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Guidelines issued by the National Cholesterol Education Program (NCEP) emphasize intensified use of nutrition, physical activity and weight control in the treatment of elevated blood cholesterol —specifically LDL cholesterol. Its "Therapeutic Lifestyle Changes (TLC) Treatment Plan" includes a cholesterol-lowering diet (the TLC diet), and guidelines for drug treatment with cholesterol-lowering drugs based on a risk assessment of LDL levels.

The TLC plan includes daily intakes of less than seven percent of calories from saturated fat and less than 200 mg of dietary cholesterol. It also allows up to 35 percent of daily calories from total fat, provided most of the fat is unsaturated fat, which doesn't raise cholesterol levels. In addition, the guidelines encourage the use of certain foods rich in soluble fiber to boost the diet's LDL-lowering power. They also include regular physical activity. It is widely accepted that the threshold for saturated fat should be applied to the combination of saturated and trans fat.

How Treatment is Determined

If you have high cholesterol you and your health care professional will determine the type of treatment that is most appropriate for you and your lifestyle. There are several major risk factors that affect your LDL cholesterol goal and will be considered when recommending a treatment plan. These are:

• Diabetes

• Kidney disease

• Coronary heart disease

• Peripheral vascular disease

• Presence of vascular disease

• Age (in general, the older you are, the more likely your health care professional will decide drug therapy is appropriate if your LDL cholesterol level is too high; for women, 55 is often the threshold age)

• Smoking (or daily exposure to secondhand smoke)

• High blood pressure (140/90 mmHg or on anti-hypertensive medication)

• Low levels of HDL cholesterol (below 40 mg/dL)

• Family history of premature heart disease (heart disease in father or brother before age 55; heart disease in mother or sister before age 65)

The NHLBI guidelines include a risk assessment tool to help an individual determine their 10-year risk of having a heart attack or dying from heart disease. This is then used to establish goals for lowering your LDL cholesterol levels. The tool assigns risk values based on age, total cholesterol levels, HDL cholesterol levels, blood pressure level and smoking status. For more complete information, please see: www.nhlbi.nih.gov.

If lifestyle changes alone don't improve your cholesterol levels, your doctor may recommend drug treatment. When to begin drug therapy typically depends on your risk factors. Several different classes of safe, effective medications for reducing cholesterol levels are available.

You may have to be proactive in getting your health care professional to consider drug therapy. One study found that health care professionals were not as aggressive as they should be in prescribing cholesterol-lowering medicines—and were much less aggressive in prescribing those drugs for women than for men with CHD. The study found that 55 percent of men with high cholesterol were prescribed a cholesterol-lowering drug while only 35 percent of women with high cholesterol were. The authors of the study were surprised by the findings, given that the health care professionals were participating in a clinical trial and had been specifically instructed to use these drugs to combat high cholesterol levels.

NCEP recommends prescribing cholesterol-lowering medication to children over age 10 whose LDL cholesterol remains high even after they've changed their dietary habits. Statin therapy is generally considered safe to use in children and adolescents with high blood cholesterol, although there is little data on their long-term use.

Here are NCEP's guidelines (updated in July 2004) for when cholesterol-lowering medications should be used to help reach LDL-target goals.

• Very high risk women have heart disease with multiple risk factors (especially diabetes) with severe or poorly controlled risk factors (especially persistent cigarette smoking), or metabolic syndrome (high triglycerides, low levels of "good" HDL cholesterol, obesity). If you have just had a heart attack, you're also considered to be at very high risk.

  Lipid-lowering medication is almost always indicated in the very high-risk group, with a goal of bringing LDL levels down below 70.

• High risk women have heart disease or diabetes or have two or more risk factors, such as smoking or high blood pressure, giving them a 20 percent risk of having a heart attack within 10 years. They generally need cholesterol-lowering medication if their LDL level is 100 mg/dL or higher. The overall goal remains an LDL level of less than 100 mg/dL.

