Review on Cholesterol Metabolism and Mechanism-Based Pharmacotherapy
DOI:
https://doi.org/10.22270/ajprd.v14i01.1691Abstract
Cholesterol is an indispensable lipid molecule that contributes to membrane structure, cellular signaling, and the synthesis of steroid hormones and bile acids. Nevertheless, chronic elevation of circulating cholesterol, particularly low-density lipoprotein cholesterol (LDL-C), is a well-established causal factor in atherosclerotic cardiovascular disease (ASCVD). Continuous progress in molecular pharmacology has clarified the regulatory networks governing cholesterol homeostasis and has enabled the development of therapeutics precisely targeting these pathways. This review systematically summarizes the physiological mechanisms of cholesterol absorption, biosynthesis, transport, and elimination, and critically examines mechanism-based pharmacotherapies currently used or under development. Emphasis is placed on molecular targets, pharmacological mechanisms, and clinical relevance, with a focus suitable for pharmaceutical sciences. The integration of mechanistic insight with therapeutic strategy underscores the evolving role of precision pharmacotherapy in cholesterol management.
Downloads
References
Brown MS, Goldstein JL. A receptor-mediated pathway for cholesterol homeostasis. Science. 1986;232(4746):34-47.
Goldstein JL, Brown MS. The LDL receptor. ArteriosclerThrombVasc Biol. 2009;29:431-438.
Goldstein JL, DeBose-Boyd RA, Brown MS. Protein sensors for membrane sterols. Cell. 2006;124(4):735-46.
Tall AR, Yvan-Charvet L. Cholesterol, inflammation and innate immunity. Nat Rev Immunol. 2015;15(2):104-16.
Wang HH, Garruti G, Liu M, Portincasa P, Wang DQ. Cholesterol absorption and metabolism. Best Pract Res Clin Gastroenterol. 2014;28(3):373-81.
Endo A. The discovery and development of HMG-CoA reductase inhibitors. J Lipid Res. 1992;33:1569–1582.
Ference BA, et al. Low-density lipoproteins cause atherosclerotic cardiovascular disease. Eur Heart J. 2017;38:2459–2472.
Nissen SE, Linnebjerg H, Nicholls SJ, et al. Lipid-Lowering Effects of the CETP Inhibitor Obicetrapib in Combination with High-Intensity Statins. J Am Coll Cardiol. 2022;80(14):1313-1324.
9.Ikonen E. Cellular cholesterol trafficking and compartmentalization. Nat Rev Mol Cell Biol. 2008;9(2):125-38.
Grundy SM, et al. 2018 AHA/ACC cholesterol guideline. Circulation. 2019;139:e1082-e1143.
Horton JD, Goldstein JL, Brown MS. SREBPs: activators of the complete program of cholesterol and fatty acid synthesis in the liver. J Clin Invest. 2002;109(9):1125-31.
Stancu C, Sima A. Statins: mechanism of action and effects. J Cell Mol Med. 2001;5(4):378-87.
Stancu C, Sima A. Statins: mechanism of action and effects. J Cell Mol Med. 2001;5(4):378-87.
Cannon CP, et al. Ezetimibe added to statin therapy after acute coronary syndromes. N Engl J Med. 2015;372:2387–2397.
Chilbert MR, VanDuyn D, Salah S, Clark CM, Ma Q.Combination Therapy of Ezetimibe and Rosuvastatin for Dyslipidemia: Current Insights. Drug Des DevelTher. 2022 Jul 7;16:2177-2186. doi: 10.2147/DDDT.S332352. eCollection 2022.
Seidah NG, et al. PCSK9: a key modulator of LDL receptor. Proc Natl Acad Sci USA. 2003;100:928–933.
Abifadel M, Varret M, Rabès JP, Allard D, Ouguerram K, Devillers M, et al. Mutations in PCSK9 cause autosomal dominant hypercholesterolemia. Nat Genet. 2003;34(2):154-6.
Ray KK, et al. Safety and efficacy of bempedoic acid. N Engl J Med. 2019;380:1022–1032.
