How to reduce cholesterol and low-density lipoprotein (LDL) levels?

From the Guidelines

To reduce cholesterol and LDL, focus on both lifestyle changes and medication if needed, with the goal of lowering LDL cholesterol to <1.4 mmol/L (<55 mg/dL) and reducing it by at least 50% if the baseline LDL-C level is 1.8-3.5 mmol/L (70-135 mg/dL) 1.

Lifestyle Changes

• Adopt a heart-healthy diet rich in fruits, vegetables, whole grains, and lean proteins while limiting saturated fats, trans fats, and dietary cholesterol.
• Aim for regular physical activity with at least 150 minutes of moderate exercise weekly.
• Maintain a healthy weight, as losing even 5-10% of body weight can significantly lower cholesterol.
• Avoid smoking and limit alcohol consumption.

Medications

• Statins are typically the first-line treatment, including atorvastatin (10-80mg daily), rosuvastatin (5-40mg daily), or simvastatin (10-40mg daily) 1.
• Other options include ezetimibe (10mg daily), PCSK9 inhibitors for severe cases, and bile acid sequestrants.
• These medications work by either reducing cholesterol production in the liver or increasing its removal from the bloodstream.

Monitoring and Adjustment

• Regular monitoring through lipid panel blood tests every 3-6 months is important to assess progress and adjust treatment as needed.
• The combination of lifestyle modifications and appropriate medication can effectively lower LDL cholesterol by 20-60%, significantly reducing the risk of cardiovascular disease 1. Some key points to consider when reducing cholesterol and LDL include:
• The importance of therapeutic lifestyle changes (TLC) as an essential modality in clinical management for persons at risk for cardiovascular disease (CVD) 1.
• The benefits of cholesterol-lowering therapy in high-risk patients, including those with diabetes 1.
• The role of exercise in improving the lipid profile, including increases in HDL cholesterol and reductions in triglycerides 1.

From the FDA Drug Label

Simvastatin acid and its metabolites are inhibitors of HMG-CoA reductase, the rate-limiting enzyme that converts HMG-CoA to mevalonate, a precursor of cholesterol. Inhibition of HMG-CoA reductase by simvastatin acid accelerates the expression of LDL-receptors, followed by the uptake of LDL-C from blood to the liver, leading to a decrease in plasma LDL-C and total cholesterol.

To reduce cholesterol and LDL, simvastatin can be used as it inhibits the production of cholesterol in the liver by blocking the enzyme HMG-CoA reductase, leading to a decrease in plasma LDL-C and total cholesterol.

• The maximum LDL-C reduction of simvastatin is usually achieved by 4 weeks and is maintained after that 2. Alternatively, ezetimibe can be used in combination with a statin, or alone when additional low density lipoprotein cholesterol (LDL-C) lowering therapy is not possible, as an adjunct to diet to reduce elevated LDL-C 3.

From the Research

Reducing Cholesterol and LDL

To reduce cholesterol and LDL, several options are available, including:

• Statins, which are the most potent drugs for lowering LDL-C and are well tolerated in most patients 4
• Ezetimibe, which can be used in combination with statins to produce additional LDL-C reduction 4, 5
• Bile acid sequestrants, which can be used individually or in combination with statins to lower LDL-C levels 4

Combination Therapies

Combination therapies, such as adding ezetimibe to a statin, can be effective in reducing LDL-C levels, especially in patients who do not reach their LDL-C target with statin monotherapy 5, 6, 7

• Adding ezetimibe to atorvastatin 10 mg reduced LDL-C significantly more than atorvastatin 20 mg or rosuvastatin 10 mg 6
• Adding ezetimibe to simvastatin, atorvastatin, or rosuvastatin monotherapy resulted in a greater reduction in LDL-C compared to doubling the statin dose 7

Non-Statin Therapies

Non-statin therapies, such as niacin, omega-3 fatty acids, and fibrates, may be useful in reducing cardiovascular events in certain clinical situations, such as patients who are unable to tolerate statin therapy or have persistent severe elevations in triglycerides 8

• Niacin may reduce cardiovascular events as monotherapy, but recent trials in combination with statins have failed to show a benefit 8
• Fibrates may improve cardiovascular outcomes as monotherapy, but trials in combination with statins have failed to show a benefit, except in those with elevated triglycerides or low HDL-C 8