July 14, 2026
90
Q: I have been taking medication for cholesterol for many decades and wonder if there is anything different or any new medications available now?
A: That is a great question but first, we would like to review what exactly cholesterol is. Cholesterol, itself, is essential for our bodies. Though we do need cholesterol to to be able to make hormones, Vitamin D, and cell membranes, too much can increase our risk of cardiovascular disease.
High cholesterol remains one of the most important preventable risk factors for heart disease and stroke. Having too much Low Density Lipoprotein (LDL), often called “bad cholesterol,” circulating in the blood stream can contribute to plaque build-up inside our arteries, narrowing them and increasing the risk of having a major heart event.
Over the past several decades, medications called statins have made a positive impact in cardiovascular care by lowering LDL cholesterol which, in turn, reduces the risk of heart attacks and strokes. The goal of cholesterol treatment is not simply to achieve a “normal” cholesterol number. Instead, your physician or nurse practitioner will consider your overall cardiovascular risk, including such factors as age, blood pressure, smoking status, diabetes, kidney disease, family history, and whether you have already had a heart attack or stroke.
A person who has already experienced cardiovascular disease may need a much lower LDL level than someone with few other risk factors. You may have discovered that when chatting with family or friends and learned that your medication and/or dose is quite different than theirs.
Chances are the medication you mentioned you have been taking for decades is one of the statins, such as rosuvastatin (Crestor), atorvastatin (Lipitor), or pravastatin (Pravachol), simvastatin (Zocor), to name a few. However, not everyone can tolerate statins, and some people with very high cardiovascular risk need additional treatment to reach their cholesterol goals. This has led to the development of several non-statin cholesterol-lowering medications.
Statins continue to remain the first choice for most people who require cholesterol medication, providing you are managing and tolerating it well. They work mainly by reducing cholesterol production in the liver and can lower LDL cholesterol by approximately 30–60 per cent, depending on the medication and dose.
More importantly, decades of research have shown that statins reduce heart attacks, strokes, and cardiovascular deaths. Statins are generally well-tolerated, but one of the more common complaints seen with statins is muscle aches. Since statins are so effective at managing cholesterol, instead of stopping the medication altogether, it is suggested to adjust the dose, change to another statin or try a different dosing schedule to see if the symptoms improve. For most people, statins continue to provide the best combination of effectiveness, safety, and cost.
Bempedoic acid (Nilemdo) is a newer oral cholesterol medication that works differently than statins. It blocks an enzyme involved earlier in the cholesterol production pathway in the liver which, in turn, avoids the activation of the muscles that are responsible for the myalgias (muscle pain). Bempedoic acid, therefore, is a useful option for people who cannot tolerate statins because of muscle symptoms. Bempedoic acid can be used on its own or as an add-on to help achieve your cholesterol goals.
Studies have shown that bempedoic acid added to a moderately-dosed statin is as effective at lowering LDL as compared to adding ezetimibe (Ezetrol) to a statin. Bempedoic acid has also been shown to be more effective when added to a moderate statin dose compared to doubling the statin dose. There are studies that have shown that bempedoic acid can reduce cardiovascular events in certain high-risk patients, particularly those who are unable to take statins.
This all sounds great. However, as with many good things, there are often downsides:
Cost - Bempedoic acid is quite expensive and many drug plans have not elected to add it to their formulary as of yet.
Myalgia - Though it can further lower LDL when added to a statin, it can increase statin-induced myopathy.
Uric Acid - Bempedoic acid can increase uric acid levels in the body which can, in turn, cause gout attacks. Uric acid levels can be monitored with blood work.
Liver enzymes - Bempedoic acid has the potential to affect the liver. Liver function tests can be monitored with blood work.
Statins continue to be the first-line medication to lower cholesterol levels. Before adding bempedoic acid to the regime, consider taking ezetimibe as an add-on as it is just as effective when added to at statin and costs significantly less. Or your health-care provider may choose to add icosapent ethyl (Vascepa) to your cholesterol-lowering medications. It is more expensive than ezetimibe but less than bempedoic acid.
If you are currently taking a statin and are tolerating it well and achieving your target goal, it is not suggested to make the switch to bempedoic acid. However, you may wish to consider bempedoic acid if you:
Cannot tolerate recommended statin doses
Need additional LDL-lowering despite taking a statin
Are at a high cardiovascular risk and need another treatment option
Another class of cholesterol-lowering medications is the PCSK9 inhibitors, including evolocumab (Repatha) and alirocumab (Praluent). These are injectable medications that work by helping the liver remove more LDL cholesterol from the blood stream. They are extremely effective, often lowering LDL cholesterol by 50–60 per cent in addition to other treatments. Because of their effectiveness and cost, they are generally reserved for people at very high risk, such as those with established cardiovascular disease who have not reached their LDL target, people with familial hypercholesterolemia (an inherited condition causing very high cholesterol) or those who cannot achieve adequate cholesterol reduction with standard treatments.
Inclisiran (Leqvio) is another injectable medication that targets the PCSK9 pathway but works differently. Instead of blocking PCSK9 after it is produced, it reduces the liver’s ability to make PCSK9. The major advantage is convenience. After the initial doses, it is administered twice yearly, which may improve adherence for some people.
Inclisiran can significantly lower LDL cholesterol, but questions remain about how it compares long-term with established therapies because cardiovascular outcome data are still developing. A major hurdle with Inclisiran is the cost as it is prohibitively expensive.
Keep in mind that newer is not always better. As previously mentioned, the right choice depends on several factors and in addition to your risk, there is the cost and plan coverage to consider. Like many new medications that appear on the market, they come with a significant higher price tag.
Even the most powerful cholesterol medication works best alongside healthy habits. A Mediterranean-style eating pattern, regular physical activity, maintaining a healthy weight, avoiding smoking, and managing blood pressure and diabetes, all contribute to reducing cardiovascular risk. If you have been treated for high cholesterol for some time and have reached your target with your current therapy, the suggestion would be to stay with the status quo. From the words of an old proverb, “If it ain’t broke, don’t fix it.”
For more information about this or any other health-related questions, contact the pharmacists at Gordon Pharmasave, Your Health and Wellness Destination. Also check the website at www.gordon-pharmasave.com/ and the Facebook page at www.facebook.com/GordonPharmasave/.
Related Stories
No related stories.