Raising Your “Good” Cholesterol

For years now, everyone's attention has been on the "bad" cholesterol — LDL, or low-density lipoprotein cholesterol. The goals were to get it below 130 milligrams per deciliter (mg/dL), then 100, and now, for high-risk patients, down to the 70 mg/dL range.

Often lost in the shuffle has been the "good" cholesterol — HDL, or high-density lipoprotein cholesterol. HDL particles act as good scavengers to take away fat from arterial walls before it becomes imbedded into plaque.

Risk of heart attack declines 1% to 3% for every 1% increase in HDL. But the treatments available to raise HDL have been overshadowed by statins and their dramatic ability to lower LDL. Now, however, as more and more people get their LDL way down, interest in raising HDL is growing. Moderate to intense physical exercise (as advised by your doctor) and one to two alcoholic beverages per day can increase HDL a little. But it usually takes medication to reach more desirable blood HDL levels.

Promising new agents that can raise HDL are in human research trials, and may be on the market soon. But there are other medications that have been available for years, so you don't have to wait until the FDA approves these newer drugs to raise your HDL.

The two main classes of existing drugs are "fibrates" and niacin and related compounds. The best known fibrate is gemfibrozil (brand name: Lopid). This pill is usually taken twice per day a half hour before meals in a dosage of 600 milligrams.

Here's the good news: Pooled data on gemfibrozil and other fibrates show they lower total cholesterol by about 25 mg/dL, LDL cholesterol by about 12 mg/dL, and triglycerides by about 70 mg/dL. HDL goes up by a little more than 4 mg/dL. Together, these effects lead to a reduction in risk of cardiac problems of about 25% from fibrates.

The problem has been that about one-third of patients have side effects. About 12% of patients have gastrointestinal problems such as abdominal pain, gas, diarrhea, or an upset stomach. Rashes are also common. Less common problems include liver and muscle damage.

Good news, bad news

Niacin is also a good news-bad news story. The good news is that these drugs lower LDL by about 21 mg/dL, and raise HDL by nearly 7 mg/dL on average. Side effects are common, though, particularly with older preparations of niacin. Most people taking the "immediate release" forms of niacin get flushing, versus only about 25% of patients taking newer preparations in which there is "sustained release" of the drug. Gastrointestinal symptoms, skin, muscle, and liver problems are other major side effects.

These relatively high rates of side effects tell you why doctors have loved pushing statins to reduce LDL for the last decade — hardly anyone has side effects, and both patient and doctor can point to lower and lower LDL results and declare "victory." However, the war against heart disease still hasn't been won, so many physicians are starting to add these HDL-raising therapies to the statins that their patients are already taking.

As bothersome as these side effects can be, there are a variety of tactics that can be used to minimize them, and most patients can learn to take fibrates or niacin without problems.

Just over the horizon are treatments that can lead to much greater increases in HDL. Five to 10 years from now, many of us will probably be using such new HDL-raising treatments. For people with coronary artery disease and those at high risk of heart attacks, the need to reduce heart-attack risk shouldn't wait. If your LDL is already low, but your HDL is also very low (for example, below 35 mg/dL), talk with your doctor about strategies to help raise that HDL level.