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How each medicine works

Every LDL-lowering medicine pulls one of a few levers. Most of them end the same way: more working LDL receptors on the liver, and fewer LDL particles in the blood.

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Example ApoB

142mg/dL

Average trial effects; yours will differ.

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Compare ApoB

Read about each medicine

Statins

Proven to cut heart attacks

atorvastatin, rosuvastatin, simvastatin, pravastatin, pitavastatin

Acts on
HMG-CoA reductase
How it's taken
Pill, daily
Average effect in trials
LDL-C down 30 to 50%+ by intensity

Slow how much cholesterol the liver makes. The liver notices it's running low and puts out more LDL receptors, which pull LDL out of your blood.

They block HMG-CoA reductase, the slowest step in making cholesterol. Low cholesterol inside the cell switches on SREBP-2, which turns up the LDL receptor gene.

Short-acting statins work best in the evening because the liver makes most of its cholesterol overnight.

Newer and specialist options (7)
  • Oral PCSK9 inhibitors (enlicitide (Lipfendra, FDA-approved July 2026); AZD0780 in trials). Approved, outcome trial running. The same idea as the PCSK9 shots, but as a daily pill.
  • Evinacumab (Evkeeza). Approved, lowers LDL. For people born with almost no working LDL receptors. It works without them.
  • ANGPTL3 siRNA (solbinsiran). In clinical trials. The inclisiran idea applied to ANGPTL3: silence its message in the liver.
  • CETP inhibitor (obicetrapib). In clinical trials. A drug class that failed years ago and has come back in a more potent form.
  • Lomitapide (Juxtapid). Approved, lowers LDL. Slows the liver's assembly line for fat particles, so fewer are built. Also for people born with almost no LDL receptors.
  • PCSK9 vaccine (virus-like particle vaccines). Lab stage. Teach your own immune system to make antibodies against PCSK9.
  • Lp(a) lowering drugs (pelacarsen, olpasiran, lepodisiran, zerlasiran, muvalaplin). In clinical trials. Lp(a) is an LDL-like particle with an extra protein attached. Its level is mostly set by your genes, and standard drugs barely move it. These new drugs target it directly.
Switch medicines on below and watch the scene respond. Go inside the liver cell to see where each one acts. Numbers are average trial effects; yours will differ.

Key takeaways

  1. 1

    Statins and bempedoic acid slow how much cholesterol the liver makes, so it builds more LDL receptors. Ezetimibe cuts cholesterol absorbed from the gut, which sends the same signal.

  2. 2

    PCSK9 antibodies catch PCSK9 in the blood, and inclisiran stops the liver making it. Either way, more receptors survive to clear LDL.

  3. 3

    Combining medicines lowers LDL further. Each one cuts a share of what is left, so effects stack but don't simply add up. Which fit you is a decision for you and your clinician.

Go deeper

▸Pills, shots and how often

Statins, ezetimibe and bempedoic acid are daily pills. PCSK9 antibodies are injections every 2 or 4 weeks. Inclisiran is an injection at day 0, month 3, then every 6 months.

Statins are first-line because they are cheap and have the strongest evidence for preventing heart attacks and strokes.

▸About the numbers shown

The effects in the animation are averages from clinical trials: about 50% for a high-intensity statin, 21 to 27% more for ezetimibe added to a statin, 50 to 60% for a PCSK9 antibody on a statin, 17 to 23% for bempedoic acid, and about 50% for inclisiran. Individual response varies widely.

Lp(a) barely moves with most medicines. PCSK9 antibodies and inclisiran lower it modestly, and newer drugs aimed directly at Lp(a) are in trials.

▸When the usual medicines aren't enough

For people born with almost no working LDL receptors, medicines like evinacumab and lomitapide work without them. Other options, including oral PCSK9 inhibitors and gene editing, are newer or still in trials. The full list is in the interactive guide's Treatments panel.

What people experienced

One person's experience isn't a prediction of yours.

Sources

Not medical advice. This exhibit is general education to help you understand your condition and talk with your clinician. It doesn't tell you what to take or change. If you have chest pain or other signs of a heart attack or stroke, call 911.

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