Alternatives to statins

Packet of statins

Statins have done a lot to reduce heart attacks and strokes, but what if they aren’t doing enough? Senior Cardiac Nurse Emily McGrath hears about alternatives from Dr Riyaz Patel.

Around eight million adults in the UK take statins, which have become the mainstay of cholesterol lowering treatment since their introduction in the 1980s. They offer important protection against heart attacks and strokes and, for the vast majority of people, they are safe and well tolerated.

Despite attention around statins and possible side effects, large and well-conducted studies have shown that only a small minority of people actually experience significant side effects. If you do need your treatment to be reviewed, your doctor should suggest a different statin or a lower or less frequent dose before considering other options.

Or it may be that, despite taking a statin, you still have high cholesterol. This is particularly relevant for the one in 250 people with familial hypercholesterolaemia (FH), an inherited condition where you have very high levels of cholesterol from birth. If you need an alternative (or an addition) to a statin, the following are the main options.


Ezetimibe is a tablet that lowers cholesterol. It may be prescribed if statins cannot be taken, or alongside a statin for extra cholesterol-lowering. It’s a ‘cholesterol absorption inhibitor’ that limits the absorption of cholesterol in the small intestine. As a result, less cholesterol is taken to the liver, which therefore increases its efforts to take more cholesterol out of the blood.

Packet of Ezetimibe tablets

Ezetimibe is not as effective as most statins but will reduce low-density lipoprotein (LDL) or ‘bad cholesterol’ by 15 to 22 per cent. It can reduce the risk of heart attacks and strokes when taken alongside a statin, but we have little evidence it can do this if used on its own.

Side effects can include stomach pain, diarrhoea, flatulence and tiredness. It’s not recommended for people with significant liver disease or women who are pregnant or breastfeeding.

PCSK9 inhibitors

PCSK9 inhibitors in a packet alongside a sharps bin

This new class of drugs is very effective in lowering cholesterol and in reducing the risk of coronary heart disease and stroke in high-risk patients.

Studies indicate they can lower LDL cholesterol by 50 to 60 per cent. Cholesterol levels will typically drop significantly after around four weeks of treatment, and then remain at this lower level. The reduction in cholesterol is even greater when taken alongside a statin.

Two have been licensed so far: alirocumab (Praluent) and evolocumab (Repatha). They work by blocking a protein called PCSK9, which binds to LDL receptors in the liver, stopping them from working.

Studies indicate PCSK9 inhibitors can lower LDL cholesterol by 50 to 60 per cent.

These receptors normally remove cholesterol from the blood, but by blocking this protein, more LDL receptors will be available to remove cholesterol from the blood.

In June 2016, the National Institute for Health and Care Excellence (NICE) recommended PCSK9 inhibitors for those who have had a heart attack or stroke, or who have FH. They are expensive and so currently are only recommended for people in these groups who can’t get their cholesterol levels low enough by taking statins, or who are intolerant to statins.

PCSK9 inhibitors have to be given as injections every two or four weeks. There appear to be few side effects, but these may include flu-like symptoms or soreness around the injection site.


LDL apheresis is a treatment that removes LDL cholesterol from your blood. It works a lot like dialysis. Your blood is removed via a needle in your arm. The blood goes through a tube and enters a special filter called a plasma separator, which separates the blood and removes the cholesterol. The cholesterol-filtered blood is then returned to your body.

Apheresis procedure

Because it’s an invasive and expensive treatment, it’s only used for people who are at very high risk because of their cholesterol levels. This means people with FH who have inherited two copies of the faulty gene (homozygous FH) from the age of seven onwards.

Having two copies of an FH gene means you have a severe form of FH and your cholesterol levels will be exceptionally high without treatment.

LDL apheresis may occasionally be used for other patients who have just one copy of the faulty gene (heterozygous FH), for people with a strong family history of premature death from coronary heart disease, or if they have worsening coronary heart disease and their cholesterol remains high when everything else has been tried.

This treatment can lower your LDL cholesterol by 60 to 75 per cent. However, it does rise again quite quickly, which is why treatment is repeated every one or two weeks. Each treatment takes two to four hours. The main side effect is tiredness. This is very mild and tends to improve with future treatments.

Dr Riyaz Patel

  • BHF Clinic Research Fellow at University College London and Consultant Cardiologist at Barts Health and UCLH NHS Trusts. His research and clinicalImage of Dr Riyaz Patel areas of interest are focused on better understanding risk factors of coronary heart disease and more accurately identifying people at risk of heart attacks.
  • Runs a new cardiovascular prevention service at the Barts Heart Centre, seeing and assessing people at high risk of heart attacks, including those with high cholesterol.

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