Lipid Lower Medications
Lipid Lowering Agents
Statins (HMG-CoA Reductase Inhibitors)
- Purpose: Lower LDL cholesterol, reduce cardiovascular risk.
- Mechanism: Inhibit the enzyme HMG-CoA reductase, decreasing cholesterol synthesis in the liver.
- Use in: Patients with high LDL cholesterol, established cardiovascular disease, diabetes (age 40–75), and high ASCVD (Atherosclerotic Cardiovascular Disease) risk.
- Avoid in: Active liver disease, pregnancy, breastfeeding, and in patients with severe muscle disorders.
- Potency:
- High: Atorvastatin (40-80 mg), Rosuvastatin (20-40 mg)
- Moderate: Atorvastatin (10-20 mg), Rosuvastatin (5-10 mg), Simvastatin (20-40 mg), Pravastatin (40-80 mg), Lovastatin (40 mg)
- Low: Simvastatin (10 mg), Pravastatin (10-20 mg), Lovastatin (20 mg)
Ezetimibe
- Purpose: Lowers LDL cholesterol; often used as an add-on to statins.
- Mechanism: Inhibits absorption of cholesterol at the small intestine.
- Use in: Patients with elevated LDL who are intolerant to statins or need additional LDL lowering with statins.
- Avoid in: Active liver disease, especially when used with a statin, and pregnancy.
- Potency: Moderate potency when used alone, enhanced effect with statins.
Bile Acid Sequestrants (e.g., Cholestyramine, Colesevelam, Colestipol)
- Purpose: Lower LDL cholesterol; may increase HDL slightly.
- Mechanism: Bind bile acids in the intestine, promoting increased excretion and lowering cholesterol.
- Use in: Patients with mild to moderate LDL elevation who cannot tolerate statins; also useful in patients with type 2 diabetes to lower blood glucose.
- Avoid in: Patients with elevated triglycerides (>300 mg/dL) and complete biliary obstruction.
- Potency: Low to moderate potency.
Fibrates (e.g., Fenofibrate, Gemfibrozil)
- Purpose: Primarily used to lower triglycerides, may modestly increase HDL.
- Mechanism: Activate PPAR-alpha, leading to increased oxidation of fatty acids and reduced triglyceride synthesis.
- Use in: Patients with significantly elevated triglycerides (>500 mg/dL) to reduce the risk of pancreatitis.
- Avoid in: Severe kidney or liver disease, gallbladder disease, and with statins (especially Gemfibrozil, due to increased risk of muscle toxicity).
- Potency: Moderate potency for triglyceride lowering.
Niacin (Nicotinic Acid)
- Purpose: Lowers triglycerides and LDL, and increases HDL.
- Mechanism: Reduces the production of VLDL, which subsequently lowers LDL and triglycerides.
- Use in: Patients needing HDL elevation or triglyceride lowering, often used when statins are insufficient or intolerable.
- Avoid in: Liver disease, peptic ulcers, gout, and uncontrolled diabetes.
- Potency: Moderate potency for raising HDL and lowering triglycerides.
Omega-3 Fatty Acids (e.g., Icosapent Ethyl, Fish Oil)
- Purpose: Lower triglycerides; certain formulations may have cardiovascular benefits.
- Mechanism: Reduce hepatic triglyceride production and increase triglyceride clearance.
- Use in: Patients with very high triglycerides (>500 mg/dL) to reduce pancreatitis risk; adjunct to statins in patients with high cardiovascular risk.
- Avoid in: Hypersensitivity to fish/shellfish; caution with anticoagulants due to increased bleeding risk.
- Potency: Moderate potency for triglyceride lowering.