Borén J, Chapman MJ, Krauss RM, Packard CJ, Bentzon JF, Binder CJ, et al. Low-density lipoproteins cause atherosclerotic cardiovascular disease. 1. Evidence from genetic, epidemiologic, and clinical studies. A consensus statement from the European Atherosclerosis Society Consensus Panel. Eur Heart J. 2020;41(24):2313-30.
Ference BA, Ginsberg HN, Graham I, Ray KK, Packard CJ, Bruckert E, et al. Low-density lipoproteins cause atherosclerotic cardiovascular disease. 2. Evidence from genetic, epidemiologic, and clinical studies. A consensus statement from the European Atherosclerosis Society Consensus Panel. Eur Heart J. 2017;38(32):2459-72.
Ray KK, Wright RS, Kallend D, Stoekenbroek RM, Garcia-Conde M, Lookinland VV, et al. Two Phase 3 Trials of Inclisiran in Patients with Elevated LDL Cholesterol. N Engl J Med. 2020;382(16):1507-19.
Sabatine MS, Giugliano RP, Keech AC, Honarpour N, Wang H, Liu T, et al. Evolocumab and Clinical Outcomes in Patients with Cardiovascular Disease. N Engl J Med. 2017;376(18):1713-22.
Bays HE, et al. Bempedoic acid safety analysis. J Clin Lipidol. 2020;14:649–659.
Graham MJ, Castellani LW, Diehl C, Xia S, Yu RZ, Amatruda JG, et al. Cardiovascular and Metabolic Effects of ANGPTL3 Antisense Oligonucleotides. N Engl J Med. 2017;377(3):222-
Dewey FE, Gusarova V, Dunbar RL, O'Dushlaine C, Schurmann C, Gottesman O, et al. Genetic and Pharmacologic Inactivation of ANGPTL3 and Cardiovascular Disease. N Engl J Med. 2017;377(3):211-21.
Nordestgaard BG, Langsted A. Lipoprotein(a) as a cause of cardiovascular disease: insights from epidemiology, genetics, and biology. J Lipid Res. 2016;57(11):1953-75.
Tall AR, Rader DJ. Illuminating the crystal ball: The future of lipid-lowering therapy. Cell Metab. 2018;27(1):85-104.
Reeskamp LF, Gipe DA, Raal FJ, Kastelein JJP. Next-generation lipid-lowering therapies: focusing on ANGPTL3 and ApoC3. CurrOpinLipidol. 2020;31(6):323-31.
Shimano H, Sato R. SREBP-regulated lipid metabolism: convergent mechanisms-divergent outcomes. Nat Rev Endocrinol. 2017;13(12):710-30.
Mach F, et al. 2019 ESC/EAS dyslipidaemia guidelines. Eur Heart J. 2020;41:111–188.
Rader DJ, Hovingh GK. HDL and reverse transport. Lancet. 2014;384:618–625.
Santos RD, et al. PCSK9 inhibition clinical perspectives. Atherosclerosis. 2015;241:251–258.
Horton JD, Goldstein JL, Brown MS. SREBPs: activators of the complete program of cholesterol and fatty acid synthesis in the liver. J Clin Invest. 2002;109(9):1125-1131.
Seidah NG, Prat A. The biology and therapeutic targeting of PCSK9. Nat Rev Drug Discov. 2012;11(5):367-383.
Downloads
Published
How to Cite
Issue
Section
License
Copyright (c) 2026 Cheolin PARK

This work is licensed under a Creative Commons Attribution-NonCommercial 4.0 International License.
AUTHORS WHO PUBLISH WITH THIS JOURNAL AGREE TO THE FOLLOWING TERMS:
Authors retain copyright and grant the journal right of first publication with the work simultaneously licensed under a Creative Commons Attribution-NonCommercial 4.0 Unported License. that allows others to share the work with an acknowledgment of the work's authorship and initial publication in this journal.
Authors are able to enter into separate, additional contractual arrangements for the non-exclusive distribution of the journal's published version of the work (e.g., post it to an institutional repository or publish it in a book), with an acknowledgment of its initial publication in this journal.
Authors are permitted and encouraged to post their work online (e.g., in institutional repositories or on their website) prior to and during the submission process, as it can lead to productive exchanges, as well as earlier and greater citation of published work (See The Effect of Open Access).
.