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CHOLESTEROL SERIES · ARTICLE 9 OF 12
Cholesterol medications
Statins, ezetimibe, and what the worry is about.
If you have followed the series up to here, you have already made the changes that lower cholesterol without tablets — food, exercise, weight, sleep, smoking, alcohol. For some people, this is enough. For most South Africans with high LDL, especially those in the high-risk or very high-risk categories from article 2, medication will still be part of the picture.
This article walks through the main groups of cholesterol medication in plain English. What each one does. Who is put on which. The side effects — what’s real and what’s overstated. The scare campaigns and what the actual evidence shows. And the single biggest mistake South Africans make: stopping the tablet because they feel fine.
Important note
This article describes how the main cholesterol drug groups work. It is not personal medical advice and it does not replace a prescription. Specific drug choice, dose, and combination should always be made with your clinic nurse, doctor or pharmacist.
Why medication, when food and walking can lower cholesterol?
Lifestyle changes are powerful — typically a 15 – 25% LDL reduction when sustained. But:
• Some people start at very high numbers. An LDL of 5.5 mmol/L needs to come down to 1.8 — that’s a 67% drop, far beyond what lifestyle alone can do.
• Some people have other conditions (diabetes, kidney disease, previous heart attack) that demand tighter targets and faster results.
• Some people have a strong genetic push (familial hypercholesterolaemia, covered in article 11) that lifestyle can’t overcome.
• Medication doesn’t replace lifestyle. The two together give the best result. Medication is the parachute. Lifestyle is the wing.
The main groups
1. Statins — the workhorses. Block the liver from making cholesterol.
2. Ezetimibe — blocks cholesterol absorption from food.
3. PCSK9 inhibitors — newer injectable drugs that aggressively lower LDL.
4. Fibrates — mainly for triglycerides, not LDL.
5. Bempedoic acid and others — newer options for specific cases.
Almost everyone with high cholesterol who needs treatment starts on a statin. Most stay on one for life. About 15 – 25% need a second drug added.
1. Statins — the workhorse
Statins are the most-studied class of medication in modern medicine. Five generations of trials have followed millions of people over more than 30 years. They consistently lower LDL by 25 – 55%, and that LDL reduction translates into a 20 – 30% drop in heart attack and stroke risk per 1 mmol/L of LDL lowered.
How they work
Statins block an enzyme in your liver called HMG-CoA reductase that the liver uses to make cholesterol. Less cholesterol made by the liver means lower LDL in the blood — both because there’s less new LDL coming in, and because the liver pulls more existing LDL out of the blood to compensate.
The five common statins in South Africa
Statin Typical daily dose Expected LDL drop Simvastatin 10 – 40 mg 25 – 40% Atorvastatin 10 – 80 mg 30 – 55% Rosuvastatin 5 – 40 mg 40 – 60% Pravastatin 20 – 40 mg 20 – 30% Fluvastatin 40 – 80 mg 20 – 35%
Simvastatin and atorvastatin are the standard public-sector choices in South Africa — both free at public clinics, both costing around R30 – R80 / month privately. Rosuvastatin is more potent but more expensive (R80 – R200 / month privately). Almost no one needs the brand-name versions; generics are equally effective and have been on the market for decades.
Common side effects
• Muscle aches — the most-talked-about side effect. Affects about 5 – 10% of patients in real-world surveys, but only 1 – 2% in randomised trials with placebo groups (more on this below).
• Mild liver enzyme rises — happens in about 1 – 2% of patients and is almost always harmless. Routine blood tests catch the rare problematic case.
• Mild rise in blood sugar — statins increase the risk of new-onset diabetes by about 9% over 5 years. This sounds bad but the cardiovascular benefit far outweighs it. Diabetics on statins still have much lower heart attack and stroke risk.
• Digestive complaints — mild nausea, constipation, or diarrhoea, usually settles within 2 weeks.
Rare but serious
• Severe muscle breakdown (rhabdomyolysis) — extremely rare (about 1 in 100 000 patients per year). Causes severe muscle pain with very dark urine. Stop the tablet and go to a clinic immediately if you have these symptoms.
• Significant liver damage — extremely rare, picked up by routine blood tests before it becomes serious.
The muscle pain question, honestly
This is the biggest reason South Africans stop statins. Worth a careful look. The data:
In randomised trials where patients didn’t know if they were getting a statin or a placebo, muscle complaints were almost equal between groups — suggesting that most “statin muscle pain” is actually background muscle pain that we attribute to the tablet because we know we’re taking it (the “nocebo effect”).
That said, some people do have genuine statin-related muscle pain. If yours is severe, persistent and affects your daily life, talk to your clinic. Options include: switching to a different statin (try 2 – 3 before giving up), lowering the dose, taking it every second day, adding ezetimibe at lower statin doses, or in rare cases switching to a PCSK9 inhibitor.
2. Ezetimibe — the second-line add-on
Ezetimibe (brand name Ezetrol, also generic) works in the gut, not the liver. It blocks a transport protein that absorbs cholesterol from food and from recycled bile. Net effect: less cholesterol gets into your blood.
On its own, ezetimibe lowers LDL by about 18%. Added to a statin, it brings down LDL by a further 20% on top of what the statin achieves. It is well-tolerated, with almost no side effects.
It is used when:
• The statin alone hasn’t brought LDL to target.
• The patient can’t tolerate higher statin doses.
• The patient genuinely can’t tolerate statins at all.
Available privately for around R150 – R400 / month. Available on some medical aid formularies. Not yet on the South African public-sector essential medicines list for general use.
3. PCSK9 inhibitors — the newer aggressive option
Alirocumab (Praluent) and evolocumab (Repatha) are monoclonal antibody injections given every 2 – 4 weeks. They lower LDL by 50 – 60% on top of statin therapy and have been shown to reduce heart attack and stroke in high-risk patients.
