Alternatives to statins for high cholesterol
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Non-Statin Medications for High Cholesterol
Several non-statin medications are now available for people who cannot tolerate statins or need additional cholesterol lowering. Ezetimibe, PCSK9 inhibitors (such as evolocumab, alirocumab, and inclisiran), and bempedoic acid are the main alternatives. These drugs have shown strong safety profiles, with few side effects and no major drug interactions. PCSK9 inhibitors are injectable and may cause mild injection site reactions, while bempedoic acid can slightly increase uric acid and the risk of gout in some people. The choice among these options often depends on cost, availability, and how much LDL cholesterol needs to be lowered 1456810.
Efficacy and Safety of Alternative Strategies
Recent studies show that combining a moderate-intensity statin with ezetimibe is as effective as high-intensity statin therapy for reducing cardiovascular events over three years. This combination also results in lower rates of new-onset diabetes and fewer people stopping or reducing their medication due to side effects. The combination is especially helpful for those who experience statin intolerance 39.
Additional Pharmacological Options
Other drug classes, such as bile acid sequestrants, fibrates, and niacin, have also been used to lower cholesterol, though they are less common today. Newer agents like volanesoren, evinacumab, and gene-based therapies (including small interfering RNAs and antisense oligonucleotides) are emerging, but most are still under investigation or reserved for specific cases like familial hypercholesterolemia 567810.
Natural and Dietary Alternatives
Some natural products, such as red yeast rice, plant sterols, and oats, have shown benefits in lowering cholesterol. These options are most effective when combined with a healthy lifestyle. However, more research is needed to fully understand their safety and the best doses, especially for red yeast rice and plant sterols .
Conclusion
For people who cannot use statins or need more cholesterol lowering, several effective and safe alternatives are available. Ezetimibe, PCSK9 inhibitors, and bempedoic acid are the most established options, with combination therapies offering similar benefits to high-intensity statins but with fewer side effects. Natural alternatives may help when used alongside healthy habits, but should be chosen carefully. The best choice depends on individual needs, side effect profiles, and access to these therapies.
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