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Nov 5, 2021


Heart Health

StatinsStatin Side-EffectsStatin SymptomsStatin Muscle PainCholesterol

Statin not enough? What else can you do?

What is a Statin and its Role in Your Health?

Statins are a class of medications that help to lower cholesterol. As a class, statins are well known to reduce symptoms and risks associated with cardiovascular diseases.

Statins are the most prescribed cholesterol-lowering drugs in the United States and are considered the first line of defense when it comes to managing elevated cholesterol.

What is Cholesterol?

Cholesterol is a waxy substance produced by your body to build cells, vitamins, and hormones. It is primarily produced by your liver, but can also be absorbed from your diet from animal foods such as meat and dairy.

Did you know Food high in saturated and trans fats can signal your liver to produce extra cholesterol. That’s why we should try to limit our intake of saturated and trans fats!

Impact of Cholesterol on your Health

Cholesterol circulates through your blood system and over time can accumulate to form a thick hard deposit within your arteries known as plaque.

Plaque can build-up over time and narrow your arteries (atherosclerosis) and can lead to blood clots or blockages, ultimately leading to a heart attack or stroke.

High cholesterol is considered a ‘silent killer’ as it has no symptoms. It is crucial to monitor and control your cholesterol levels on a regular basis.

How Statins Help

Statins work to lower LDL-C (“Bad Cholesterol”), by blocking an enzyme in the liver that facilitates the production of cholesterol.

Statins are widely prescribed and consumed throughout the United States and across racial and social demographics. They are taken by an estimated 22% of Americans over the age of 45.

Despite their widespread use, statins are relatively underutilized in the U.S. healthcare system. It’s estimated that 33.5% of Americans have high cholesterol (71 million people), yet only 1 in 3 actually have the condition under control.

There are currently 7 different statins approved for managing cholesterol in the U.S.:

  1. Fluvastatin
  2. Atorvastatin
  3. Pravastatin
  4. Simvastatin
  5. Pitavastatin
  6. Lovastatin
  7. Rosuvastatin

Did you know There is a consensus among the medical and scientific community that the benefits of statin use outweigh the chance of any possible negative side effects.

The American College of Cardiology reports that around 10% of patients prescribed statins stop taking the medication altogether due to complaints.

The most common side effects of statins include:

  1. Back pain
  2. Muscle pain and/or weakness
  3. Constipation
  4. Diarrhea
  5. Pain in the legs or arms

When one experiences side effects it is best to talk to your doctor right away. Switching statins or the doses of the statin which you are on are both reasonable options your healthcare provider will consider.

Why People Stop Takings Statins

Non-adherence to statin medication ranges from 30% to a substantial 60% based on a variety of clinical trials, with the majority listing causes relating to muscle pain, aches, inflammation of joints, and cramps.

The cost-efficiency of a statin is also a major issue for people without health insurance or benefits. Cash payments for a month’s worth of statin medication can range from $29 for the generic lovastatin (20 mg tablet) to $400 for the brand name Livalo® (pitavastatin) (2mg tablet.). Check out an alternative to Livalo® which we offer at Marley Drug.

With a significant number of Americans not managing their cholesterol or properly being compliant with their medications, health regulatory bodies and pharmaceutical entities are working together to educate patients on the importance of managing cholesterol in a hope to improve compliance.

While there are statin alternatives becoming available, nothing has been shown to be a replacement for statin therapy.

Additional Medications When Statins Therapy Is Not Enough

In some instances, additional pharmacotherapies are needed to help manage one’s cholesterol levels. This happens when a patient is at a very high risk for heart disease, when statin therapy alone isn’t enough to manage their cholesterol levels, or if a patient cannot tolerate higher doses of statin therapy. In such cases add-on cholesterol lowering therapies is often recommended.

Additional types of cholesterol lowering medications include:

  1. Cholesterol Absorption Inhibitors
  2. Bile Acid Sequestrants
  3. Fibrates
  4. PCSK9 Inhibitors
  5. ACL Inhibitors

Cholesterol Absorption Inhibitors

Cholesterol Absorption Inhibitors do just that. They prevent your body from absorbing cholesterol in the small intestine. If it can’t be absorbed, it won’t reach your bloodstream.

One popular example of this class of medication is generic Zetia® (Ezetimibe). Prices for the generic drug Ezetimibe for a monthly supply are estimated at around $47. We sell generic Zetia (ezetimibe) for 90% less at Marley Drug.

Bile Acid Sequestrants

Bile acid sequestrants work to lower cholesterol by blocking your stomach’s ability to absorb bile acid. This causes your liver to make more bile acid, which in turn reduces your cholesterol levels as your body needs cholesterol to make bile acid. Their use has markedly decreased since the introduction of statins in the 1980s.

Bile acid sequestrants can modestly raise triglycerides and therefore should not be used if triglycerides are elevated.

Some examples include cholestyramine (generic Questran®), colestipol (generic Colestid®), and colesevelam (Welchol®).


Fibrates are a medicine that help to lower high triglyceride levels as well as raise HDL-C (“Good Cholesterol”). They work by stimulating our livers to do a better job of absorbing triglycerides from the blood.

Importantly fibrates are not effective in lowering LDL-C (“Bad Cholesterol”). In addition, fibrates should not be used in combination with statins as it can increase the risk of serious muscle problems, called rhabdomyolysis.

PCSK9 Inhibitors

PCSK9 Inhibitors are lipid-lowering drugs and a promising therapeutic alternative for treating patients who are intolerant to statins. There is one catch; they are extremely expensive and are only available in brand form: Repatha® (evolocumab) and Praluent® (alirocumab).

PCSK9 inhibitors, as the name indicates, work by blocking a protein called PCSK9. This protein’s job is to break down a receptor on our cell which is responsible for absorbing cholesterol. By blocking its function, our cells have more of this receptor, and as a result our body becomes better at absorbing cholesterol, thereby, lowering our blood cholesterol levels.

ACL Inhibitors

Adenosine triphosphate-citrate lyase (ACL) inhibitors are the newest class of cholesterol lowering medications. They work to lower cholesterol by blocking our liver’s ability to produce cholesterol.

Bempedoic acid, sold as brand name Nexletol®, is the only ACL inhibitor available to date. As a brand name medication, it can be quite cost prohibitive to patients.

Nexletol® (bempedoic acid) is intended to be used in combination with a statin and has been shown to provide an additional 18% reduction in LDL-C when used with a statin.

The makers of Nexletol® have also launched a combination pill, bempedoic acid and ezetimibe, called Nexlizet® which, when used in combination with a statin adds another 38% reduction in LDL-C, or bad cholesterol.

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