Statins are first line. They are HMG-CoA reductase inhibitors, meaning ❌ cannot reduce ❌ to ❌ acid, which is the precursor to cholesterol. They are very effective in lowering ❌ and proven to decrease ❌ of CHD, stroke and death​.

Cholesterol synthesis peaks overnight so ❌ half life statins (e.g. ❌) are recommended to be taken at ❌​.
Statins with a ❌ half-life (e.g. ❌) can be taken either in the morning or at night and have the same efficacy​,

Statins are well tolerated​ but ADRs may include elevated liver enzymes, myopathy and rhabdomyolysis​.
- Increased liver ❌ reported in less than 2% of patients – obtain levels at baseline​
- Myopathy is muscle symptoms (❌) with a ❌ kinase level x10 than normal​
- Rhabdomyolysis (rare) is muscle ❌ and the release of intracellular muscle constituents in the blood stream, presenting with muscle pain, elevated creatine kinase, brown ❌ and myoglobinuria​.

Fibrates decrease ❌ levels (20%-50%) and increase ❌ levels by (9%-30%)​. They work by reducing apoproteins ❌ and increasing apoproteins ❌.
Common side effects are dyspepsia, ❌ pain, diarrhoea, flatulence, rash, muscle pain and ❌​. Myopathy and rhabdomyolysis can occur – the risk increases with ❌ insufficiency and concurrent use of statins. They ❌ be given in pregnant or breastfeeding women.

Bile acid binding agents​ available in NZ are cholestyramine and colestipol. These are bile acid binding resins/sequestrants ​which ❌ to bile acids (produced from ❌) in the gut​. The resin-bile acid complex is then ❌ in the faeces​. The loss of bile causes a ’❌’ response – conversion of hepatic cholesterol to bile (leading to reduction in hepatocellular stores)​.
This drug is not absorbed so side effects are limited to the ❌ tract​. 20% of patients report constipation, bloating and flatulence, causing some to stop therapy​. You can increase ❌ intake to minimize constipation​.
Time until peak effect of these drugs is generally 2-4 ❌​.
Patients taking other medications should be advised of the potential for ❌ absorption of other medicines – space out dose​.
Not suitable for pregnant and breastfeeding women.

Cholesterol absorption inhibitors: Ezetimibe
Interacts with a cholesterol ❌ in the intestinal ❌, and stops cholesterol ❌ from the GI tract.​
Ezetimibe should be prescribed either with a statin, fibrate or nicotinic acid derivative – ❌ by itself​. It has a synergistic effect in lowering LDL levels when used with statin​.
AVOID IN PREGNANCY AND BREASTFEEDING​