Statin Alternatives: How to Lower Cholesterol without Statin Medications
Statins are prescription medications that can lower your LDL (bad) cholesterol levels. Millions of Americans take these drugs, with most people tolerating them well. However, some people do not tolerate statins and many others don’t reach their LDL goals despite maximally tolerated statin doses. These individuals must look to alternatives to help manage their cholesterol numbers.
It is estimated that 9% of people who have been prescribed statins cannot tolerate them because they develop one or more side effects, such as muscle pain, cognitive decline, or a drug interaction. Other people may simply prefer to avoid statins and control their cholesterol naturally. In fact, 30-40% of people prescribed statins never fill the prescription in the first place.
In October 2022 The American College of Cardiology (ACC) revised its guidelines for non-statin therapies for individuals who need to look beyond statins to achieve cholesterol goals. The new guidelines recommend starting with lifestyle changes, including a diet featuring foods high in fiber and plant sterols.
✅ Medically reviewed by Elizabeth Klodas, MD FACC
Last Updated: November 2022✅ Medically reviewed by Elizabeth Klodas, MD FACC
Last Updated: November 2022What can I take instead of statins?
Whether people have a physiological intolerance for statin medications, or are simply interested in a different approach, many adults are looking for a statin alternative to improve their cholesterol numbers. The following is a roundup of the current (2022) options for managing cholesterol without using statin medications:
Dietary Changes
Eating to support healthy cholesterol is step one to better health. The data on the power of food to lower cholesterol, improve cardiovascular health and lower rates of heart attack and stroke is vast and consistent. In fact, improving lifestyle, and especially food intake is more impactful in affecting outcomes than any drug or procedure.
A heart-healthy diet includes avoiding animal-based saturated fats, trans fats, and simple/processed carbohydrates, and incorporating whole, plant-based foods full of:
- Fiber that binds to cholesterol particles in the digestive system and moves them out of the body
- Antioxidants help prevent the build-up of plaque in blood vessels.
- Plant Sterols block cholesterol absorption in the digestive tract.
- Omega-3 fatty acids reduce inflammation and help raise HDL (good) cholesterol and lower triglycerides
Step One Foods is a pharmaceutical-free solution which blocks cholesterol absorption in the digestive system when two servings are eaten per day. Profound changes in cholesterol levels are possible with simply eating two doses of this ready-made food each day, and no other lifestyle changes. In fact, in a randomized controlled clinical trial, on average, Step One Foods' products lowered LDL (bad) cholesterol by an average of 9% in just 30 days.
Fiber and Plant Sterol Supplements
To see a cholesterol benefit, you need to add at least 10 grams of fiber and 2 grams of plant sterols to your diet, ideally spread out throughout the day. These supplements should be taken with your meals in order to obtain the most benefit.
While fiber and plant sterol supplementation has been shown to help improve cholesterol levels, the data for improved outcomes is strongest when higher fiber intakes come from dietary changes rather than supplements.
Bergamot
Although bergamot is considered relatively safe, it shares some biochemical properties with grapefruit. This means people on statins should avoid using bergamot due to potential for a toxic interaction.
Niacin (vitamin B-3)
Niacin, a B vitamin, lowers LDL (bad) cholesterol when taken in high doses. But just because it is a vitamin does not mean it is without side effects when consumed in massive doses.
The recommended daily allowance for niacin (for optimal nutrition) is around 15-20 mg per day. The amount of niacin prescribed to meaningfully lower LDL cholesterol can be as high as 2000 mg per day.
When you take niacin at those doses, you can develop flushing, itching, digestive issues, liver enzyme abnormalities and muscle side effects. Therefore, when taking niacin for cholesterol, you need to be monitored as closely as if you were on statin medications.
The form of niacin that is active for cholesterol lowering is nicotinic acid. Nicotinamide, another form of niacin, has no effects on cholesterol levels.
Niacin has been shown to lower LDL (bad) cholesterol, raise HDL (good) cholesterol and lower triglycerides. However, the data on improved outcomes (including rates of heart attack and stroke) based on niacin use is less impressive. Nevertheless, this is a reasonable option for people who cannot tolerate statin medications and have exhausted all dietary options.
It should be noted that niacin can worsen blood sugar control. Diabetics should be especially careful when using niacin for managing cholesterol levels.
