How should patients with hyperlipidemia choose between bile acid sequestrants and niacin-based medications?

Common Medications for Patients with Hyperlipidemia
For stubborn and severe hyperlipidemia, appropriate drug treatment is necessary. Since hyperlipidemia is the result of metabolic disorders caused by the long-term combined effects of multiple factors, there are currently no lipid-lowering drugs that perfectly meet physiological requirements. However, if blood lipid levels remain significantly elevated after 3-6 months of strict dietary control, especially in middle-aged and elderly individuals and those with other risk factors, drug treatment is necessary. The commonly used lipid-lowering drugs include the following categories:

Bile Acid Sequestrants
Bile acid sequestrants are also known as bile acid binding agents. These drugs can only lower the levels of total cholesterol and low-density lipoprotein cholesterol in the blood, but cannot lower triglyceride levels. Therefore, they are only suitable for simple hypercholesterolemia. Because these drugs have more side effects and their lipid-lowering effect is not as good as statins, they are less commonly used clinically and are not the first-line medication for patients with hyperlipidemia.

(1) Cholestyramine. Used to treat primary hypercholesterolemia, it can also remove irritating bile acids, thereby relieving skin itching caused by primary biliary cirrhosis and biliary obstruction. It can lower low-density lipoprotein and cholesterol levels.
(2) Colestipol. It can be used to lower serum cholesterol and low-density lipoprotein cholesterol levels, and can cause atherosclerotic plaques to regress or slow their progression, but it has no significant effect on triglycerides.
(3) Probucol. It can lower cholesterol and low-density lipoprotein cholesterol levels, which is beneficial for the prevention and treatment of arteriosclerosis, and can also treat Achilles tendon xanthoma and skin xanthoma in patients.
Nicotinic Acid and its Derivatives
These drugs are related to inhibiting the breakdown of adipose tissue and reducing the synthesis and secretion of very low-density lipoprotein by the liver, and can lower cholesterol, triglycerides, and low-density lipoprotein.
(1) Nicotinic acid. Nicotinic acid can increase high-density lipoprotein levels. Its efficacy and dosage are related to the blood lipid level before medication. Combined with bile acid sequestrants, it can increase the cholesterol-lowering effect. Long-term treatment can cause xanthomas to regress.
(2) Acipimox. Acipimox is a derivative of nicotinic acid that can significantly lower triglyceride and cholesterol levels and increase high-density lipoprotein levels. Its lipid-lowering effect is 20 times stronger than that of nicotinic acid.