Lowering Cholesterol Without Statins: Diet, Non-Statin Medications, and Red Yeast Rice

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• Why he takes a statin himself
• Genes and a plant-based diet
• Ezetimibe and cholesterol from the liver
• Colesevelam, bile, and niacin
• PCSK9 inhibitors
• Red yeast rice and its drawbacks
• Full Transcript

Why he takes a statin himself

Statin use is where cardiologist Dr. Paul D. Thompson, MD, begins when Dr. Anton Titov, MD, asks how to lower cholesterol without statins. He agrees that everybody wants to take as little medication as possible, but he says he never misses his own statin because statins are so good at reducing heart disease.

He gives the example of the Boston cardiologist Eugene Braunwald, who, he says, put himself on lovastatin when statins were released and stayed on a statin until he died in his late 90s. In Dr. Thompson's words, a very famous and smart cardiologist treated himself with statins.

Genes and a plant-based diet

Genes come first in Dr. Thompson's explanation. He jokes that the best way to lower cholesterol without statins is to pick the right parents, because so much of the cholesterol level depends on them. He adds that even the response to diet is probably related to parents: some people can lower their cholesterol a lot, and many cannot.

His dietary advice runs from strict to less strict. Be a vegan; if not, a vegetarian; if not, a vegetarian who eats anything from the sea except the cow or the pig that fell in; and if not, a vegetarian who eats fish and as little red meat as possible. He warns that chicken also contains a lot of saturated fat, so he advises removing the skin and fat before eating it. Later in the answer, he calls a very strict diet, most of the time, a fiction.

Ezetimibe and cholesterol from the liver

Ezetimibe, sold as Zetia, is the first non-statin medication Dr. Thompson describes for people who will not use statins. He says it is so hard to bring patients' cholesterol levels down to where heart attacks are stopped without using other medications. Ezetimibe blocks the absorption of cholesterol in the intestine, and he says it lowers LDL, which he calls the "ugly" cholesterol, by about 20%.

Many patients tell him they do not eat any cholesterol. His reply is that the liver makes more cholesterol than people eat. He says the average American eats about 500 milligrams a day, while the liver produces at least 1,000 milligrams, which goes into the bile and then into the gut. He says ezetimibe works even on a very low cholesterol diet because it blocks the absorption of dietary cholesterol. He also links this to gallstones, which are made of cholesterol coming into the bile from the liver.

Colesevelam, bile, and niacin

Colesevelam, sold as Welchol, is an older medication that Dr. Thompson says works. He calls it a bile sequestrant. Bile is made from cholesterol and is normally not wasted: it is reabsorbed in the terminal ileum, a part of the intestine, and goes back to the liver. Colesevelam binds bile in the gut and takes it out with the bowel movement instead, which he describes with humor as the "poop chute."

He also mentions niacin, an old medication that he says is out of favor but works.

PCSK9 inhibitors

PCSK9 inhibitors are the newer medications in his answer. Several are injectable, and he says Merck has just made an oral one. He explains that the LDL receptor carries cholesterol into the liver and comes back for more, unless PCSK9 binds it, in which case the receptor is broken down in the liver. Medicines that block PCSK9 from grabbing the LDL receptor lower LDL cholesterol by about 50 percent, he says.

He names Praluent, Repatha, and Leqvio among the medicines that target PCSK9. His summary of the choices returns to where he started: pick the right parents, go on a very strict diet, or use medication from a clinician you trust.

Red yeast rice and its drawbacks

Red yeast rice is an over-the-counter natural product made by a fungus, and Dr. Thompson explains his reservations about it. It contains lovastatin and lowers cholesterol, by about 20% in his estimate, which is not as much as prescription statins.

He describes two problems. Red yeast rice contains small amounts of citrinin, a toxin that affects the kidneys, which he gives as one reason the US Food and Drug Administration is not a fan of it. And because it is not made by a pharmaceutical company, the amount of lovastatin varies from batch to batch, so the response can vary too.

He still uses it, he says, because many of his patients will take anything except what he writes on a prescription pad. He tells them about citrinin, about the variability, and that it is not really inspected by a pharmaceutical company, and many still prefer it.

Full Transcript

Dr. Anton Titov, MD: How can I lower my cholesterol without taking statins? And if I get muscle pain on a statin, what then?

Dr. Paul D. Thompson, MD: So that is a great question. First of all, everybody wants to be on as little drug as possible, and I agree with that. I will point out that I never miss my statin because they are so good at reducing heart disease.

Dr. Paul D. Thompson, MD: There is a very famous Boston cardiologist, Eugene Braunwald, who just recently died. When statins were released in 1989, he put himself on lovastatin, and he stayed on a statin until he died in his late 90s, just this last year. So a very famous, smart cardiologist treated himself with statins.

Dr. Paul D. Thompson, MD: The best way to lower your cholesterol without taking statins is to pick the right parents, because so much of what happens to your cholesterol level depends on whom you pick for parents. Even your response to diet is probably related to whom you pick for parents, because people respond differently to diet. Some people can lower their cholesterol level a lot.

Dr. Paul D. Thompson, MD: Many people cannot. The best way to lower your cholesterol level without statins and without using any drugs is to be a vegan. If you cannot be a vegan, be a vegetarian.

