For decades, statins have been the workhorse of cholesterol control – small pills with a big reputation for lowering LDL, the so-called “bad” cholesterol that fuels heart attacks and strokes.
They’re inexpensive, widely prescribed, and backed by nearly 50 years of data. But for a sizable group of patients, those little pills come with a big problem – they simply can’t tolerate them.
“About 10 to 15 percent of the population have statin intolerance,” said Dr. Vikranth Gongidi, a cardiologist with Premier Cardiology in Vero Beach. “And that can range from just generalized weakness to specific weakness of the arms or legs. Some people just can’t take statins.”
Muscle pain is the most common complaint, and for some patients it’s more than a nuisance – it’s debilitating enough to stop treatment altogether. That’s troubling, because high cholesterol is one of the most powerful risk factors for heart disease – and it’s not just about lifestyle choices.
“About 75 percent of cholesterol levels are determined by genetics,” Dr. Gongidi explained. “So even people who eat well and exercise can still struggle to get their numbers where they need to be.”
Until recently, patients who couldn’t tolerate statins, or whose cholesterol remained stubbornly high despite them, had limited options. That’s now changing with the growing use of injectable cholesterol-lowering medications, including Repatha and Leqvio.
A few years ago, cardiologists began prescribing Repatha and related drugs, which work differently than statins. Instead of blocking cholesterol production, these medications help the liver remove more LDL from the bloodstream by targeting a certain protein known by the catchy name PCSK9.
“They’re injections, kind of like the diabetic pens or the weight-loss pens we see nowadays,” Dr. Gongidi said. “The patient gives it to themselves, and it’s usually every two weeks.”
More recently, an even newer option, Leqvio, entered the picture, and Gongidi says it has been a game-changer for certain patients.
“This one I’m really excited about,” he said. “It’s an injection that’s given every six months, right here in the office.”
Leqvio also targets PCSK9, but it does so in a different way. Rather than blocking the protein after it’s made, the medication works in the liver to reduce PCSK9 production altogether. The result is a significant drop in LDL cholesterol of about 50 percent, according to Dr. Gongidi, with far fewer doses.
“For people who are already taking a lot of pills, this is one less thing to worry about,” he said. “And from my perspective as a cardiologist, compliance is always an issue. When a patient gets the medication in the office, I know they got it.”
That reliability matters, especially for patients with advanced heart disease.
“We’ve had really good responses with this therapy, especially in patients who’ve had multiple stents or open-heart surgery and just couldn’t go on a statin,” Dr. Gongidi said. “If you’re not on a statin or something else to lower your LDL, it can clog up those arteries again. We were kind of in a pickle until now.”
One common misconception is that injectable cholesterol medications are reserved only for patients who have already had a heart attack. That’s no longer the case.
“It’s actually approved for people even before they get to that point,” Dr. Gongidi said. “You don’t have to have a heart attack to qualify.”
Current guidelines recommend LDL levels below 100 for most adults, and even lower – under 70 – for people with heart disease, diabetes or multiple risk factors. Those targets can be difficult to reach with diet alone.
“I always tell patients we can try diet,” Dr. Gongidi said. “But if you have diabetes, a strong family history or other risk factors, and you can’t take a statin, this becomes another option.”
Injectables aren’t just for people who can’t tolerate statins. They’re also used alongside statins when cholesterol levels remain too high despite maximum doses.
“That way, it lowers your risk of another heart attack or another stroke,” Dr. Gongidi said.
As for side effects, injectable therapies tend to be well tolerated. The most common side effect is mild irritation at the injection site, especially at the beginning. Compared to the muscle pain often associated with statins, many patients find the trade-off worthwhile.
Dr. Gongidi also emphasizes that, while medication doesn’t replace healthy habits, it can complement them. A plant-based diet, reducing saturated fats, increasing fiber intake, and fiber supplements can help lower cholesterol modestly.
“Diet alone may reduce cholesterol by about 15 percent,” he said. “If you combine strategies, maybe you get a 25 percent reduction. That works for some people. But if your cholesterol is 130 and you need it under 100, or under 70, diet may not be enough.”
Regular cholesterol monitoring is key. Dr. Gongidi recommends annual testing for most adults, every six months for those with high cholesterol, and every three to four months for patients with very elevated numbers or active heart disease.
While statins remain the first-line treatment, injectable therapies are carving out an important role.
“Statins are still the cornerstone of treatment,” Dr. Gongidi said. “They’re tried and true, and they’re inexpensive. But for people who can’t take them, or whose cholesterol still isn’t where it needs to be, these injectables fills a big gap.”
And for patients worried about cost, there’s encouraging news: Medicare covers injectable cholesterol medications, making them accessible to many of the people who need them most.
In the fight against heart disease and related health problems, the message is clear – cholesterol control is no longer a one-size-fits-all approach. With new injectable options on the table, patients who once felt stuck now have another path forward, one that may be as simple as two shots a year, and as powerful as a second chance at heart health.
Dr. Gongidi recently opened Premier Cardiology, a unique concierge/hybrid practice where members can choose between having direct 24-hour access to him, or be treated by his nurse practitioner, under his supervision, on a fee basis covered by insurance.
Dr. Vikranth Gongidi is a graduate of the University of North Carolina, Chapel Hill, and he completed his internal medicine internship and residency at Botsford Hospital in Farmington Hill, Michigan. His cardiology fellowship was completed at the University of Medicine and Dentistry of New Jersey in Stratford. Premier Cardiology is located at 787 37th St. Suite 250, Vero Beach. Call 772-494-0794 or visit premiercardiologyvb.com to get more information or make an appointment.