  Therapeutic lifestyle changes (TLC), including intensive use of nutrition, physical activity, and weight control, are also important for cholesterol management. These should definitely be discussed with your health care professional if you are high risk and your LDL is at or greater than 100 mg/dL.

• Moderate risk means you have two or more risk factors for heart disease and/or heart attack, with a 10 to 20 percent risk of having a heart attack or other cardiovascular event within the next 10 years. Your LDL goal should be 130 mg/dL or lower, but you may have a goal of under 100 mg/dL and use drug therapy at LDL levels of 100-129 mg/dL to reach this lower goal. If your LDL cholesterol level is higher than this target, the TLC dietary and other lifestyle changes will be recommended as a cholesterol-lowering strategy.

  If your LDL cholesterol level is 130 mg/dL or more, drug therapy may also be recommended. If your LDL is less than 130 mg/dL, you need to follow a heart healthy diet.

• Lowest risk means you have one or no risk factors for heart disease or heart attack, or two or more risk factors plus a less than 10 percent risk of having a heart attack or other cardiovascular event in the next 10 years. Your LDL goal is less than 160 mg/dL.

  If your LDL is 160 mg/dL or above, you should start the TLC diet. If your LDL level is still 160 mg/dL or more after three months of diet alone, you may need to start drug therapy.

Medication Options for Treating High Cholesterol

There are several medications that reduce cholesterol levels. Before taking these or any other medications, talk to your health care professional about other conditions you have and medications you are taking, including birth control pills (statins, for example, can raise blood levels of birth control hormones) and over-the-counter medications, including vitamins and nutritional supplements.

Statins. Six statin drugs are available in the U.S.: atorvastatin (Lipitor), fluvastatin (Lescol), lovastatin (Mevacor), pravastatin (Pravachol), simvastatin (Zocor) and rosuvastatin (Crestor). These highly effective drugs typically produce a 30 to 63 percent reduction in LDL cholesterol levels. They also provide the added benefits of increasing HDL cholesterol somewhat and reducing triglyceride levels.

Statins work by inhibiting an enzyme called HMG-CoA reductase, which controls the body's cholesterol production rate. They ramp down production of cholesterol and boost the liver's ability to remove LDL cholesterol from the blood. In several large clinical trials, they have proven their merit not only in lowering cholesterol levels, but also in achieving the ultimate goal: reducing heart attacks and deaths related to heart disease.

Most statins are usually 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. After six to eight weeks, your health care professional will probably check your LDL cholesterol and perhaps adjust your medication.

According to the U.S. Food and Drug Administration, all statin drugs have been associated with reports of a rare and potentially fatal muscle condition called rhabdomyolysis, which causes muscle cells to breakdown and enter the bloodstream. One statin, cerivastatin (Baycol), was recalled a few years ago because it caused significant rhabdomyolysis and 31 deaths.

However, the risk of rhabdomyolysis from statin use is slight unless you use statins along with fibrates, medications that lower high triglyceride levels. The risk is still low but higher than when statin medications are used alone. For this reason, fibrates and statins should not be prescribed together unless the benefits outweigh the risks.

The most common side effects associated with statins are upset stomach, gas, constipation, abdominal pain or cramps and muscle pain. The effects are usually mild to moderate and fade as your body adjusts to the drug. However, if you experience brown urine or muscle soreness, pain or weakness—possible symptoms of rhabdomyolysis—contact your health care professional immediately.

Bile acid sequestrants. The three main bile acid resins prescribed in the U.S. are cholestyramine (Questran), colestipol (Colestid) and colesevelam (WelChol), although their use is limited today except by those people who can't take other classes of lipid-lowering drugs. They typically lower LDL cholesterol by 10 to 20percent and are available as powders, tablets, or granules. These drugs work by binding with bile acids in the intestines that contain cholesterol. The cholesterol is then eliminated in the stool. A bile acid sequestrant may be prescribed in combination with another drug if you have high triglycerides or a history of severe constipation.

