levels.

Additionally, some people need to lower their cholesterol levels because they are at high risk for future cardiovascular events. They should take cholesterol-lowering medications and not rely on lifestyle modifications alone.

Statins are a type of cholesterol medication used to lower bad cholesterol and lower risk for cardiovascular disease. They lower cholesterol by blocking your body’s ability to use an enzyme needed to make cholesterol.

Statins are for anyone who has high cholesterol levels and who previously had a heart attack or stroke or who is at high risk for a cardiovascular event.

PCSK9 inhibitors are a newer class of cholesterol-lowering medication. Two medications, alirocumab (Praluent) and evolocumab (Repatha), were approved for use by the Food and Drug Administration (FDA) in 2015. They are given by injection every 2 to 4 weeks to lower LDL (“bad”) cholesterol levels.

PCSK9 is a protein in the liver that blocks it from getting rid of LDLs. PCSK9 inhibitors block PCSK9, which allows the liver to regain its ability to get rid of LDL. It can be taken on its own or along with a statin.

If your LDL cholesterol levels aren’t responding well to a statin alone, a doctor may prescribe a PCSK9 inhibitor.

Small interfering RNA (siRNA) is the latest class of cholesterol-lowering medications aimed at blocking the production of PCSK9.

It stops the translation of PCSK9 messenger RNA, which can lead to lower levels of PCSK9. As a result, siRNA can lower LDL levels.

Inclisiran is the first drug in this class of medications. It’s been shown to cause a 30 to 46 percent decrease in LDL levels at 1 year.

It hasn’t received FDA approval for consumer use in the United States, but it’s been approved in Europe.

Statins are usually recommended to treat high cholesterol. If you’re unable to tolerate statins, your doctor may recommend cholesterol-lowering medications, such as:

  • fibrates
  • niacin
  • cholesterol absorption inhibitor (ezetimibe)
  • citrate lyase inhibitors (bempedoic acid)
  • bile acid sequestrants (cholestyramine)
  • fish oil

Your doctor may also prescribe one of these medications in addition to a statin if you have both high LDLs and high triglycerides (greater than 500 mg/dL).

Yes, high cholesterol medications are generally safe.

Up to 3 percent of people may experience muscle aches on statins. This is known as a myopathy. Your doctor will ask you whether you’re experiencing muscle pains after you start a statin.

Up to 5.5 percent of people may develop liver injury with statin use. Your doctor will also check for liver damage by testing liver enzymes with a blood test.

If you show any signs of myopathy or liver damage, your doctor can lower the statin dose or prescribe a different cholesterol medication.

There is also a small risk of increase in blood sugar levels on statins. In people with diabetes mellitus, the benefits of lowering LDL levels and reducing the risk for a heart attack or stroke with medication outweigh any risk.

Some people may be able to manage their cholesterol with diet, exercise, and weight management and can safely come off of cholesterol-lowering medications.

Others may need to stay on cholesterol-lowering medications for the rest of their lives due to a strong family history for high cholesterol or because they have a high risk for cardiovascular disease.

Even if you need to take a cholesterol-lowering medication, lifestyle strategies are still important. You should aim to:

  • increase fiber in your diet
  • lower your saturated fat intake
  • exercise 150 minutes per week
  • give up smoking or drinking alcohol, if you consume a lot, as these habits can increase your cholesterol levels

Dr. Alana Biggers is an internal medicine physician. She graduated from the University of Illinois at Chicago. She is an assistant professor at the University of Illinois at Chicago College of Medicine, where she specializes in internal medicine. She also has a master’s of public health in chronic disease epidemiology.