High cholesterol is, alongside hypertension, one of the major cardiovascular risk factors. In Romania, about 50% of adults have total cholesterol above 200 mg/dL. Effective treatment exists — statins have been on the market since 1987 and are among the most studied medicines in history.
Reference values
- Total cholesterol: optimal below 200 mg/dL.
- LDL (“bad cholesterol”): below 100 mg/dL (below 70 in people with diabetes, below 55 in patients with a previous heart attack/stroke).
- HDL (“good cholesterol”): above 40 (men), above 50 (women).
- Triglycerides: below 150 mg/dL.
Statins — the gold standard
Statins inhibit the enzyme HMG-CoA reductase, reducing cholesterol production in the liver. LDL reduction: 25-60% depending on the statin and the dose. They reduce the risk of heart attack by 25-30%, the risk of stroke by 20-25% and cardiovascular mortality by 20%.
Atorvastatin
The most prescribed in Romania. Doses 10-80 mg. At 40 mg it lowers LDL by 40-50%. Very cheap generics (Terapia, Zentiva, Actavis, Krka).
Rosuvastatin
The most potent. 10 mg is equivalent to 40 mg of atorvastatin. Doses 5-40 mg. Brand: Crestor. Generics: Rosuvastatin Teva, Krka, Zentiva.
Simvastatin
A classic, and cheap. Doses 10-40 mg. Caution — the 80 mg dose has been withdrawn for many patients because of the risk of myopathy. Less used today.
Pravastatin, fluvastatin, pitavastatin
Alternatives for special cases (interactions, intolerance). Less commonly used.
Statin side effects — reality vs myth
Reality: muscle pain (myalgia) in 5-10% of patients, slight rises in liver transaminases, rarely diabetes in predisposed people.
Myths: “statins destroy the liver” (false — periodic monitoring is enough), “they cause dementia” (false — large studies do not confirm it), “they are not needed for slightly raised levels” (discuss with your cardiologist — overall cardiovascular risk is what matters).
Other classes of cholesterol medicines
Ezetimibe
It inhibits the intestinal absorption of cholesterol. It lowers LDL by 15-20%. Used in combination with statins (Inegy = simvastatin + ezetimibe; Atozet = atorvastatin + ezetimibe).
PCSK9 inhibitors
Injections once every 2-4 weeks. Evolocumab (Repatha), alirocumab (Praluent). They lower LDL by a further 50-60% on top of statins. Very expensive — reserved for patients at very high risk (familial hypercholesterolaemia, recurrent heart attack).
Fibrates
Fenofibrate, bezafibrate. They act mainly on triglycerides. The first choice when triglycerides are the main problem (above 400 mg/dL).
Nicotinic acid (niacin)
Rarely used today — studies have shown that lowering LDL brings no additional clinical benefit on top of statins.
Natural alternatives and supplements
Monacolin K (Chinese red yeast rice)
Chemically identical to lovastatin (the first statin). It lowers LDL by 15-25% at a dose of 10 mg. Caution: EFSA has restricted the dose to 3 mg/day in the EU since 2022 — medical supervision is required. Older preparations could contain high, unregulated doses.
Phytosterols (Benecol, Danacol)
Dairy products and spreads enriched with 2 g of phytosterols/day lower LDL by 7-10%. Useful as an addition to the diet, not as a replacement for medication.
Omega 3
It lowers triglycerides by 20-30% at high doses (2-4 g EPA+DHA/day). Minimal effect on LDL. Useful for hypertriglyceridaemia. The low doses in ordinary OTC supplements are insufficient.
Soluble fibre (psyllium, oats)
30-50 g of fibre/day lowers LDL by 5-10%. Effective, but hard to obtain from the diet.
Lifestyle changes with an impact
- Saturated fat below 7% of calories — effect: -8-10% LDL.
- Cutting out trans fats (hydrogenated margarines, industrial products) — effect: a notable fall in LDL and a rise in HDL.
- Aerobic exercise 150 min/week — effect: +5-10% HDL, -10% triglycerides.
- Losing 5-10% of body weight — effect: -10-15% triglycerides, a slight fall in LDL.
Statin prices in Romania
The price is capped through CANAMED. Generics: atorvastatin 20 mg x 30 tablets ~20-30 RON, rosuvastatin 10 mg x 30 tablets ~25-40 RON. With CNAS reimbursement (list C), you pay 10-20% of the price. Full comparisons in the HartaFarmacii Cholesterol category.
Who should be given a statin
The European cardiology guidelines (ESC/EAS 2019-2024) recommend a statin for:
- Secondary prevention — anyone who has had a heart attack, a stroke, angioplasty, a bypass or peripheral arterial disease. Mandatory, for life.
- Type 2 diabetes over the age of 40 — a cardiovascular risk equivalent to that of a patient after a heart attack.
- Chronic kidney disease — statins reduce mortality.
- LDL above 190 mg/dL — possibly familial hypercholesterolaemia, immediate treatment.
- A 10-year cardiovascular risk above 10% — calculated with the SCORE2 score or similar.
Check-ups and monitoring
After starting a statin:
- At 3 months — lipid profile (LDL, HDL, triglycerides), transaminases (ALT, AST), creatine kinase (CK) in patients with muscle pain.
- At 6-12 months — a recheck. If LDL is on target, continue at the same dose.
- Every year after that — a lipid profile + transaminases check.
Conclusion
Statins remain the basic treatment. Combining them with ezetimibe is the modern strategy for aggressive targets. Supplements (monacolin K, phytosterols, omega 3) play a marginal role, but they do NOT replace medication in patients at high cardiovascular risk. Follow your medical instructions, have tests every 3-6 months at first, then every year. Compare prices in the HartaFarmacii Cholesterol category.
Frequently asked questions
- Do statins destroy the liver?
- No. Slight rises in transaminases occur in 1-3% of patients and are rarely clinically relevant. They are monitored with tests every 3-6 months at first, then every year. The real risk is much smaller than the cardiovascular benefit.
- Can I replace my statin with monacolin K from the pharmacy?
- Monacolin K is chemically identical to lovastatin, but in the EU the dose is limited to 3 mg/day — not enough for high-risk patients. It may be useful at mild-to-moderate risk, but not for patients with a previous heart attack or familial hypercholesterolaemia.
- Why do statins cause muscle pain?
- 5-10% of patients report myalgia — probably caused by a direct effect on the muscle cell. With significant pain, the dose is reduced, the statin is changed, or coenzyme Q10 (100-200 mg/day) is added.
- Do I have to take the statin for life?
- Yes, for most patients. Stopping it brings LDL back up within 2-4 weeks. Rare exceptions: patients who lower their LDL substantially through diet and major weight loss, under medical supervision.
- Can omega 3 replace cholesterol medication?
- Not for LDL. Omega 3 lowers triglycerides at high doses (2-4 g/day) but has a minimal effect on LDL. Useful in isolated hypertriglyceridaemia, not in general hypercholesterolaemia.