Treatment:

In 2004, the National Cholesterol Education Program issued its latest recommendations for cholesterol control and management. These guidelines increase the number of Americans who should be taking LDL-lowering medication.

Starting Medications. Even modest lowering of high cholesterol levels, whether through drug therapy or lifestyle changes, reduces the risk of disability and death from heart disease. Most experts now focus on lowering LDL ("bad") cholesterol. Reducing LDL levels is particularly critical for patients with diabetes.

The doctor will start or consider medication, increase dosage of medication, or add new medication when:

• LDL cholesterol is 190 mg/dL or higher.
• LDL cholesterol is 160 mg/dL or higher AND patient has one risk factor for heart disease.
• LDL cholesterol is 130 mg/dL or higher AND patient has either diabetes or two other risk factors for heart disease.
• LDL cholesterol is 100 mg/dL or higher AND patient has heart disease. (If patient has diabetes, even without heart disease, medication may be considered for an LDL cholesterol of 100 mg/dL.)
• LDL cholesterol is greater than 70 mg/dL AND patient has had a recent heart attack or has known heart disease along with diabetes, current cigarette smoking, poorly controlled high blood pressure, or the metabolic syndrome (high triglycerides, low HDL, and obesity).

Risk factors for heart disease include:

• Having a first-degree female relative diagnosed with heart disease before age 65 or a first-degree male relative diagnosed before age 55
• Being male and over age 45 or female and over age 55
• Cigarette smoking
• Diabetes
• High blood pressure
• Metabolic syndrome (risk factors associated with obesity such as low HDL levels and high triglycerides)

Statin therapy has been proven to decrease the incidence of major coronary events, the need for coronary revascularization procedures, and the incidence of stroke. These benefits seem to occur no matter what cholesterol level is present at the beginning of treatment and the reduction in risk continues for the most part at all lipid levels. Generally, this benefit is present for all age groups, both genders, and whether or not the patient has pre-existing vascular disease.

Recent studies have found that aggressive lipid lowering with high-dose or intensive statin therapy is more beneficial than standard statin therapy in patients with existing heart disease. Data from several trials suggest that intensive statin therapy produces greater reductions in LDL and C reactive protein (CRP) levels.

The hope has been that the more statins can lower LDL, the more effective they will be in slowing and even reversing the progression of atherosclerosis. However, to date statins have only been shown to slow the rate of atherosclerotic progression, and not reverse heart disease. Future studies will continue to investigate this issue. Many experts believe that the more that LDL is reduced through statin therapy, the greater the reduction in risk for heart disease, heart attack, and stroke

It is important to emphasize that cholesterol-lowering medications are used along with healthy lifestyle habits, not in place of them.

Choosing the Correct Lipid-Lowering Medication. Experts now recommend that drug treatments be tailored for raising or lowering specific lipids, depending on the patient's blood lipid picture:

• Statins are now the standard drugs for most people who require LDL-lowering therapy. Bile-acid binding resins or niacin may be considered. If LDL goals are not achieved, combinations of a statin with a bile-acid resin or niacin should be considered.
• Fibrates or niacin are beneficial for people who need to lower triglycerides and increase HDL.

Considerations for Children and Adolescents. In 2007, the American Heart Association (AHA) issued a scientific statement addressing the use of cholesterol drugs in children and adolescents. The AHA recommends that overweight or obese children should undergo lifestyle modifications (diet, exercise) before trying drug therapy to lower high cholesterol levels.

For children and adolescents who have high-risk cholesterol imbalances -- and a family history of high cholesterol, heart attack, stroke, and diabetes -- the AHA now recommends statins as the first-line drug therapy.

Considerations for People with Diabetes. At this time, statins are recommended as the best drugs for improving cholesterol and lipid levels in people with diabetes. Studies suggest that they can reduce the risk for adverse heart events in people with diabetes, even if patients' cholesterol levels are normal or if their diabetes is mild. Fibrates may also be useful for people with type 2 diabetes. Niacin (nicotinic acid) has the best effect on the cholesterol profile of people with diabetes, but it also increases blood sugar levels and can be difficult to tolerate.