There are a number of different classes of medications for lowering cholesterol but the overwhelming majority of such prescriptions belong to the class of drugs called statins. These drugs work by blocking the production of cholesterol in the liver. All of their chemical names end in "statin" and so that name has been attached to the whole group. In increasing order of potency, the available statins are fluvastatin (Lescol); lovastatin (Mevacor); pravastatin (Pravachol); simvastatin (Zocor); atorvastatin (Lipitor); and rosuvastatin (Crestor).
Some of these drugs have been around for a long time. Lovastatin was the very first drug in this category, and has now been available for over 25 years. Lovastatin, pravastatin, and simvastatin are all available as generics at low cost. These are probably the most studied medications on Earth - scientific studies of this class of drugs have involved numbers of individuals in the hundreds of thousands. They are astonishingly safe. Although my patients often worry that their livers are going to rot I have actually never in my entire career seen serious liver disease from these drugs. They do occasionally cause muscle aches but these are rarely serious. However, patients on immune system suppressive therapy because of organ transplants or other diseases requiring such treatment are at higher risk from these drugs. These patients often need lipid-lowering therapy anyway, but it needs to be used very cautiously.
The statins have been shown to reduce risk of cardiac death or heart attack by at least one third, and have similar beneficial effects on stroke and vascular disease. Their benefit is remarkably greater than their risk, and there is simply no doubt that these medications are safer than drugs such as aspirin and ibuprofen which can be purchased without prescription in any supermarket.
These medications can be taken at any time, with or without food, and can be taken together with other medications. Some of the older statins such as lovastatin and pravastatin are slightly more effective when taken in the evening, although the difference is small and if even an occasional pill is forgotten because of the need to take it in the evening that will completely offset the small benefit. For all of the newer statins (simvastatin, atorvastatin, and rosuvastatin) it makes no difference when the medication is taken.
Grapefruit juice has been reported to interfere with the metabolism of many of the statins and so can create a situation where a small a dose of the drug has the same effect as a larger dose would ordinarily have had. This can increase the likelihood of side effects. The studies that have been done indicate that a glass of grapefruit juice a day is unlikely to have an important effect but larger amounts may, and if you love grapefruit juice this should be discussed with your doctor. The effect is smaller with some of the statins, especially pravastatin.