🧠 First — Important Context

• LDL (“bad cholesterol”) reduction is crucial to prevent heart attack & stroke.

• Statins remain first-line for high-risk patients.

• Alternatives are used when:

  • Statins cause side effects

  • LDL target not achieved with statins alone

  • Patient prefers non-statin therapy

🔹 MEDICAL (NON-STATIN) ALTERNATIVES

1️⃣ Ezetimibe

Best & most common statin alternative

• How it works: Blocks cholesterol absorption from intestine

• LDL reduction: 🔽 18–25%

• Dose: 10 mg once daily

• Advantages:

  • Very well tolerated

  • Minimal muscle pain

• Use case:

  • Alone (if statin intolerant)

  • With statin (add-on therapy)

👉 Often first choice alternative

2️⃣ Bempedoic Acid (Newer option)

• LDL reduction: 🔽 20–25%

• Key advantage:

  • Activated only in liver → less muscle pain

• Good for:

  • Statin-intolerant patients

• Available in India: Limited but increasing

⚠ May increase uric acid (gout risk)

3️⃣ PCSK9 Inhibitors (Very powerful)

Examples: Alirocumab, Evolocumab

• LDL reduction: 🔽 50–60%

• Injection: Once every 2–4 weeks

• Used for:

  • Very high LDL

  • Familial hypercholesterolemia

  • High cardiovascular risk

❌ Expensive
✅ Extremely effective

4️⃣ Bile Acid Sequestrants

Examples: Cholestyramine, Colesevelam

• LDL reduction: 🔽 15–20%

• Mechanism: Prevent bile acid reabsorption

• Drawbacks:

  • GI issues (bloating, constipation)

  • Drug interaction issues

Used less commonly today

🌿 NATURAL & NUTRACEUTICAL OPTIONS

(Useful for mild–moderate LDL or supportive therapy)

5️⃣ Plant Sterols & Stanols

• LDL reduction: 🔽 8–15%

• Found in:

  • Fortified oils

  • Supplements

• Mechanism similar to ezetimibe

6️⃣ Soluble Fiber

Examples:

• Psyllium husk (Isabgol)

• Oats, barley

• Flaxseed

• LDL reduction: 🔽 5–10%

• Also improves gut & sugar control

7️⃣ Omega-3 Fatty Acids

• Mainly reduces triglycerides

• Mild LDL effect

• Cardioprotective

8️⃣ Red Yeast Rice

⚠ Caution

• Contains natural statin (monacolin K)

• Can still cause statin-like side effects

• Quality varies → not routinely recommended

🥗 LIFESTYLE = FOUNDATION (Non-Negotiable)

Even the best medicines fail without this 👇

✅ Diet

• Mediterranean / DASH diet

• Reduce:

  • Refined carbs

  • Trans-fats

• Increase:

  • Nuts, seeds

  • Fruits & vegetables

  • Olive / mustard oil

✅ Exercise

• 150 min/week brisk walking

• Resistance training 2× weekly

✅ Weight & Thyroid

• Hypothyroidism raises LDL

• Ensure TSH is optimally controlled

(Important in your case, given your health-related interests)

📊 QUICK COMPARISON

⚠️ Final Medical Advice

• If LDL ≥ 190 mg/dL or heart disease present, non-statins alone may be insufficient.

• Combination therapy is often safest & most effective.