Bile-Acid Sequestrant and Fibrate Therapy

Which patients are good candidates for fenofibric acid?

A 66-year-old patient with phenylketonuria Phenylketonuria is a contraindication to treatment with bile-acid sequestrant powders containing phenylalanine. This is not a concern with fenofibric acid. A 48-year-old patient with iron-deficiency anemia There is no concern with using fenofibric acid in a patient with iron-deficiency anemia.

A 64-year-old patient has been prescribed cholestyramine in addition to statin therapy to provide additional lipid-lowering effects. In addition to dyslipidemia, this patient has hypertension, atrial fibrillation, a partial bowel obstruction, and a history of myocardial infarction from 1 year ago. Which of the patient's current medical conditions alerts the nurse to contact the health care provider about avoiding the initiation of cholestyramine?

Bowel obstruction Bowel obstruction is a contraindication to treatment with bile-acid sequestrants like cholestyramine based on their mechanism of action. The nurse would contact the health care provider before initiation in this patient.

Which drug is considered a bile-acid sequestrant?

Cholestyramine Cholestyramine is considered a bile-acid sequestrant. Other bile-acid sequestrants include colesevelam and colestipol.

Which statements are accurate with respect to the pharmacokinetic profile of colesevelam?

Colesevelam is not absorbed upon oral administration. Colesevelam is not absorbed in the gastrointestinal tract and passes through the intestines to be excreted. The drug is excreted in the feces. Because colesevelam is not absorbed and passes through the gastrointestinal tract, it is excreted in the feces.

Which drug would a nurse anticipate may require additional monitoring because of reduced absorption of vitamins A, D, E, and K?

Colestipol Colestipol is a bile-acid sequestrant, which can reduce the absorption of vitamins A, D, E, and K.

Which phrases accurately describe the rationale for using colesevelam instead of cholestyramine or colestipol?

Fewer gastrointestinal effects One of the reasons that colesevelam is preferred over other bile-acid sequestrants is better tolerability because of fewer gastrointestinal effects. Lower drug-drug interaction potential One reason that colesevelam is preferred over other bile-acid sequestrants is the lower potential for drug-drug interactions. Lack of reduced absorption of fat-soluble vitamins A reason for colesevelam preference over other bile-acid sequestrants is a lack of reduced absorption of fat-soluble vitamins (e.g., A, D, E, and K).

A 62-year-old patient has been prescribed fenofibrate and rosuvastatin for dyslipidemia. This patient also has type 2 diabetes managed with metformin and glipizide. Which teaching points will a nurse provide to ensure this patient safely and effectively receives therapy with fenofibrate?

Follow up with the health care provider for monitoring of lipids and liver function tests. The patient would be instructed to follow up with the health care provider to monitor lipid levels and liver function tests. Exercise, eat a diet low in cholesterol and fat, and log interventions in a lifestyle diary. Patients with high cholesterol would be instructed to eat a diet low in cholesterol and fat. Exercise is also important. To help determine the effect of these interventions, they should ideally be logged in a lifestyle diary for easy recall. Report any muscle pains, severe abdominal pain, or decreased urination to a health care provider immediately. Patients receiving fenofibrate (or any fibrate) should report muscle pains, severe abdominal pain, or decreased urination immediately to a health care provider. These could indicate rhabdomyolysis, particularly because this patient is also on statin therapy.

A 58-year-old male patient is being initiated on gemfibrozil 600 mg PO twice daily for dyslipidemia management. He also takes glipizide for diabetes, hydrochlorothiazide and lisinopril for hypertension, simvastatin for dyslipidemia, and sildenafil for erectile dysfunction. Which medications that this patient is currently taking may interact with gemfibrozil?

Glipizide When taking a sulfonylurea like glipizide with gemfibrozil, an increase in blood glucose lowering may occur. This patient would need to be aware of this interaction and monitor his blood glucose levels carefully. Simvastatin The combination of simvastatin and gemfibrozil should be avoided because of an increased risk for myositis, myalgias, and rhabdomyolysis.

Which phrases accurately describe gemfibrozil's mechanism of action?

Inhibition of hepatic triglyceride synthesis Fibrates like gemfibrozil lower cholesterol in part by blocking the liver's synthesis of triglycerides. Suppression of free fatty acid release from adipose tissue Fibrates like gemfibrozil suppress free fatty acids being released from fat. Activation of peroxisome proliferator-activated receptor-alpha in the liver Fibrates like gemfibrozil activate peroxisome proliferator-activated receptor-alpha in the liver, which in turn enhances the synthesis of lipoprotein lipase, an enzyme responsible for the breakdown of cholesterol.

Which laboratory values will a nurse ensure are ordered for a patient as part of monitoring after a dosage adjustment of colesevelam?

Lipid panel A lipid panel, including low-density lipoprotein (LDL) cholesterol, high-density lipoprotein (HDL) cholesterol, triglycerides, and total cholesterol should be assessed in a patient who has been receiving colesevelam to monitor safety and efficacy. Liver enzymes Liver enzymes should be assessed for safety reasons after a dosage adjustment.

About which adverse effect will a nurse counsel a patient who is receiving colesevelam?

None; no adverse effects expected Because bile-acid sequestrants like colesevelam are not absorbed, they are not associated with any systemic effects. As such, adverse effects are not expected.

Based on its pharmacokinetic profile, which counseling point would a nurse provide a patient who has been prescribed gemfibrozil?

Take daily 30 minutes before meals. Gemfibrozil is typically dosed twice daily. It should be taken 30 minutes before meals because food can reduce the area under the curve, which is a measurement of the body's exposure to the drug.

A nurse receives a prescription for gemfibrozil for a patient who is also receiving cyclosporine (posttransplant) and amoxicillin (infection). What is the rationale for the nurse's intervention to contact the health care provider?

The combination of gemfibrozil and cyclosporine can cause nephrotoxicity. There is an increased risk for nephrotoxicity in patients receiving fibrates while taking cyclosporine. The patient will either need to be monitored closely or ideally switched to an alternative drug.