Most of the cholesterol in your body is made by your liver from saturated fat in your diet. Some cholesterol also comes from foods such as eggs, meats and dairy products.

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While some cholesterol is needed for good health, too much cholesterol in your blood can raise your risk of having a heart attack or stroke.

The extra cholesterol in your blood may be stored in your arteries (blood vessels) and cause them to narrow. (This is called atherosclerosis.) Large deposits of cholesterol can completely block an artery, so the blood can't flow through.

If an artery that supplies blood to your heart becomes blocked, a heart attack can occur. If an artery that supplies blood to your brain becomes blocked, a stroke can occur.

The Lifestyle Changes will help you keep your blood cholesterol and chance for developing heart disease low. You will learn about the Heart Healthy Diet and being more physically active.

The Therapeutic Lifestyle Changes (TLC) will help you lower a blood cholesterol that is too high and reduce your chance of developing heart disease by following a low saturated fat, low cholesterol diet (TLC Diet) and how to be more physically active.

For some people it is necessary to combine cholesterol lowering medications with changes in life habits to get enough of a reduction in cholesterol. Your doctor can help to decide which combination of cholesterol-lowering activities is right for you. This section outlines the medications that are available.

In some cases, you may need to take a cholesterol-lowering medicine in addition to making the life habit changes already mentioned to reach the LDL cholesterol goal recommended by your doctor.

Cholesterol-Lowering Medications

If following a low-saturated-fat, low-cholesterol diet, increasing your physical activity, and losing weight have not lowered your risk for developing CHD after about 3 months, your doctor may consider prescribing a cholesterol-lowering medication. If your doctor prescribes medicine, you also will need to:

• Continue to follow your cholesterol-lowering diet
• Be more physically active
• Lose weight if overweight
• Control all of your other heart disease risk factors, including smoking, high blood pressure, and diabetes

Taking all these steps together may lessen the amount of medicine you need or make the medicine work better--and that reduces your risk for developing heart disease. The following is a description of cholesterol-lowering medicines.

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Statins

There are currently five statin drugs on the market in the United States: lovastatin, simvastatin, pravastatin, fluvastatin, and atorvastatin (cerivastatin was withdrawn from the market by the manufacturer in August 2001). The major effect of the statins is to lower LDL-cholesterol levels, and they lower LDL-cholesterol more than other types of drugs. Statins inhibit an enzyme, HMG-CoA reductase, that controls the rate of cholesterol production in the body. These drugs lower cholesterol by slowing down the production of cholesterol and by increasing the liver's ability to remove the LDL-cholesterol already in the blood. Statins were used to lower cholesterol levels in both the West of Scotland and AFCAPS/TexCAPS studies. The large reductions in total and LDL-cholesterol produced by these drugs resulted in large reductions in heart attacks and heart disease deaths. Thanks to their track record in these studies and their ability to lower LDL-cholesterol, statins have become the drugs most often prescribed when a person needs a cholesterol-lowering medicine.

Studies using statins have reported 20 to 60 percent lower LDL-cholesterol levels in patients on these drugs. Statins also reduce elevated triglyceride levels and produce a modest increase in HDL-cholesterol.

The statins are usually given in a single dose at the evening meal or at bedtime. It is important that these medications be given in the evening to take advantage of the fact that the body makes more cholesterol at night than during the day.

You should begin to see results from the statins after several weeks, with a maximum effect in 4 to 6 weeks. After about 6 to 8 weeks, your doctor can do the first check of your LDL-cholesterol while on the medication. A second measurement of your LDL-cholesterol level will have to be averaged with the first for your doctor to decide whether your dose of medicine should be changed to help you meet your goal.

The statins are well tolerated by most patients, and serious side effects are rare. A few patients will experience an upset stomach, gas, constipation, and abdominal pain or cramps. These symptoms usually are mild to moderate in severity and generally go away as your body adjusts. Rarely a patient will develop abnormalities in blood tests of the liver. Also rare is the side effect of muscle problems. The symptoms are muscle soreness, pain, and weakness. If this happens, or you have brown urine, contact your doctor right away to get blood tests for possible muscle problems.

