Pharmacist's Cholesterol Course Part 2 | How much can medication lower it? Latest evidence on cholesterol treatment
I was told my LDL is high, but I don't know if I should take medication.
I have an impression that statins have scary side effects.
I want to know specifically how much it will lower my levels.
Many people have these questions.
In fact, cholesterol medication is one of the few types of drugs where the extent of the reduction is clearly indicated by numbers.
Furthermore, in recent years, this has become a field with very strong evidence (scientific basis).
In this article, from a pharmacist's perspective, I will explain:
Which drugs lower it and by how much?
Who should take the medication?
I will explain this in a way that is easy for the general public to understand while maintaining professional accuracy.
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1. Criteria for using medication: It is not determined solely by the LDL level.
Cholesterol treatment is determined by the combination of:
LDL level x Arteriosclerosis risk
as the criteria for judgment.
● LDL level guidelines (general criteria)
160 or higher: Strongly consider treatment
140-159: Treatment based on risk
120-139: Focus on lifestyle improvements
Below 120: Good
However, there are some people who need medication even if their LDL is 140,
while others start with lifestyle improvements even at 160.
● Having "risk factors" increases the priority for medication
Diabetes
Hypertension
Smoking
Family history (myocardial infarction/cerebral infarction)
Obesity
Familial hypercholesterolemia (FH)
In particular, drug therapy is recommended for those with diabetes and an LDL of 140 or higher.
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2. Statins (HMG-CoA reductase inhibitors) — The medication with the strongest evidence
Statins are the "core" medication for cholesterol treatment.
● Efficacy (LDL reduction rate)
20-50% reduction (depending on the type and dose of medication)
● Why are statins the first choice?
They reduce the incidence of myocardial infarction and cerebral infarction
They are also highly effective in preventing recurrence
There are numerous large-scale studies, making them highly reliable
● Side effects (the reality)
Muscle pain (1–5%)
Elevated liver enzymes (1–3%)
Rhabdomyolysis (extremely rare)
While many people say they are afraid of side effects,
serious side effects are extremely rare,
and it is known that the benefits of preventing cardiovascular events are overwhelmingly greater.
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3. Ezetimibe — Blocking dietary cholesterol
Ezetimibe is the medication used after statins.
● Effect (LDL reduction rate)
15–20% reduction
It can be used alone, but
it is characterized by a significant increase in effectiveness when used in combination with statins.
● Benefits of combination therapy
Can lower LDL further without increasing the statin dose
Fewer side effects
Proven effectiveness in suppressing cardiovascular events
It is an excellent "next step" when statins alone do not lower levels sufficiently.
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4. PCSK9 inhibitors — "Top-tier" drugs that lower levels dramatically
With injectable drugs that have appeared in recent years,
there is an overwhelming effect of lowering LDL by 50-60%.
● Effect (LDL reduction rate)
50-60% reduction (more powerful than statin + ezetimibe combination)
● Who is it for?
Familial hypercholesterolemia (FH)
Those who do not get sufficient reduction even with statins + ezetimibe
Those with a history of myocardial infarction who need recurrence prevention
● Disadvantages
High cost (out-of-pocket expenses are significant even with insurance coverage)
Injection (once every 2-4 weeks)
However, the effect is overwhelming, and
it is the most powerful option for people who "definitely want to lower their LDL."
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5. Choosing the right medication - Determined by "how much you want to lower it"
The goal of treatment is
determined by how much you need to lower your LDL.
● Target value guidelines
General: Less than 100
High risk (diabetes, etc.): Less than 70
Ultra-high risk (history of myocardial infarction): Below 55
● Concept of usage
Mild high LDL: Low-dose statin or ezetimibe
Moderate: Moderate-dose statin
Severe: High-dose statin + ezetimibe
FH or ultra-high risk: Add PCSK9 inhibitor
As a pharmacist,
I emphasize that "how much it needs to be lowered" is more important than "which medication to use."
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6. Key points for pharmacist explanation — Helping patients understand the meaning of continued medication
The most common misunderstanding in cholesterol treatment is
the idea that "I can stop the medication because my numbers have gone down."
In reality,
the numbers have only gone down because of the medication, and they will almost certainly return to previous levels if the medication is stopped.
The purpose of taking the medication is
not "to lower current numbers," but "to prevent future myocardial infarction."
When patients understand this perspective,
treatment adherence changes significantly.
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■ Summary: An Era of Choosing Medication Based on "How Much You Want to Lower It"
A key feature of cholesterol-lowering medications is that
the extent to which they lower levels is clearly indicated by numbers.
Statins: 20–50%
Ezetimibe: 15–20%
PCSK9 inhibitors: 50–60%
Furthermore, the purpose of using these medications is
"to prevent future myocardial infarction and cerebral infarction."
When understood in conjunction with
the roles of LDL and HDL
that we learned in Part 1,
the overall picture of treatment becomes clear.