1. 50 Drugs that Help Normalize Cholesterol & Triglyceride Levels
AKA: Antilipemic Agents

2. Lipids and Cardiovascular Disease
Hyperlipidemia
High levels of lipids in blood major risk factor
Most patients asymptomatic until cardiovascular disease produces symptoms
May be inherited or acquired
Diets high in saturated fat and lack of exercise contribute
Genetics determines ability to metabolize lipids 2

3. Types of Hyerlipidemia
Hypercholesterolemia
Elevated blood cholesterol
Dyslipidemia
Abnormal levels of lipoproteins
Can refer to excess or deficit of different lipoproteins 3

4. Types of Lipids Triglycerides Phospholipids Steroids
Most common 90% of lipids
Major storage form of fat in body
Provide fuel for body
Phospholipids
Builds plasma membranes (lecithins most common)
Steroids
Cholesterol
Building block for biochemicals
Vitamin D, bile acids cortisol, estrogen, testosterone

5. Lipid Proteins Lipids must be packaged for transport throught he blood
Protein carrier (apoprotein) attached to the lipid
Classified as to weight, size, composition
Three types
VLDL (LDL synthesized from VLDL)
LDL
HDL

6. LDL LDL transports cholesterol from liver to tissues and organs
Used to build plasma membranes and synthesize other steroids
Carries highest amount of cholesterol
Known as bad cholesterol
Contributes to plaque deposits and coronary artery disease
VLDL: Primary carrier of triglycerides in blood 6

7. HDL ”H” is for happy Manufactured in liver and small intestine
Reverse cholesterol transport
Assists in transport of cholesterol away from body tissues and back to liver
Known as good cholesterol
***Transports cholesterol for destruction and removal from body 7

8. Therapeutic Lifestyle Changes
Monitor blood-lipid levels
Maintain weight; exercise
Reduce dietary saturated fats and cholesterol
Increase soluble fiber in diet
Reduce or eliminate tobacco use 8

9. Metabolic Syndrome High TG Low HDL Hyperglycemia High Blood Pressure
> 40 inches waist circumference for men or 35 inches for women

10. Five Main Classes HMG CoA reductase inhibitors (Statins)
Bile Acid Sequestrants
Nicotinic Acid
Fibrates
Cholesterol Absorption Inhibitors
*** Table 50-5 page 565

11. HMG-CoA Reductase Inhibitors (Statins)
Works by interfering with critical enzyme (HMG-coA reductase in the synthesis of cholesterol
First line of treatment for lipid disorders
Drop LDL, lower triglycerides and increase HDLs
Reduces cardiovascular events by 25% to 30%

12. HMG-CoA Reductase Inhibitors (Statins)
Prototype drug: atorvastatin (Lipitor)
Mechanism of action: inhibits HMG-CoA reductase
Primary use: Reduces serum-lipid levels
Adverse effects: headache, fatigue, muscle or joint pain, and heartburn, rarely rhabdomyolysis
See Table 50-8 page 571 12

13. Nursing Care and Statins
Watch for muscle pain and rhabdomyolysis
Administer at night (cholesterol synthesis highest then)
Avoid macrolides (i.e., erythromycin) azole antifungals*** (i.e., ketoconazole - Nizoral) , fibric acid agents, immunosuppressants (can cause rhabdomyolysis)
Often given in conjunction with cholesterol absorption inhibitors***
Watch for hepatotoxicity and myopathy
Pregnancy Risk X

14. Bile Acid Sequestrants
Work by increasing excretion of cholesterol in the stool
They bind bile acids which contain a high amount of cholesterol making them unable to be absorbed in the small intestine promoting their excretion
used in primarily in conjunction with statins
These used to be primary way to treat lipid disorders before statins discovered

15. Bile-Acid Resins
Prototype drug: cholestyramine (Questran)
Mechanism of action: bind with bile acids increasing cholesterol excretion in stool
Primary use: to lower serum-lipid levels
Adverse effects: GI tract, such as bloating and constipation
Can bind other drugs, increasing potential for drug interactions
Bind with bile acids to increase excretion of cholesterol in stool
Used in combination with statins
Examples: Welchol, Colestid 15

16. Nursing Care and Bile Acid Resins
Main adverse effects will be GI
***Assess bowel sounds
Avoid constipation with high fiber foods, fluids
Can decrease fat soluble vitamins
May need supplement
Interfers with absorption of digoxin, warfarin, thiazides and tetracyclines
Advise to take other medications 1 hour before or 4 hours after taking bile sequestrants

17. Nicotinic Acid (Niacin)
B complex vitamin
Much larger doses required for antilipid effect
Decreases LDL and triglyceride levels
Increases HDL

18. Nicotinic Acid Prototype drug: niacin
Mechanism of action: acts in the liver and adipose tissue to inhobit synthesis of TGs and thereby decreasing VLDL, how it increases HDL is unclear.
Primary use: to reduce triglycerides; increase HDL levels
Adverse effects: intense flushing, hot flashes, nausea, excess gas, diarrhea; more serious effects like hepatotoxicity and gout possible
B-complex vitamin
Decreases VLDL and LDL levels 18

19. Nursing Care and Nicotinic Acid
Almost all patients will experience flushing
***Advise to take one aspirin 325 mg 30 minutes before niacin to reduce flushing symptoms
GI effects common
Nausea, gas, diarrhea
Hepatotoxicity and gout (elevation of uric acid) are possible , hyperglycemia
May give 3 times a day, or extended release at nighttime

20. Fibric-Acid Agents Not used as frequently since statins developed
Drug of choice for treating high triglyceride levels
Mechanism of action (see page 574)

21. Fibric-Acid Agents Prototype drug: gemfibrozil (Lopid)
Mechanism of action: unknown
Primary use: treating severe hypertriglyceridemia
Adverse effects: GI distress, rash, watch for bleeding with clients on anticoagulants, gallstones, myopathy, liver injury
Drugs of choice for treating severe hypertriglyceridemia
Examples: Atromid-S, Tricor 21

22. Nursing Care and Fibric-Acid Agents
Increase likelihood of gallstones
GI related side effects most common
Dyspepsia, diarrhea, nausea and cramping
Give with meals to decrease GI symptoms
Fatty foods may decrease absorption
Avoid with severe renal or hepatic dysfunction
Avoid with gallstones

23. Cholesterol Absorption Inhibitors
Inhibits absorption of cholesterol secreted in the bile and from food
Cholesterol is normall abslored in jejunum of small intesting
Meds block 50% of absorption
Unfortunately, body responds by manufacturing more cholesterol; thus, a statin may be given also

24. Cholesterol Absorption Inhibitor
Prototype drug: ezetimibe (Zetia)
Mechanism of action: inhibits absorption of cholesterol
Primary use: modest reduction in LDL
Adverse effects: No serious side effects
New class of drug
Inhibits the absorption of cholesterol
Example: ezetimibe (Zetia) 24

25. Nursing Care and Cholesterol Absorption Inhibitor
Note: ezetimibe (Zetia) is the only drug in this class!
Watch for side effect of hepatitis
Monitor liver function
Observe for liver dysfunction
Avoid alcholol
Watch for myopathy
Educate patient to report signs