The triad in the management of high cholesterol is dietary life styles, exercise, and medications. Several diseases and drugs can cause high cholesterol, but for most people, a high-fat diet, obesity, a sedentary lifestyle, smoking, excessive alcohol consumption, or inherited risk factors are the main causes.

 

Dietary life styles

Low saturated fat and low cholesterol diet

• Total fat- Less than 30% of calories
• Saturated fat- Less than 7% of calories
• Polyunsaturated fat- Less than or equal to 10% of calories
• Monounsaturated fat- Approximately 10-15% of calories
• Carbohydrates (complex) - 50-60% of calories

Foods to avoid

• Fatty (saturated) foods- butter, cheese, curd, ghee and others
• Junk foods (oily and spicy foods) and carbonated drinks
• Red meat (lamb and beef) and yellow portion of boiled egg

Foods low in saturated fat and low in cholesterol

Add more soluble fiber (found in cereal grains, beans, peas, and many fruits and vegetables)

• Whole wheat bread, corn, cereals, whole grains (millets, hominy)
• Fresh fruits
• Green leafy vegetables and others (carrot, pumpkin, garlic, and others)
• Fat free skimmed milk
• Low fat or non fat yogurt
• Vegetable oil- canola, olive and sunflower oil
• White meat fish- herring, sardine and others
• Chicken or turkey skin removed

Exercises

There are 2 types of exercise

Aerobic exercise- brisk walking, jogging, cycling, swimming and others

Cardio exercise- tread mill, cycling, cross runners and others

• Regular aerobic exercise (brisk walking) helps prevent high blood pressure and raises HDL (the good) cholesterol level. At least 30 minute a day for 4-5 days in a week.
• If you can't work on a 30-minute block of exercise all at once, do a few minutes of exercise here and there throughout the day (climb the stairs at work, walk around the block on your lunch break, park and walk).
• The more physical activity you engage in, the more fat you burn and more reduction in cholesterol

Lipid lowering agents

Statins- HMG CoA reductase inhibitors

• Statins (most prominently Rosuvastatin, Atorvastatin, Simvastatin, or Pravastatin) are the first line drugs.
• Statins lower LDL (bad cholesterol) levels more than other types of drugs.
• Statins inhibit an enzyme, HMG-CoA reductase that controls the rate of cholesterol and synthesis in the body.
• The Statins are most often given in a single dose at the evening meal or at bedtime.
• It is important that these medications be given in the evening to take advantage of the fact that the body makes more cholesterol at night than during the day.
• Statins have reported 20-60% lower LDL cholesterol levels in people taking them.
• Statins also reduce high triglyceride levels modestly and produce a mild increase in HDL cholesterol.
• The Statins are well tolerated, and serious side effects are rare (liver problems, rhabdomyolysis muscle soreness, pain, weakness, gas, constipation, and abdominal cramps)

Cholesterol absorption inhibitors - Ezetimibe

• This drug inhibits cholesterol absorption in the gut.  
• Ezetimibe reduces LDL cholesterol by 18-20%. Adding ezetimibe to a statin is equivalent to doubling or tripling the statin dose.
• It is probably most useful in people who cannot take Statins or as an additional drug for people who take Statins but who notice side effects when the statin dose is increased.
• Cholesterol absorption inhibitors may rarely be associated with tongue swelling (angioedema).

Fibrates (Gemfibrozil, Bezafibrate, Fenofibrate)

• These cholesterol-lowering drugs are primarily effective in lowering triglycerides and, increasing HDL cholesterol levels.
• However, Gemfibrozil is not very effective for lowering LDL cholesterol.
• Another fibrate is Fenofibrate which is more effective at lowering triglycerides and LDL cholesterol.
• Side effects are stomach and abdominal discomfort, and risk of developing gall stones.

Vitamin B3 (Niacin)

• Nicotinic acid (Niacin) is a B-complex (B3) vitamin.
• It lowers LDL cholesterol and raises HDL cholesterol.
• The main side effects are flushing, itching, tingling, headache, peptic ulcers, gout, and high blood sugars others
• Most people develop a tolerance to flushing; it can be decreased by taking the drug during or after meals or by the use of aspirin 30 minutes prior to taking niacin.

Bile acid sequestrants (Cholestyramine)

• Cholestyramine binds with cholesterol-containing bile acids in the intestines and is then eliminated in the stool.
• Bile acid sequestrants are to lower LDL cholesterol by about 10-20%.
• Sequestrant therapy may produce a variety of side effects, including constipation, bloating, nausea, and gas

LDL apheresis

LDL apheresis is a form of apheresis, resembling dialysis, to eliminate the lipoprotein LDL cholesterol from the bloodstream.

It is used in diseases featuring high LDL, such as the rare homozygous familial hypercholesterolemia, when the heterozygous hypercholesterolemia form does not respond to medical treatment, or when the treatment has led to serious side-effects (such as rhabdomyolysis).

Liver transplantation

Liver transplantation in severe hereditary hypercholesterolemia condition.