New Cholesterol Guidelines (2026) - Part 3: How cholesterol medications work

Year after year, new medications are produced that have an effect on lowering cholesterol. When I was a medical student 14 plus years ago, I recall these being the choices: statins, Zetia, fibrates, niacin, and bile acid sequestrants. Of these, I really only prescribe statins and Zetia today. And, there are now a plethora of new medications that do a better job of lowering heart disease risk. However, many are quite pricey, which is the downside.

Before I talk about the different types of cholesterol-lowering medications, I think it's important to note that the main reason we try to lower cholesterol is to reduce cardiovascular risk (e.g., heart attacks, strokes). It's important to note that some cholesterol medications do indeed improve cholesterol numbers, but have failed to show a benefit in clinical trial of lowering cardiovascular risk. For example, niacin, which we used to use all the time to raise someone's good cholesterol (HDL), is now not even recommended anymore because it doesn't improve cardiovascular outcomes and also leads several side effects (e.g., flushing of the skin).

Below, I will discuss some, but not all, of the types of cholesterol-lowering medications that the new cholesterol guidelines from ACC/AHA recommend:

Statins Statins reduce cholesterol synthesis in the liver. These drugs are everyone's favorite (*cough*). There is not a day goes by that I don't hear about people complaining about something they read about statins online. However, my opinion is that statins are a very good class of medications. Why? They have reduced cardiovascular risk consistently by 25% in numerous clinical trials. They improve cholesterol significantly, including total, LDL, and triglyceride values. And, they have been generic for years, which means they are not expensive. People tend to complain about statins because there is a small risk of muscle aches (myopathy) compared with placebo. Let me emphasize small risk. The vast majority of people do not develop these side effects. I don't mean to demean what you read on the internet, but I have had so many patients through the years who already have chronic back pain, or arthritis, or are just getting older and have aches and pains, etc. They go golfing or do something strenuous in the yard, they go in and tell their spouse they are hurting, their spouse tells them it's probably the statin, and then they tell me they want to stop taking the statin they've been on for months or years. Can statins cause muscle aches or myopathy? Rarely, in a few people, yes. Does it cause joint pains. No, I don't think so. Should you blame every ache and pain on the statins... no. Why? Because if you come off the statin unnecessarily, then you are limiting for yourself an inexpensive treatment that greatly reduces the risk of heart attack and stroke, a top 2 cause of death in the United States. Other options are much more expensive, and some are not as effective as the statins. Before you stop the statin, make sure you talk to your doctor first. That's all I'm saying. Ok, I'm done ranting. Thanks for listening.

Ezetimibe (Zetia)

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