Bile Acid Sequestrants

Bile acid sequestrants bind with cholesterol-containing bile acids in the intestines and are then eliminated in the stool. The usual effect of bile acid sequestrants is to lower LDL-cholesterol by about 10 to 20 percent. Small doses of sequestrants can produce useful reductions in LDL-cholesterol. Bile acid sequestrants are sometimes prescribed with a statin to increase cholesterol reduction. When these drugs are combined, their effects are added together to lower LDL-cholesterol by over 40 percent. Cholestyramine, colestipol, and colesevelam are the three main bile acid sequestrants currently available. These three drugs are available as powders or tablets. They are not absorbed from the gastrointestinal tract and 30 years of experience with the sequestrants indicate that their long-term use is safe.

Bile acid sequestrant powders must be mixed with water or fruit juice and taken once or twice (rarely three times) daily with meals. Tablets must be taken with large amounts of fluids to avoid gastrointestinal symptoms. Sequestrant therapy may produce a variety of symptoms including constipation, bloating, nausea, and gas.

The bile acid sequestrants are not prescribed as the sole medicine to lower your cholesterol if you have high triglycerides or a history of severe constipation.

Although sequestrants are not absorbed, they may interfere with the absorption of other medicines if taken at the same time. Other medications therefore should be taken at least 1 hour before or 4 to 6 hours after the sequestrant. Talk to your doctor about the best time to take this medicine, especially if you take other medications.

Nicotinic Acid

Nicotinic acid or niacin, the water-soluble B vitamin, improves all lipoproteins when given in doses well above the vitamin requirement. Nicotinic acid lowers total cholesterol, LDL-cholesterol, and triglyceride levels, while raising HDL-cholesterol levels. There are three types of nicotinic acid: immediate release, timed release, and extended release. Most experts recommend starting with the immediate-release form; discuss with your doctor which type is best for you. Nicotinic acid is inexpensive and widely accessible to patients without a prescription but must not be used for cholesterol lowering without the monitoring of a physician because of the potential side effects. (Nicotinamide, another form of the vitamin niacin, does not lower cholesterol levels and should not be used in the place of nicotinic acid.)

All patients taking nicotinic acid to lower serum cholesterol should be closely monitored by their doctor to avoid complications from this medication. Self-medication with nicotinic acid should definitely be avoided because of the possibility of missing a serious side effect if not under a doctor's care.

Patients on nicotinic acid are usually started on low daily doses and gradually increased to an average daily dose of 1.5 to 3 grams per day for the immediate release form and 1.5 to 2 grams per day for the other forms.

Nicotinic acid reduces LDL-cholesterol levels by 10 to 20 percent, reduces triglycerides by 20 to 50 percent, and raises HDL-cholesterol by 15 to 35 percent.

A common and troublesome side effect of nicotinic acid is flushing or hot flashes, which are the result of blood vessels opening wide. Most patients develop a tolerance to flushing, and in some patients, it can be decreased by taking the drug during or after meals or by the use of aspirin or other similar medications prescribed by your doctor. The extended release form may cause less flushing than the other forms. The effect of high blood pressure medicines may also be increased while you are on niacin. If you are taking high blood pressure medication, it is important to set up a blood pressure monitoring system while you are getting used to your new niacin regimen. A variety of gastrointestinal symptoms including nausea, indigestion, gas, vomiting, diarrhea, and the activation of peptic ulcers have been seen with the use of nicotinic acid. Three other major adverse effects include liver problems, gout, and high blood sugar. Risk of the latter three increases as the dose of nicotinic acid is increased. Your doctor may possibly not prescribe this medicine for you if you have diabetes, because of the effect on your blood sugar.

Fibrates

The cholesterol-lowering drugs called fibrates are primarily effective in lowering triglycerides and, to a lesser extent, in increasing HDL-cholesterol levels. Gemfibrozil, the fibrate most widely used in the United States, can be very effective for patients with high triglyceride levels. However, it is not very effective for lowering LDL- cholesterol. It is used in some patients with heart disease for whom a goal of treatment is lowering triglycerides or raising HDL. One study found that patients with heart disease, somewhat elevated triglycerides, and low HDL who took fibrates had reduced risk for a heart attack. Fibrates are usually given in two daily doses 30 minutes before the morning and evening meals. The reductions in triglycerides generally are in the range of 20 to 50 percent with increases in HDL-cholesterol of 10 to 15 percent.

Fibrates are generally well tolerated by most patients. Gastrointestinal complaints are the most common side effect and fibrates appear to increase the likelihood of developing cholesterol gallstones. Fibrates can increase the effect of medications that thin the blood, and this should be monitored closely by your physician.