Why cholesterol matters

Lifestyle changes

• Lose weight, or avoid becoming overweight. Even 5-10 pounds will have a significant effect on your cholesterol.
  
• Take more exercise. Exercise helps increase the amount of HDL, the 'good' cholesterol, as well as helping with weight loss.
  
• Modify your diet. It's important to reduce the amount of saturated fats, usually fats from animal sources, while still having a well-balanced, nutritious and enjoyable diet. Changing your diet can achieve up to a 10 per cent fall in cholesterol levels.

Medication
In addition to lifestyle changes your doctor may prescribe drugs to lower your cholesterol. This will depend on risk factors such as age, smoking, high blood pressure, low levels of HDL cholesterol and a family history of heart disease, particularly in men younger than 55 or women younger than 65.

If you don't achieved your target LDL cholesterol level after three months on a single medication, your doctor may recommend adding a second one. Various combinations have been shown to be effective and safe. Lower doses of each individual drug can reduce the risk of side effects.

Types of drugs
Statins. Introduced in the mid 1990's, these drugs can lower cholesterol by up to 20 per cent by inhibiting an enzyme called HMG-CoA reductase, which controls the body's cholesterol production rate. The two prescribed in the UK are simvastatin and pravastatin. A trial has shown statins to be effective in reducing the risks of heart attack and stroke in high-risk people by around one third. Statins are taken once a day in the evening or before bed. The timing is important, since the body makes more cholesterol at night than during the day. It takes about four to six weeks to achieve the full effect.

A selective cholesterol absorption inhibitor, called ezetimibe, works by reducing the amount absorbed from the intestines. It is used in addition to a statin drugs and helps 72% of those unable to reach recommended cholesterol levels with a statin alone to reach their goal.

A bile acid sequestrant (colestryramine) and an anion-exchange resin can typically lower cholesterol by 10-20 per cent and are available as powders or tablets. They bind with bile acids that contain cholesterol in the intestines, and the cholesterol complexes are then eliminated in the stool. They may be prescribed in combination with another drug if you have high triglycerides or a history of severe constipation.

Fibrates. These drugs reduce triglycerides by 20-50 per cent and raise HDL cholesterol 10-15 per cent. Fibrates drugs include bezafibrate, ciprofibrate, fenofibrate and gemfibrozil. They are not recommended as the sole drug therapy for women with heart disease for whom LDL cholesterol reduction is necessary. Fibrates are usually prescribed in twice-daily doses before breakfast and dinner. Side effects are rare, with gastrointestinal problems the most common. They may also increase the risk of cholesterol gallstones and can boost the effects of anticoagulants.