Ezetimibe
Ezetimibe, also known as Zetia®, is a medication that can be added to statins to boost their effects. So, strictly speaking, it’s not really a statin substitute, but it does facilitate lower statin dosing – and this is important since statin side effects are more likely with higher statin doses.
Zetia® can be taken as a stand-alone prescription medication or can be part of a combination tablet, like Vytorin® (ezetimibe with simvastatin).
Although adding Zetia® to even a low-dose statin can result in profound LDL lowering, the data on outcomes has been less robust.
We know that real food has profoundly positive effects on health. Combining strategic food intake with lower statin doses is, therefore, a better option than relying on combinations of medications.
Red Yeast Rice
Red yeast rice, an over-the-counter supplement, has been shown to lower LDL cholesterol. The reason for this is that red yeast rice contains a compound structurally identical to lovastatin (one of the statin drugs). As such, red yeast rice can cause the same side effects as statins. People taking this supplement should be monitored in the same way as those on a prescription cholesterol lowering medication.
Additionally, the supplement industry is not well regulated, which means the dose of the active ingredient in red yeast rice can vary from bottle to bottle and from pill to pill.Other substances can also be present in the pill that are not listed or monitored, affecting safety and efficacy.
PCSK9 Inhibitors
PCSK9 inhibitors (like Praluent® and Repatha®) are antibodies that lower LDL cholesterol by neutralizing a substance called PCSK9.
PCSK9 is a protein that controls the number of cholesterol receptors in the liver. If PCSK9 levels are lowered, the number of liver cholesterol receptors increases, allowing more LDL to get removed from the bloodstream. In other words, if PCSK9 is destroyed by antibodies, LDL levels fall.
Praluent® and Repatha® need to be injected once to twice per month but are extremely effective in lowering LDL (by as much as 70%).
Although they appear to be relatively safe, these medications are new and we are still learning about all their possible side effects. So far, runny nose, sore throat, or flu-like symptoms appear to be most common. But muscle aches, diarrhea, and urinary tract infections are also being seen.
With more extensive use of these medications, we’re learning that lowering LDL to very low levels does not appear to be associated with any untoward effects – at least in the near term.
Inclisiran
This drug also lowers PCSK9 levels but does this by affecting genes that control PCSK9 production – thus preventing PCSK9 from being made in the first place.
Inclisiran (Levquio®) requires injection under the skin only twice per year, which is a significant advantage over PCSK9 inhibitors, and so far appears well tolerated. Trials looking at long-term outcomes are currently under way.
Bempedoic Acid
Bempedoic acid blocks an enzyme in the liver called adenosine triphosphate citrate lyase. This enzyme is involved in making cholesterol and blocking this enzyme causes LDL levels to fall.
The drug, approved in early 2020, is sold under the name Nexletol®, and lowers LDL by 18%, on average. A combination drug, Nexlizet® (bempedoic acid with ezetimibe) is also available and has been shown to lower LDL by 38% when added to maximally tolerated statin doses.
Reported side effects include back pain, muscle spasms, liver function abnormalities, flu-like symptoms, elevations in uric acid levels (a significant concern for those with a history of gout), and tendon rupture. In fact, bempedoic acid preparations are probably not the best choice for people over age 60 as this is the group at the highest risk of tendon complications.
Icosapent Ethyl
Icosapent ethyl, marketed under the name Vascepa®, is a pill form of purified EPA omega-3 fatty acid. It is designed to help lower serum triglyceride levels but has been shown to lower heart event rates in patients at high risk of heart disease, regardless of triglyceride level reductions. This drug is now being prescribed more and more in patients with established heart disease, even if they’re on statins and even if their LDL is well controlled. It does not lower LDL per se.
Side effects of Vascepa® include muscle and joint pain, ankle swelling, constipation, gout and heart rhythm abnormalities. In addition, Vascepa® can increase the risk of bleeding, especially in patients who take blood thinners.
What is statin intolerance?
Cardiologist Elizabeth Klodas gives an overview of statin intolerance, and shares her perspective on what to do for patients who can't, or won't take statin medications.
In Summary
If you have known heart or vascular disease, you should take statins if you can tolerate them. But there are many options for lowering cholesterol that don’t involve these drugs. And even if you do need to take statins, doing everything you can to reduce the dose required to control your cholesterol readings makes sense in order to reduce your risk of developing side effects.
Changing your diet is often the best option because improving nutrition not only helps lower cholesterol levels, but also has wide ranging positive effects on health overall.
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