Cholesterol Medications — Statins and Alternatives Explained (2026)
- Statins reduce LDL cholesterol by 30–50% and cardiovascular events by 25–35%
- Muscle pain (myalgia) affects 5–10% of statin users — but true myopathy is rare
- Rosuvastatin and atorvastatin are the most potent statins available
- Ezetimibe is the main alternative — reduces LDL by 18–20% with minimal side effects
- Anyone with existing cardiovascular disease should be on a statin unless contraindicated
When Are Cholesterol Medications Needed?
The decision to prescribe cholesterol-lowering medication depends on your absolute cardiovascular risk — not just your cholesterol level. Two people with identical LDL levels may have very different treatment needs based on age, blood pressure, smoking status, diabetes, and family history.
Types of Cholesterol Medication
1. Statins — First-Line Treatment
Statins inhibit HMG-CoA reductase — the enzyme that produces cholesterol in the liver. They are the most extensively studied cardiovascular medications available, with over 170,000 participants in randomised controlled trials.
| Statin | Intensity | LDL Reduction | Notes |
|---|---|---|---|
| Rosuvastatin 20–40mg | High | 45–55% | Best tolerated high-intensity |
| Atorvastatin 40–80mg | High | 40–50% | Most prescribed worldwide |
| Simvastatin 20–40mg | Moderate | 30–40% | Older, more interactions |
| Pravastatin 40mg | Moderate | 25–35% | Safest with liver conditions |
2. Ezetimibe (Ezetrol)
Ezetimibe reduces cholesterol absorption in the intestine. LDL reduction: 18–20% as monotherapy, 20–25% added to a statin. Excellent safety profile — minimal side effects. Used when statins are insufficient or not tolerated.
3. PCSK9 Inhibitors (Evolocumab, Alirocumab)
Injectable medications (monthly or fortnightly) that dramatically reduce LDL by 50–60% when added to maximum statin therapy. Approved for familial hypercholesterolaemia and very high cardiovascular risk. NHS restricts to specialist prescribing due to cost.
4. Inclisiran (Leqvio)
A newer injectable given just twice per year (after initial doses). Reduces LDL by 50–55%. NHS approved 2022 — increasingly available via community cardiology services. Excellent for patients who struggle with medication adherence.
Statin Side Effects — The Truth
Statin side effects are often overstated. In blinded studies where patients do not know whether they are taking statin or placebo, the reported muscle symptom rate is identical — suggesting most reported muscle pain is nocebo effect. True statin myopathy (muscle damage measurable by CK elevation) is rare (1 in 10,000).