How to Lower LDL Cholesterol in Adults
Begin with therapeutic lifestyle changes for 3 months, then initiate statin therapy if LDL remains ≥130 mg/dL, with a target goal of <100 mg/dL. 1
Immediate Dietary Modifications
Limit saturated fat to 5-6% of total calories (or <7% at minimum), which can lower LDL-C by 11-13 mg/dL compared to typical American diets containing 14-15% saturated fat. 1 This represents the single most effective dietary intervention for LDL reduction. 1
Fat Replacement Strategy (in order of effectiveness):
- Replace saturated fats with polyunsaturated fats first (corn oil, peanuts): reduces LDL by 1.8 mg/dL per 1% energy substitution 1
- Replace with monounsaturated fats second (olive oil, canola oil): reduces LDL by 1.3 mg/dL per 1% energy substitution 1
- Replace with complex carbohydrates as third option: reduces LDL by 1.2 mg/dL per 1% energy substitution, though this may raise triglycerides and lower HDL 1
Additional Dietary Interventions:
- Eliminate all trans fats completely: replacing just 1% of energy from trans fats with polyunsaturated fats lowers LDL by 2.0 mg/dL 1
- Add 10-25 grams of soluble fiber daily: provides additional 5-10% LDL reduction 1, 2
- Add 2 grams of plant stanols/sterols daily: provides an additional 10% LDL reduction 1, 2
- Consider increased nut consumption: can reduce LDL by approximately 8% 2
Expected dietary impact: Maximal medical nutrition therapy typically reduces LDL cholesterol by 15-25 mg/dL (0.40-0.65 mmol/L). 3
Physical Activity and Weight Management
- Increase physical activity and pursue weight loss if overweight: these interventions modestly lower LDL while also decreasing triglycerides and increasing HDL 3
- Evaluate lifestyle interventions at 6-week intervals, with consideration of pharmacological therapy between 3-6 months if LDL goals are not met 3
Pharmacological Therapy Initiation
When to Start Medication:
Initiate statin therapy when LDL ≥130 mg/dL after 3 months of lifestyle modification in adults without cardiovascular disease. 3, 1 For patients with established cardiovascular disease or LDL >200 mg/dL, start pharmacological therapy immediately alongside lifestyle changes. 3
First-Line Pharmacotherapy:
Statins (HMG-CoA reductase inhibitors) are the preferred first-line drug therapy for LDL lowering. 3, 4 Atorvastatin is FDA-approved as an adjunct to diet to reduce LDL-C in adults with primary hyperlipidemia. 4
- Target LDL goal: <100 mg/dL (2.60 mmol/L) for all adults 3
- For higher cardiovascular risk patients: aim for LDL <70 mg/dL (or <55 mg/dL with established atherosclerotic disease) using high-intensity statin therapy 1
Second-Line and Combination Therapy:
If LDL remains ≥70 mg/dL on maximum tolerated statin therapy, add ezetimibe (10 mg daily). 1, 5 Ezetimibe is FDA-approved in combination with a statin or alone when additional LDL-lowering is needed. 5
Alternative second-line agents (if statins cannot be used): 3
- Bile acid binding resins
- Cholesterol absorption inhibitors (ezetimibe)
- Fenofibrate
Treatment Algorithm Summary:
- Weeks 0-12: Implement therapeutic lifestyle changes (reduce saturated fat to 5-6%, add fiber and plant sterols, increase physical activity)
- Week 12 assessment: If LDL ≥130 mg/dL, initiate statin therapy
- Ongoing monitoring: Assess LDL as early as 4 weeks after starting medication 5
- If inadequate response: Add ezetimibe to statin therapy if LDL remains ≥70 mg/dL on maximum tolerated statin dose 1
Critical Caveats:
- Monitor for myopathy/rhabdomyolysis with statin therapy, particularly when combining with other lipid-lowering agents 5
- Check liver enzymes as clinically indicated; consider withdrawing therapy if ALT/AST ≥3x upper limit of normal persists 5
- Combination therapy with statins plus fibrates or niacin carries increased risk of myositis and requires careful monitoring 3
- Dietary cholesterol restriction: Current evidence is insufficient to determine whether lowering dietary cholesterol significantly reduces LDL-C, representing a shift from older recommendations 1