Used for:
• Patients with familial hypercholesterolaemia who can’t reach target on statins and ezetimibe.
• Patients who have had a recent heart attack or stroke and need very aggressive LDL lowering.
• Patients with true statin intolerance and very high cardiovascular risk.
Cost: around R3 000 – R8 000 / month privately. Some medical aid formularies cover it for specific indications. Not available in the public sector.
4. Fibrates — mainly for triglycerides
Fenofibrate and gemfibrozil work mostly on triglycerides, dropping them by 30 – 50%. They have a smaller LDL effect and modestly raise HDL.
Used for:
• Very high triglycerides (above 5.6 mmol/L), to prevent pancreatitis.
• Patients with the “diabetic dyslipidaemia” pattern of high triglycerides plus low HDL.
Available privately for R150 – R350 / month. Available on the public sector for specific indications.
5. Newer options — bempedoic acid, inclisiran
Bempedoic acid (Nexletol) is an oral pill that lowers LDL by about 18% and works for some patients with statin muscle pain. Inclisiran (Leqvio) is an injection given twice a year. Both are newer; neither is widely available in South Africa yet. Worth knowing about for the future.
The “but I feel fine” trap
This is the place where, in our experience, more South Africans fail their cholesterol treatment than anywhere else.
You start a statin. Your LDL comes down from 4.5 to 2.5. You feel exactly the same — because high cholesterol has no symptoms. After a few months, the tablet feels unnecessary. You skip a day. Nothing happens. You skip a week. Still nothing. So you stop.
Within four weeks, your LDL is back up. Plaque continues to build quietly. Ten or twenty years later, the body finally complains — in the form of a heart attack or a stroke. By then the choices have been made — years earlier — by whether or not you took the tablet every day.
Cholesterol medication is for life. Not for “until you feel better”. For life.
That can feel heavy when you first hear it. But it should also be reassuring: you are not on the tablet because something is going wrong day to day. You are on it because the protection it provides is quietly compounding in your arteries every single day you take it.
How to take cholesterol medication well
• Take it at the same time every day. Most statins can be taken any time, but simvastatin is best taken at night (the liver makes more cholesterol at night). Atorvastatin and rosuvastatin can be morning or night.
• If you miss a dose, take it as soon as you remember. Unless it is nearly time for the next dose — skip the missed one. Never double up.
• Keep a supply ahead. Don’t be down to your last tablet before refill day.
• Don’t combine with grapefruit if you’re on simvastatin or atorvastatin. Grapefruit blocks the enzyme that breaks down some statins, raising their levels in the blood. Other statins are fine.
• Take your home BP readings and your lipid panel seriously. The numbers are how you know the dose is right.
• Don’t stop on your own. If you want to come off, talk to your clinic first.
Drug interactions to know about
• Grapefruit juice — interacts with simvastatin and atorvastatin (not rosuvastatin). Eat oranges instead.
• Certain antibiotics (erythromycin, clarithromycin) and antifungal tablets — can raise statin levels. Tell your clinic which statin you take when they prescribe.
• Some HIV medications — significant interactions. Specialist HIV care will manage this.
• Warfarin — some statins increase its effect. INR monitoring needs to be tighter.
• Niacin (vitamin B3) — high doses combined with statins increase muscle-pain risk.
The statin scare campaigns
You will read articles claiming statins cause memory loss, depression, cancer, suicide, or are a giant pharma plot. These claims have been investigated in dozens of large studies. None hold up. Statins are not magic and not for everyone, but the side effect profile is one of the best-understood in medicine — and the benefit in the right patients is enormous.
If you are worried, look at sources that include the trial data: the Cochrane Collaboration reviews, the Lancet meta-analyses, or the NICE / Heart and Stroke Foundation guidelines. These are honest, well-referenced, and largely reassuring.
What if my LDL still isn’t coming down?
Sometimes LDL stays above target even on a statin. Before deciding the medication isn’t working, your clinic will usually check:
• Are you actually taking the tablet every day? The most common reason LDL doesn’t respond is missed doses. There is no shame in being honest about this.
• How much saturated fat are you still eating? Article 6.
• How much sugar and alcohol? Triglycerides drive the rest.
• Is the dose right? Most patients start at a low dose; many need a higher one.
• Is it time to add a second drug? Ezetimibe at this point is reasonable.
• Could it be familial hypercholesterolaemia? Worth investigating — covered in article 11.
The bigger picture
Statins have a reputation for being controversial. The actual research is one of the cleanest stories in modern medicine: they lower LDL, the LDL reduction reduces heart attacks and strokes, the side effects are mostly mild and manageable, and the benefit/harm balance favours treatment for almost everyone at high enough risk.
If you remember one thing from this article, let it be this: the tablet works in the background, every day, even when you feel fine. The feeling fine is the medication doing its job. Stopping does not undo the high cholesterol — it just hides the warning sign until something serious happens.
The next article in the series covers the metabolic triad — high BP, diabetes and cholesterol together — and how the three conditions amplify each other when they travel together (which they almost always do).
Where to get more help
Your nearest public clinic — free statin prescriptions and monthly refills.
Your community pharmacist — even if your prescription is from a clinic, any retail pharmacist will explain side effects, interactions and timing for free.
Heart and Stroke Foundation South Africa — heartfoundation.co.za · 021 422 1586.
Lipid and Atherosclerosis Society of Southern Africa — lasousa.org — clinical guidelines.
Phila Today Cholesterol Series — next: the metabolic triad — high BP, diabetes and cholesterol.
Phila Today · Article 9 of 12 in the Cholesterol Series