How to reduce cholesterol levels when using steroids

Anabolic steroids are known to cause some alterations in cholesterol levels, including an increase in LDL cholesterol (bad cholesterol) and a decrease in HDL cholesterol (good cholesterol).

As in every other individual with high LDL and low HDL (frequently found in obese patients) the recommended approach is to use Statins (a family of different medications)

These agents inhibit of HMG-CoA reductase (an enzyme from the liver), limiting cholesterol biosynthesis (generation). They occupy a portion of the binding site of HMG-CoA, blocking access of this substrate to the active site on the enzyme.

Currently available statins include lovastatin, pravastatin, simvastatin, fluvastatin, atorvastatin, rosuvastatin, and pitavastatin.

They’re all very similar and can reduce the cholesterol levels from 30 to 60% approximately.

The theoretical “potency” in decreasing order would be:

⦁ Rosuvastatin
⦁ Atorvastatin
⦁ Pravastatin
⦁ Pitavastatin
⦁ Simvastatin
⦁ Lovastatin
⦁ Fluvastatin

Sadly these medications are also somewhat hepatotoxic and can cause myopathy (muscle inflammation) although both of these are rare (5% of cases or less).

If any of these side effects appear it is recommended to switch to a different one.
The most recommended statins to combine with anabolic steroids are Pravastatin and Fluvastatin, as these tend to have fewer pharmaceutical interactions, are less hepatotoxic and appear to cause fewer muscle toxicity.

In patients with renal impairment, fluvastatin and atorvastatin are more recommended.
If intense treatment is needed for lowering cholesterol, rosuvastatin and atorvastatin would be the best choices, though atorvastatin has more pharmaceutical interactions than rosuvastatin.

Practically all of them (except pitavastatin and pravastatin) can be taken with food, and most of them can be taken any time during the day (except lovastatin and fluvatatin, recommended to be taken in the morning).

If for some reason statins are not well tolerated, a fibrate can be used instead (much less effective, but the best second choice)

The fibrates currently available are gemfibrozil, fenofibrate and bezafibrate, they are all less effective than statins and they all can cause myopathy too (although rare) and gemfibrozil seems more likely to cause it.

If fibrates and statins are combined the myopathy risk increases exponentially, so the combination is not recommended, but if needed fluvastatin and pravastatin are less likely to cause this when combined with a fibrate.

There are many other options out there (ezetimibe, nicotinic acid, cholestyramine, etc) but none of these have shown a benefit as high as statins or fibrates.

Some additional treatments that although not very effective, may be good to add, would be a Mediterranean diet, fish oil and omega-3 fatty acids, which have some evidence of being useful to decrease cholesterol levels without significant adverse effects.

Bibliography

1-. Roseson. Statins: Actions, side effects, and administration. UpToDate. 2015
(http://www.uptodate.com/contents/statins-actions-side-effects-and-administration? )