How to lower cholesterol levels?

How to Lower Cholesterol

Start with therapeutic lifestyle changes for all patients, limiting saturated fat to <7% of total energy intake and dietary cholesterol to <200 mg/day, then add high-intensity statin therapy (atorvastatin 40-80 mg or rosuvastatin 20-40 mg) if LDL-C goals are not achieved after 3-6 months. 1, 2

Immediate Dietary Modifications (First-Line for All Patients)

Saturated fat restriction is the single most powerful dietary intervention, reducing LDL-C by approximately 15-25 mg/dL when implemented maximally. 2, 3

• Limit saturated fatty acids to <7% of total energy intake (this means choosing lean meats, removing poultry skin, selecting fat-free or low-fat dairy products). 4, 1
• Restrict dietary cholesterol to <200 mg/day (limit egg yolks, organ meats, full-fat dairy). 4, 1, 2
• Completely eliminate trans-unsaturated fatty acids from the diet (avoid partially hydrogenated oils found in commercial baked goods, fried foods, and many margarines). 4, 2
• Replace saturated fats with either carbohydrates from whole grains or monounsaturated fats (olive oil, avocados, nuts). 4

Add Cholesterol-Lowering Food Components

These additions provide additive LDL-C lowering effects of 15-30% when combined. 3

• Plant stanols/sterols at 2 g/day lower LDL-C by 8-29 mg/dL (available in fortified margarines, orange juice, or soft gel capsules; must be consumed daily like medication). 4, 1, 2
• Increase soluble (viscous) fiber to 10-25 g/day (each gram reduces LDL-C by approximately 2.2 mg/dL; sources include oats, barley, beans, lentils, apples, citrus fruits). 4, 1
• Consider incorporating soy protein and nuts into the diet (nuts reduce LDL-C by approximately 8%, soy protein by 3-10%). 3, 5

Weight Loss and Physical Activity

• Modest weight loss beneficially affects all lipid parameters and is particularly effective for patients with elevated triglycerides and low HDL-C. 4, 2
• Engage in regular aerobic exercise to raise HDL-C and lower triglycerides (though exercise has modest effects on LDL-C directly, it enhances insulin sensitivity and reduces visceral adiposity). 4, 1
• For patients with metabolic syndrome (elevated triglycerides, low HDL-C, small dense LDL particles), weight reduction and increased physical activity are critical interventions. 4

When to Initiate Statin Therapy

Assess response to lifestyle changes at 3-6 months; if LDL-C goals are not met, initiate pharmacological therapy. 1, 2

Risk-Based LDL-C Targets:

• High-risk patients (established cardiovascular disease, diabetes): Target LDL-C <100 mg/dL, with <70 mg/dL for very high-risk patients. 1, 2
• Moderately high-risk patients: Target LDL-C <130 mg/dL, with <100 mg/dL as a therapeutic option. 1
• Lower-risk patients: Target LDL-C <160 mg/dL. 1

Statin Dosing Strategy:

• Initiate high-intensity statin therapy (atorvastatin 40-80 mg or rosuvastatin 20-40 mg) to achieve at least 30-40% LDL-C reduction in high-risk patients. 1, 2
• Statins reduce LDL-C by 30-50% and are the preferred first-line drug therapy for most patients. 1, 2, 6
• Reassess LDL-C as early as 4 weeks after initiating or adjusting therapy. 1, 7

Combination Therapy When Statins Alone Are Insufficient

• Add ezetimibe 10 mg daily if LDL-C goals are not achieved on statin monotherapy (ezetimibe can be administered with or without food, at least 2 hours before or 4 hours after bile acid sequestrants). 1, 7
• Consider PCSK9 inhibitors for very high-risk patients not achieving LDL-C <55 mg/dL on statin plus ezetimibe. 1
• Bile acid resins can augment statin effects, reducing LDL-C by an additional 15-30%. 1, 6

Special Considerations for Elevated Triglycerides

If triglycerides are 200-499 mg/dL, target non-HDL cholesterol <130 mg/dL and consider adding fibrates (fenofibrate preferred over gemfibrozil when combining with statins due to lower myositis risk) or niacin after optimizing glycemic control. 2

If triglycerides are ≥500 mg/dL, immediate pharmacological treatment is required to prevent pancreatitis; restrict all dietary fat and consider omega-3 fatty acids (2-4 g/day). 4, 2

Critical Pitfalls to Avoid

• Never abandon lifestyle modifications when starting medications—therapeutic lifestyle changes must be reinforced at every visit as they provide complementary benefits beyond LDL-C lowering (improved insulin sensitivity, blood pressure reduction, weight management). 1, 2, 8
• Monitor for myopathy/rhabdomyolysis, especially when combining statins with fibrates (fenofibrate is safer than gemfibrozil for combination therapy). 2, 7
• Perform liver enzyme testing as clinically indicated; consider withdrawing therapy if ALT or AST elevations ≥3 times upper limit of normal persist. 7
• Alcohol intake must be limited to no more than 1 drink per day for women and 2 drinks per day for men, consumed with meals (alcohol can aggravate hypertriglyceridemia). 4
• Monitor lipid levels and adherence to lifestyle changes every 4-6 months. 4, 2