Cholesterol plays a vital role in maintaining your health. It helps build cell membranes and produces hormones, bile acids, and other substances your body needs. However, having excessive cholesterol in your bloodstream greatly ramps up your chance of experiencing a heart attack or stroke. For most healthy adults, it’s best to keep your LDL cholesterol (the “bad” kind) under 3.4 mmol/L (130 mg/dL).
Staying active and eating well—especially following a diet rich in whole, plant-based foods—can help lower cholesterol for many people. But let’s be honest: sticking to those changes long-term is tricky, and not everyone wants to give up animal products entirely (yes, even if it means missing out on cheese, braai meat, and boerewors).
On top of that, genetics can play a powerful role in determining your cholesterol levels. If your family history is stacked with high cholesterol or heart disease, no amount of kale may be enough to move the needle into a healthy range. So, what are your options if your cholesterol remains high despite your best lifestyle efforts? At some point, you may need to consider medication.
Who Should Think About Medication?
Certain groups benefit significantly from cholesterol-lowering medication, especially statins. These drugs lower your risk of heart attack and stroke—and may even help you live longer. If any of the situations below sound familiar, it’s a good idea to raise the topic with your healthcare provider:
- You’ve already developed plaque in your arteries. In this case, your LDL target is stricter: ideally below 1.8 mmol/L (70 mg/dL) and at least below 2.6 mmol/L (100 mg/dL).
- You have diabetes. People with diabetes over age 40 are typically advised to take a statin, since higher blood sugar levels can dramatically raise your risk for heart disease.
- Your LDL cholesterol is extremely high (over 4.9 mmol/L or 190 mg/dL). This puts you at major risk, and medication can lower your cholesterol sharply (and safely).
- Your overall risk of heart disease is high due to a combination of factors—like your age, blood pressure, cholesterol levels, and smoking history. Even if you don’t have any plaque, your doctor can use a 10-year risk calculator. If your score is over 7.5%, a statin generally offers effective protection.
- You have a high coronary artery calcium score. If your calculated risk is intermediate but your family history worries you, a CT scan can check for calcium in your arteries. A high score signals a greater need to lower cholesterol quickly.
Which Cholesterol Medication Should You Choose?
Statins are the gold standard for lowering cholesterol and reducing heart disease risk. Taking a statin can decrease your chance of heart attack or stroke by about 20 to 30 percent.
You might have heard rumors that statins cause severe muscle pain, but in reality, side effects are rare. Large studies show that muscle cramps are only slightly more common than in patients taking placebo, and fewer than one in 500 people experience serious muscle issues that require stopping the medication.
There is a very small chance—less than 1 in 200—that taking high doses of statins could heighten your diabetes risk. However, for most, this is a minimal concern compared to the considerable benefits of protecting your heart. If you do start statins, you’ll need to avoid grapefruit juice, as it can increase statin levels in the bloodstream. Fortunately, that’s often an easy swap.
Are There Alternatives to Statins?
Given their effectiveness and safety record, statins are usually the first prescription medication for high cholesterol. However, if statins alone aren’t enough to get your cholesterol under control—or if you can’t tolerate their side effects—there are secondary options:
- Ezetimibe (Zetia): This tablet blocks cholesterol absorption in your gut, lowering LDL cholesterol in addition to what statins accomplish.
- PCSK9 inhibitors: These injectable prescriptions—like alirocumab (Praluent) and evolocumab (Repatha)—prompt your liver to clear more LDL from your blood. They can cut LDL by more than half, are generally well-tolerated, but are costly and mostly available via private care in South Africa. Statins usually remain the first choice.
What About Omega-3 Fats, Fish Oil, and Niacin?
These supplements are better at lowering triglycerides—a different type of fat—than tackling your cholesterol directly. Elevated triglycerides are also linked with increased cardiovascular risk. While omega-3s (from fish oil) and niacin effectively drop triglyceride numbers, most research shows they don’t reliably reduce the risk of heart attacks or strokes overall. Even a recent, well-publicized trial of purified fish oil offered only modest heart protection—and flagged some extra risks like irregular heart rhythms. That said, including oily fish like snoek, sardines, or salmon in your meals is still a heart-healthy habit.
