What over-the-counter (OTC) medications can help reduce atherosclerosis?

Over-the-Counter Medications for Atherosclerosis Reduction

No over-the-counter medications have proven efficacy in reducing atherosclerosis or cardiovascular events—prescription statins remain the only evidence-based pharmacologic intervention for atherosclerosis reduction. 1

Why OTC Medications Are Insufficient

Statins Are Not Available OTC

• Statins are the cornerstone of atherosclerosis treatment and consistently reduce atherosclerotic cardiovascular disease (ASCVD) events across all patient populations, but they require prescription in the United States 1
• High-intensity statins (atorvastatin 40-80 mg or rosuvastatin 20-40 mg) reduce LDL-C by ≥50% and provide the greatest ASCVD risk reduction 1
• Moderate-intensity statins reduce LDL-C by 30-50% and are effective for primary prevention 1

OTC Supplements Lack Evidence

• Omega-3 fatty acids are mentioned as adjunctive therapy for high triglycerides but have no proven benefit for atherosclerosis reduction as monotherapy 1
• Plant sterols/stanols and soluble fiber (psyllium) can modestly lower LDL-C by 5-15% but have no randomized controlled trial evidence demonstrating reduction in cardiovascular events or atherosclerosis progression 1
• Niacin (nicotinic acid), while available OTC, showed no benefit in reducing ASCVD events when added to statin therapy in the AIM-HIGH trial and is associated with increased diabetes risk 1, 2
• Red yeast rice contains lovastatin but in unregulated amounts, making it unreliable and potentially unsafe

What Actually Works: Prescription Therapy

Evidence-Based Lipid Targets

• LDL-C <55 mg/dL (1.4 mmol/L) with >50% reduction for patients with established atherosclerotic disease 1
• LDL-C <70 mg/dL (1.8 mmol/L) for very high-risk primary prevention patients 1, 3
• LDL-C <100 mg/dL (2.6 mmol/L) for high-risk primary prevention 1, 3

Treatment Algorithm for Atherosclerosis

1. Start high-intensity statin (atorvastatin 40-80 mg or rosuvastatin 20-40 mg) for all patients with established ASCVD 1
2. Add ezetimibe 10 mg if LDL-C target not achieved after 4-6 weeks on maximally tolerated statin 1
3. Add PCSK9 inhibitor (alirocumab, evolocumab) or inclisiran if target still not met after another 4-6 weeks 1
4. Consider bempedoic acid for statin-intolerant patients or as add-on therapy 1

Lifestyle Modifications: The True "OTC" Intervention

Lifestyle changes are the foundation of atherosclerosis prevention and can improve outcomes even in patients on intensive pharmacologic therapy 1, 4

Dietary Interventions

• Mediterranean diet rich in legumes, dietary fiber, nuts, fruits, vegetables, and high flavonoid intake is recommended for cardiovascular disease prevention 1
• Reduce saturated fat to <7% of total calories and dietary cholesterol to <200 mg/day 1
• Increase soluble fiber intake, which independently predicts improvement in endothelial function and carotid plaque burden 4
• Maintain serum total cholesterol <150 mg/dL through diet to prevent plaque deposition 5

Physical Activity

• 30-60 minutes of moderate-intensity aerobic activity (brisk walking) on most days of the week, supplemented by increased daily lifestyle activities 1
• Exercise training is an independent predictor of improved endothelial function and reduced atherosclerosis progression, even with intensive pharmacologic therapy 4
• Low- to moderate-intensity aerobic activities increase overall and pain-free walking distance in patients with peripheral arterial disease 1

Weight Management

• Target BMI 18.5-24.9 kg/m² and waist circumference <40 inches (men) or <35 inches (women) 1
• Reducing body weight and body fat percentage independently predicts improvements in endothelial function and carotid plaque burden 4

Smoking Cessation

• Complete cessation and abstinence from smoking of any kind is mandatory to reduce risk of atherosclerotic disease progression, myocardial infarction, death, and limb ischemia 1

Critical Pitfalls to Avoid

• Do not delay prescription statin therapy while attempting lifestyle modifications alone in high-risk patients—this results in missed opportunities for cardiovascular risk reduction 3
• Do not rely on OTC supplements as substitutes for proven prescription therapies 1
• Do not use fibrates for cholesterol lowering—they are not recommended and showed no benefit in the ACCORD trial 1
• Avoid niacin due to lack of efficacy in reducing ASCVD events and increased diabetes risk 1, 2

The Bottom Line

If you have atherosclerosis or are at high risk, you need prescription medication—specifically statins—combined with aggressive lifestyle modification. No OTC medication has demonstrated the ability to reduce atherosclerotic cardiovascular events or mortality 1. Lifestyle changes including Mediterranean diet, regular exercise, weight management, and smoking cessation are essential but must be combined with evidence-based prescription pharmacotherapy for optimal outcomes 1, 4.