Ozempic for High Cholesterol: Evidence and NHS Treatment Options

Ozempic (semaglutide) is a GLP-1 receptor agonist licensed in the UK for treating type 2 diabetes mellitus in adults. Whilst clinical trials have shown modest improvements in cholesterol levels amongst patients using Ozempic, these changes appear largely secondary to weight loss rather than direct lipid-lowering effects. Importantly, Ozempic is not licensed or recommended by NICE as a treatment for high cholesterol. Statins remain the first-line, evidence-based therapy for managing dyslipidaemia in the UK. This article examines the evidence surrounding Ozempic's effects on cholesterol, NHS-approved treatments for high cholesterol, and when to consult your GP about lipid management.

What Is Ozempic and How Does It Work?

Ozempic (semaglutide) is a prescription medicine licensed in the UK by the Medicines and Healthcare products Regulatory Agency (MHRA) for the treatment of type 2 diabetes mellitus in adults. It belongs to a class of medications called glucagon-like peptide-1 (GLP-1) receptor agonists, which work by mimicking the action of a naturally occurring hormone in the body.

The primary mechanism of action involves stimulating insulin secretion from the pancreas when blood glucose levels are elevated, whilst simultaneously suppressing the release of glucagon, a hormone that raises blood sugar. Ozempic also slows gastric emptying, which helps to reduce post-meal glucose spikes and promotes a feeling of fullness. This latter effect often leads to reduced calorie intake and subsequent weight loss, which is a common secondary benefit observed in clinical trials.

Administered as a once-weekly subcutaneous injection, Ozempic is typically prescribed alongside diet and exercise modifications to improve glycaemic control in adults with type 2 diabetes. The medication is available in pre-filled pens containing different dose strengths. Treatment begins with 0.25 mg once weekly for 4 weeks as an initiation dose (not intended for glycaemic control), then increases to 0.5 mg once weekly. After at least 4 weeks, the dose can be increased to 1 mg or 2 mg weekly based on individual response and tolerability.

Whilst Ozempic's primary indication remains diabetes management, research has explored various cardiovascular and metabolic effects associated with GLP-1 receptor agonists. It is important to note that Ozempic is not currently licensed in the UK specifically for cholesterol management or weight loss in individuals without type 2 diabetes. For weight management, a different formulation of semaglutide (Wegovy) has a separate UK licence.

Evidence for Ozempic's Effects on Cholesterol Levels

Clinical trial data suggest that semaglutide may have modest effects on lipid profiles, though these changes appear to be largely secondary to weight loss rather than direct lipid-lowering action. The landmark SUSTAIN clinical trial programme, which evaluated Ozempic in patients with type 2 diabetes, reported small improvements in certain cholesterol parameters alongside significant reductions in body weight and HbA1c levels.

In the SUSTAIN trials, patients treated with semaglutide experienced modest reductions in total cholesterol and LDL cholesterol (often referred to as 'bad' cholesterol), typically in the range of 2–5% compared to baseline. There were also small increases in HDL cholesterol ('good' cholesterol) and reductions in triglycerides observed in some studies. However, these lipid changes were generally considered secondary outcomes rather than primary endpoints.

The cardiovascular outcomes trial SUSTAIN-6 demonstrated that semaglutide reduced the risk of major adverse cardiovascular events in patients with type 2 diabetes and established cardiovascular disease. Whilst this suggests cardiovascular benefit, the mechanisms likely involve multiple factors including improved glycaemic control, weight reduction, blood pressure lowering, and potential anti-inflammatory effects, rather than cholesterol reduction alone.

It is crucial to understand that there is no official indication for using Ozempic specifically to treat high cholesterol. The observed lipid improvements in clinical trials occurred in the context of diabetes treatment, and the magnitude of cholesterol reduction is substantially less than that achieved with established lipid-lowering therapies such as statins. NICE guidance does not recommend GLP-1 receptor agonists as primary treatment for dyslipidaemia (abnormal cholesterol levels).

NHS-Approved Treatments for High Cholesterol

The National Institute for Health and Care Excellence (NICE) provides clear, evidence-based guidance on managing high cholesterol, with statins remaining the first-line pharmacological treatment for most patients requiring lipid-lowering therapy. Statins work by inhibiting an enzyme involved in cholesterol production in the liver, typically reducing LDL cholesterol by 30–50% depending on the dose and specific agent used.

NICE recommends offering atorvastatin 20 mg as initial treatment for primary prevention of cardiovascular disease in adults with a 10-year cardiovascular risk of 10% or more (calculated using the QRISK assessment tool). For secondary prevention in patients with established cardiovascular disease, atorvastatin 80 mg is typically recommended. Other statins such as simvastatin, pravastatin, and rosuvastatin may be used based on individual patient factors, tolerability, and cost-effectiveness considerations.

For patients who cannot tolerate statins or require additional lipid lowering despite maximum tolerated statin therapy, NICE guidance supports several alternative or adjunctive treatments:

• Ezetimibe: Reduces cholesterol absorption from the intestine and can be used alone or in combination with statins

• PCSK9 inhibitors (evolocumab, alirocumab): Injectable medications reserved for specific high-risk patients with familial hypercholesterolaemia or established cardiovascular disease who have not achieved targets with other therapies

• Bempedoic acid: A newer oral option for patients with statin intolerance

• Inclisiran: An injectable treatment given twice yearly for primary hypercholesterolaemia or mixed dyslipidaemia in line with NICE criteria

• Icosapent ethyl: For people with established cardiovascular disease and raised triglycerides despite statin therapy

• Fibrates: Primarily used for severe hypertriglyceridaemia

Lifestyle modifications remain fundamental to cholesterol management and should be implemented alongside any pharmacological treatment. These include adopting a heart-healthy diet low in saturated fats, increasing physical activity, maintaining a healthy weight, stopping smoking, and moderating alcohol consumption. The NHS provides access to dietetic services and lifestyle programmes to support these changes.