Bile acid sequestrant powders are mixed with water or fruit juice and usually taken once or twice a day with meals. They should be taken with plenty of water to avoid gastrointestinal side effects, such as constipation, bloating, nausea and gas.

If you take bile acid sequestrants, you should take any other medications at least one hour before or four to six hours after taking a bile acid resin because the bile acids can interfere with the absorption of other medications.

Niacin. This compound is more commonly known as nicotinic acid, a water-soluble B vitamin. Unfortunately, you can't lower your cholesterol by taking a vitamin supplement —to have such an effect it must be taken in doses well above the daily vitamin requirement. Although nicotinic acid is inexpensive and available over the counter, never take it for cholesterol reduction without a health care professional's oversight because of potential side effects.

Niacin lowers LDL cholesterol by 10 to 20 percent and triglyceride levels by 20 to 50 percent, while increasing HDL levels 15 percent to 35 percent. It comes in capsule and tablet forms, both regular and time released. An initial dose will probably be low then gradually increased to between 1.5 grams and 6 grams a day.

Niacin also widens blood vessels, making flushing and hot flashes frequent side effects. These side effects may be reduced by taking the drug with meals or by taking aspirin or a similar medication with nicotinic acid. The extended release form, available by prescription as Niaspan, results in less flushing and liver toxicity than the immediate or sustained release forms.

Nicotinic acid can also intensify the effect of high blood pressure medication and produce various gastrointestinal problems—nausea, indigestion, gas, vomiting, diarrhea and activation of peptic ulcers. Serious side effects include liver problems, gout and high blood sugar, with risk rising in tandem with the dose.

This drug may not be prescribed if you have diabetes because it can raise blood sugar slightly. If you have diabetes, talk about the pros and cons with your health care professional.

Fibrates. These drugs reduce triglycerides by 35 to 50 percent and usually raise HDL cholesterol 15 percent to 25 percent. Fibrates are not recommended as the sole drug therapy for women with heart disease if the primary goal is reducing LDL cholesterol levels. Available fibrates are fenofibrate (Tricor), clofibrate (Atromid-S, Abitrate) and gemfibrozil (Lopid).

Side effects are rare, with gastrointestinal problems the most common. Fibrates may also increase the risk of cholesterol gallstones and can boost the effects of blood thinners—a possibility your health care professional should watch out for. Fibrates should not be taken in combination with a statin because they may increase the risk of developing rhabdomyolysis.

Cholesterol absorption inhibitors. This new class of drugs lowers cholesterol by preventing it from being absorbed in the intestine. More specifically, Zetia acts in the small intestine to prevent cholesterol absorption so less cholesterol reaches the liver and more is cleared from the blood. The first approved drug in this class is ezetimibe (Zetia). Studies find it lowers LDL cholesterol by about 25 percent. Zetia works particularly well when it's prescribed along with a statin.

Combination drug therapy. If you haven't achieved your target LDL cholesterol level after a few months on a single medication, your health care professional may recommend adding another. Various combinations have been shown to be effective and safe. Lower doses of each individual drug can reduce the risk of side effects.

Other medications commonly prescribed for heart disease include aspirin and beta-blockers. Aspirin reduces the tendency of platelets to stick together and form clots, while beta-blockers work by slowing the heart and reducing its contracting force.

Update on Postmenopausal Hormone Therapy for Treating Elevated Cholesterol

Postmenopausal hormone therapy once was considered a medical option for treating elevated cholesterol in postmenopausal women because research suggested it might prevent the development of heart disease—the end result of high cholesterol levels for a long time.

The National Cholesterol Education Program at NHLBI now advises against using menopausal hormone therapy to prevent heart disease. Studies to date have not shown hormone therapy reduces the risk for major coronary events or deaths among postmenopausal women, particularly when compared to statins.