What are cholesterol medications in order of relative strength?

Cholesterol Medications in Order of Relative Strength

High-intensity statins (LDL-C reduction ≥50%) are the strongest cholesterol-lowering medications, with rosuvastatin 20-40 mg and atorvastatin 40-80 mg being the most potent options available. 1

Statin Medications by Intensity

High-Intensity Statins (LDL-C reduction ≥50%)

• Rosuvastatin 20-40 mg
• Atorvastatin 40-80 mg

Moderate-Intensity Statins (LDL-C reduction 30-49%)

• Atorvastatin 10-20 mg
• Rosuvastatin 5-10 mg
• Simvastatin 20-40 mg
• Pravastatin 40-80 mg
• Lovastatin 40-80 mg
• Fluvastatin XL 80 mg
• Fluvastatin 40 mg twice daily
• Pitavastatin 1-4 mg

Low-Intensity Statins (LDL-C reduction <30%)

• Simvastatin 10 mg
• Pravastatin 10-20 mg
• Lovastatin 20 mg
• Fluvastatin 20-40 mg

Comparative Potency of Statins

When comparing the most potent statins head-to-head, research shows that rosuvastatin 40 mg provides greater LDL-C reduction than atorvastatin 80 mg (56% vs. 52% reduction) 2. This makes rosuvastatin the most potent statin currently available.

Non-Statin Cholesterol Medications (in order of LDL-C lowering potency)

1. PCSK9 Inhibitors - Can provide an additional 50-60% LDL-C reduction when added to statin therapy

   • Indicated for very high-risk patients with ASCVD who have LDL-C ≥70 mg/dL despite maximally tolerated statin therapy plus ezetimibe 1

2. Ezetimibe - Provides an additional 15-25% LDL-C reduction when added to statin therapy

   • Reasonable to add in patients with clinical ASCVD who are on maximally tolerated statin therapy and judged to be at very high risk with LDL-C ≥70 mg/dL 1

3. Bile Acid Sequestrants - Typically reduce LDL-C by 15-20%

   • Colesevelam is the best tolerated bile acid sequestrant 3

4. Fibrates - Primarily used for triglyceride reduction; modest 5-15% LDL-C reduction

   • Not recommended as add-on therapy to statins for LDL-C reduction 1

5. Niacin - Can reduce LDL-C by 10-20%

   • Extended-release niacin is the best tolerated niacin preparation 3
   • Not recommended as add-on therapy to statins for LDL-C reduction 1

Important Clinical Considerations

• Statin selection: When choosing a statin, consider both potency and individual patient factors. High-intensity statins are recommended for patients with established ASCVD, LDL-C ≥190 mg/dL, or diabetes with multiple risk factors 4.

• Diabetes risk: High-intensity statins are associated with a 36% increased relative risk of new-onset diabetes compared to placebo, while moderate-intensity statins have a 10% increased risk 1. This risk should be weighed against the cardiovascular benefits.

• Alternative dosing: For patients with statin intolerance, alternative dosing strategies (such as once weekly high-dose rosuvastatin) may be considered, though this is not the preferred approach for most patients 5.

• Cost considerations: Generic statins (simvastatin, lovastatin, pravastatin, fluvastatin) may offer cost benefits while still providing effective LDL-C reduction 3.

• Asian populations: Certain Asian populations may have a greater response to statins and may require lower doses to achieve similar LDL-C reductions 1.

Monitoring and Follow-up

• Check lipid panel 4-12 weeks after initiating therapy to assess response 4.
• For patients over 75 years, consider starting with a moderate-intensity statin with potential uptitration if tolerated 4.

Remember that the primary goal of cholesterol-lowering therapy is to reduce cardiovascular risk, and medication selection should be based on the patient's overall risk profile and treatment goals.