Dr. Paul D. Thompson, MD: If you cannot be a vegetarian, be a vegetarian that eats anything from the sea except the cow or the pig that fell in. If you cannot do that, then be a vegetarian who eats fish and as little red meat as possible. Now, everybody thinks chicken is a benign thing, but chicken contains a lot of saturated fat as well.

Dr. Paul D. Thompson, MD: So if you eat chicken, what you want to make sure is that you de-skin it and de-fat it before you eat, because chicken fat is also a saturated fat. If you are not going to use statins, though, there are other medications that you can use, because I think I have told you a couple of times that I am a drug dealer. It is always legal drugs, but it is so hard to get patients' cholesterol levels down to where we know we stop heart attacks without using other medications.

Dr. Paul D. Thompson, MD: So there is a medication called ezetimibe, or Zetia. What Zetia does is block the absorption of cholesterol in your intestine. So it lowers your cholesterol level, your ugly cholesterol level, by about 20%, because it blocks you from absorbing cholesterol.

Dr. Paul D. Thompson, MD: Now, a lot of patients say to me, "But Dr. Thompson, I do not eat any cholesterol." Believe it or not, your liver makes more cholesterol than you eat.

Dr. Paul D. Thompson, MD: The average American eats about 500 milligrams of cholesterol a day. Your liver produces at least 1,000 milligrams. That cholesterol is put into the bile, and the bile is put into the gut to help absorb fats.

Dr. Paul D. Thompson, MD: So there is more cholesterol coming out of your liver going into the gut than there is coming in by mouth. So ezetimibe, or Zetia; ezetimibe is the generic name. Ezetimibe works even if you are on a very low cholesterol diet because it blocks the absorption of your dietary cholesterol.

Dr. Paul D. Thompson, MD: Now, remember, gallstones are made of what? Gallstones are made of cholesterol. That is because there is a lot of cholesterol coming into your bile, coming into your gallbladder from your liver.

Dr. Paul D. Thompson, MD: Now, there is another old drug that works, and it is something called Welchol, or colesevelam. What that does is it binds cholesterol. It binds cholesterol in your gut and takes it out the poop chute. Medical term.

Dr. Paul D. Thompson, MD: The poop chute. It takes bile out with your bowel movement. Bile is secreted into the intestine, and bile is made from cholesterol.

Dr. Paul D. Thompson, MD: So bile is not wasted. It is reabsorbed. Bile is reabsorbed in the terminal ileum, a part of the intestine, and it goes back to the liver.

Dr. Paul D. Thompson, MD: We call it a bile sequestrant because it sequesters bile. What this drug does is it binds bile and takes it out the poop chute. So there is ezetimibe; there is this drug called colesevelam.

Dr. Paul D. Thompson, MD: They work. There is an old drug called niacin, which is out of favor. It works.

Dr. Paul D. Thompson, MD: And then there are new drugs. There are these injectable drugs, and Merck has just made an oral drug. They are called PCSK9 inhibitors.

Dr. Paul D. Thompson, MD: Remember, I talked about the fact that the LDL receptor goes into the liver, drops off cholesterol, comes back, and gets more cholesterol, unless it gets bound by PCSK9, and then it goes into the liver and gets broken down. So we have these drugs that block PCSK9 from grabbing the LDL receptor, and those drugs lower cholesterol levels, LDL cholesterol levels, about 50 percent. They are named Praluent, that is the brand name, Praluent; Repatha; there is something called Leqvio; and there is another drug that has just been made by Merck called Lipfendra.

Dr. Paul D. Thompson, MD: These medicines target PCSK9. So how do you lower your cholesterol levels? Pick the right parents.

Dr. Paul D. Thompson, MD: Go on a very strict diet. Even that is, most of the time, a fiction. Or use medication from some clinician, some doctor that you trust.

Dr. Paul D. Thompson, MD: Now, you can use some over-the-counter medications. I should mention red yeast rice. Red yeast rice is a natural product.

Dr. Paul D. Thompson, MD: It is made by a fungus. There are two problems with red yeast rice. It contains lovastatin.

Dr. Paul D. Thompson, MD: It contains lovastatin, and it lowers the cholesterol level a lot. Now, there are a couple of problems. One is that red yeast rice contains small amounts of a renal toxin called citrinin.

Dr. Paul D. Thompson, MD: And that is one of the reasons that the FDA, the Food and Drug Administration in the United States, is not a fan of over-the-counter red yeast rice, because it contains small amounts of citrinin. I will come back to that in a minute. The other thing about red yeast rice is that because it is not made by a pharmaceutical company, how much lovastatin there is in each batch of red yeast rice varies a fair amount.

Dr. Paul D. Thompson, MD: So you might get a very good response from one batch of red yeast rice and not such a good response from another batch of yeast. Now, why do I use red yeast rice at all? Because I have a lot of patients who will take anything except what I write on a prescription pad.

Dr. Paul D. Thompson, MD: "If I wrote it on a prescription pad and it is made by one of those terrible drug companies, I am not taking it." So they will take some over-the-counter agent that does work to lower cholesterol, about 20%, not as much as the real statins, the real drug statins. They will take an over-the-counter drug despite the fact that I tell them about citrinin, despite the fact that I tell them about the variability, despite the fact that I tell them that it is not really inspected by a drug company.

Dr. Paul D. Thompson, MD: But a lot of patients will take anything except what I write on a prescription pad, unfortunately.