Ezetimibe is a tablet that lowers cholesterol. It may be prescribed if statins cannot be taken, or alongside a statin for extra cholesterol-lowering. It’s a ‘cholesterol absorption inhibitor’ that limits the absorption of cholesterol in the small intestine. As a result, less cholesterol is taken to the liver, which therefore increases its efforts to take more cholesterol out of the blood.
Ezetimibe is not as effective as most statins but will reduce low-density lipoprotein (LDL) or ‘bad cholesterol’ by 15 to 22 per cent. It can reduce the risk of heart attacks and strokes when taken alongside a statin, but we have little evidence it can do this if used on its own. Side effects can include stomach pain, diarrhoea, flatulence and tiredness. It’s not recommended for people with significant liver disease or women who are pregnant or breastfeeding.
PCSK9 inhibitors This new class of drugs is very effective in lowering cholesterol and in reducing the risk of coronary heart disease and stroke in high-risk patients. Studies indicate they can lower LDL cholesterol by 50 to 60 per cent. Cholesterol levels will typically drop significantly after around four weeks of treatment, and then remain at this lower level. The reduction in cholesterol is even greater when taken alongside a statin. Two have been licensed so far: alirocumab (Praluent) and evolocumab (Repatha). They work by blocking a protein called PCSK9, which binds to LDL receptors in the liver, stopping them from working. These receptors normally remove cholesterol from the blood, but by blocking this protein, more LDL receptors will be available to remove cholesterol from the blood. In June 2016, the National Institute for Health and Care Excellence (NICE) recommended PCSK9 inhibitors for those who have had a heart attack or stroke, or who have FH. They are expensive and so currently are only recommended for people in these groups who can’t get their cholesterol levels low enough by taking statins, or who are intolerant to statins. PCSK9 inhibitors have to be given as injections every two or four weeks. There appear to be few side effects, but these may include flu-like symptoms or soreness around the injection site.
Apheresis
LDL apheresis is a treatment that removes LDL cholesterol from your blood. It works a lot like dialysis. Your blood is removed via a needle in your arm. The blood goes through a tube and enters a special filter called a plasma separator, which separates the blood and removes the cholesterol. The cholesterol-filtered blood is then returned to your body.
Because it’s an invasive and expensive treatment, it’s only used for people who are at very high risk because of their cholesterol levels. This means people with FH who have inherited two copies of the faulty gene (homozygous FH) from the age of seven onwards.
Having two copies of an FH gene means you have a severe form of FH and your cholesterol levels will be exceptionally high without treatment.
LDL apheresis may occasionally be used for other patients who have just one copy of the faulty gene (heterozygous FH), for people with a strong family history of premature death from coronary heart disease, or if they have worsening coronary heart disease and their cholesterol remains high when everything else has been tried.
This treatment can lower your LDL cholesterol by 60 to 75 per cent. However, it does rise again quite quickly, which is why treatment is repeated every one or two weeks. Each treatment takes two to four hours. The main side effect is tiredness. This is very mild and tends to improve with future treatments.
Statins and Liver 
poisoned by statins
Stopping Statins
Statins and the Liver
Alternative to Spironolactone