NICE recommends checking non-HDL cholesterol at 3 months after starting treatment, aiming for at least a 40% reduction in primary prevention. If targets aren't met, medication adherence should be reviewed and dose escalation or additional therapies considered.

Side Effects and Safety Considerations

Like all medications, Ozempic carries a risk of adverse effects that patients and healthcare professionals must consider carefully. The most commonly reported side effects are gastrointestinal in nature, affecting a significant proportion of users, particularly during the initial weeks of treatment or following dose increases.

Common gastrointestinal side effects include:

• Nausea (reported in up to 20% of patients in clinical trials)

• Vomiting and diarrhoea

• Constipation

• Abdominal pain and bloating

• Reduced appetite

These symptoms are typically mild to moderate in severity and often improve over time as the body adjusts to the medication. Starting with a lower dose and gradually titrating upwards can help minimise these effects.

More serious but less common adverse effects require immediate medical attention. These include:

• Pancreatitis (inflammation of the pancreas): Symptoms include severe, persistent abdominal pain that may radiate to the back, often accompanied by nausea and vomiting. Patients experiencing these symptoms should stop Ozempic and seek urgent medical assessment.

• Gallbladder problems: Rapid weight loss associated with GLP-1 receptor agonists may increase the risk of gallstones and cholecystitis.

• Hypoglycaemia (low blood sugar): Risk is increased when Ozempic is used in combination with insulin or sulfonylureas. Symptoms include trembling, sweating, confusion, and palpitations.

• Diabetic retinopathy complications: Patients with pre-existing diabetic eye disease should be monitored closely, as rapid improvement in blood glucose control may temporarily worsen retinopathy.

• Acute kidney injury: Dehydration from gastrointestinal side effects may impair kidney function, particularly in patients with existing renal impairment.

In animal studies, semaglutide was associated with thyroid C-cell tumours. While the relevance to humans remains uncertain, patients should seek medical advice if they develop symptoms such as a neck mass, dysphagia, persistent hoarseness or breathing difficulties.

Ozempic should not be used during pregnancy or breastfeeding. Women of childbearing potential should use effective contraception while taking semaglutide and discontinue treatment at least 2 months before a planned pregnancy.

Patients should inform their GP about all medications they are taking, as drug interactions may occur, particularly with other diabetes medications that affect blood glucose levels.

If you experience any side effects, talk to your doctor, pharmacist or nurse. This includes any possible side effects not listed in the package leaflet. You can also report side effects directly via the Yellow Card Scheme at yellowcard.mhra.gov.uk.

When to Speak with Your GP About Cholesterol Management

Regular cholesterol monitoring is an important aspect of cardiovascular disease prevention, and there are several circumstances when you should discuss cholesterol management with your GP. The NHS Health Check programme offers free cardiovascular risk assessments to adults aged 40–74 without pre-existing conditions every five years, which includes cholesterol testing.

You should arrange to speak with your GP about cholesterol screening if:

• You have a family history of premature cardiovascular disease (heart attack or stroke in a first-degree relative before age 60) or familial hypercholesterolaemia

• You have been diagnosed with type 2 diabetes, high blood pressure, or chronic kidney disease

• You are significantly overweight or obese (BMI ≥30 kg/m²)

• You smoke or have recently quit smoking

• You have other cardiovascular risk factors such as a sedentary lifestyle or unhealthy diet

• You have a QRISK3 score of 10% or higher (if previously calculated)

• You have signs that might suggest familial hypercholesterolaemia, such as tendon xanthomata (fatty deposits around tendons) or very high LDL cholesterol levels

If you are already taking cholesterol-lowering medication, you should contact your GP if you experience:

• Unexplained muscle pain, tenderness, or weakness (potential sign of statin-related myopathy)

• Severe muscle pain with dark urine (seek urgent medical attention as this could indicate rhabdomyolysis)

• Persistent gastrointestinal symptoms affecting your quality of life

• Concerns about medication side effects or interactions

• Difficulty adhering to your prescribed treatment regimen

For patients with type 2 diabetes currently taking Ozempic who are concerned about their cholesterol levels, it is important to have an open conversation with your GP or diabetes specialist nurse. They can arrange appropriate lipid profile testing and determine whether additional lipid-lowering therapy is indicated based on your individual cardiovascular risk profile and current cholesterol levels.

Do not stop or start any medication without medical supervision. Your GP can provide personalised advice on the most appropriate evidence-based treatments for your specific circumstances, taking into account your complete medical history, current medications, and treatment goals. They can also refer you to specialist services if needed, such as lipid clinics for complex dyslipidaemia or familial hypercholesterolaemia, or diabetes specialist teams for optimisation of diabetes management.

Remember that cholesterol management is just one component of overall cardiovascular health. Your GP can help you develop a comprehensive approach that addresses all modifiable risk factors through both lifestyle interventions and appropriate pharmacological therapy when indicated.

Frequently Asked Questions