Statins

(Atorvastatin, Rosuvastatin, Pravastatin, Simvastatin, Fluvastatin)

Statins have been available for more than 30 years. They are the first choice because they have the strongest evidence not only for lowering cholesterol but also for reducing heart attacks and strokes. Atorvastatin is the statin that most people start with.

How do statins work?

Statins increase the amount of cholesterol that the liver takes out of the blood. The effectiveness of statins varies, but the most commonly used statins will reduce the cholesterol level in the blood to half of what it was before starting statins. Statins also lower triglycerides and can raise HDL, although their main effect is on LDL.

How do I take a statin?

Statins are tablets that are taken once a day. It is important to keep taking your statin even when your cholesterol comes down as your cholesterol will go up again if you stop.

Do statins have side effects?

Most people get on with statins without any problems at all and it is worth bearing in mind that all medicines can cause side effects. The most common side effect of statins is muscle pain.

Statins and muscle pain

You would usually notice this within a few days of starting the statin and the pains should go away if you stop taking the statin.

If you do notice pains, it is important to have a think about:

• Is the pain different from the pains that you have had before?
• Have you done anything different other than starting the statin (eg lifting, unaccustomed or strenuous physical activity etc)?

The different statins are handled differently within the body. This means that having muscle pains on one statin does not mean that you will have pain on all the statins.

Discuss any muscle pains with your healthcare team. You can try a different statin or a lower dose and you will need a blood test.

Ezetimibe (also known as “Ezetrol”)

Ezetimibe is a tablet that is taken once a day and is the most commonly used tablet medication after statins. Ezetimibe is used if people don’t get on with statins or if statins alone don’t get the cholesterol low enough.

How does Ezetimibe work?

Ezetimibe reduces the amount of cholesterol absorbed from food, reducing the cholesterol level in the blood by up to a third. Ezetimibe can also reduce the risk of heart attacks in some people.

Does Ezetimibe have side effects?

Side effects are rare with Ezetimibe. Some people notice abdominal pain, nausea, and diarrhoea. Very often these symptoms are mild and don’t last long. Occasionally, people taking Ezetimibe with statins notice muscle pain side effects as above.

Bempedoic acid

Bempedoic acid is a newer tablet medication for cholesterol. It is generally used with Ezetimibe if statins and Ezetimibe are not getting the cholesterol low enough or for people who don’t get on with statins. In some areas, you would need to see a cholesterol specialist before you can receive Bempedoic acid.

How does Bempedoic acid work?

Bempedoic acid reduces how much cholesterol you absorb from your diet with the knock-on effect that it increases the amount of cholesterol that the liver takes out of the blood. Bempedoic acid reduces cholesterol levels by about a third and also reduces the risk of heart attacks in some people.

Does Bempedoic acid have side effects?

All medicines can have side effects, but most people get on well with Bempedoic acid. The rare side effects that people notice are pain in the shoulders, legs, or arms, anaemia, constipation, and gout. These side effects go away if Bempedoic acid is stopped.

Injectable treatments

There are 2 forms of injectable treatment;

• Evolocumab (Repatha) and Alirocumab (Praluent) are injections that you give yourself every 2 or 4 weeks using a device that is very similar to an insulin pen.
• Inclisiran is an injection every 6 months, usually given at your GP surgery.

The injectable treatments are considered for people who have a cholesterol that is not where it should be despite being on tablet medication. In some areas, you would need to see a cholesterol specialist before you can receive the injectable treatments.

How do the injectable treatments work?

The injections increase the amount of LDL removed from the blood by the liver. They reduce the LDL by around half. Evolocumab (Repatha) and Alirocumab (Praluent) have also been shown to reduce heart attacks. There is ongoing research to see whether Inclisiran reduces heart attacks as well as reducing LDL.

Do the injectable treatments have side effects?

Side effects are not common with the injectable treatments.

Occasionally, Evolocumab (Repatha) and Alirocumab (Praluent) are associated with a runny nose, sore throat, or cold type symptoms. This is usually only for a day or two after the injections and often improves with time. Some people notice a bit of irritation of the skin where they do the injections.

The only side effect reported for Inclisiran is an irritation at the site where the injection is done, but this is uncommon.

Medication for triglycerides

Lifestyle change is extremely effective in bringing triglycerides down. If you can eat well, maintain a healthy body weight, do plenty of physical activity, and be careful about how much alcohol you drink, it is likely that you will not need medication for triglycerides.

The commonest medication used to control triglycerides are fibrates (Fenofibrate or Bezafibrate). Fibrates work on several aspects of fat metabolism. Fibrates can reduce triglycerides by up to a half but only work effectively in combination with healthy lifestyle changes.