Chapter 50 - Prophylaxis of Atherosclerotic Cardiovascular Disease: Drugs That Help Normalize Cholesterol and Triglyceride Levels

What is a drug interaction associated with gemfibrozil (Lopid)?

-displaces warfarin from plasma albumin

What is a generic of a Fibrate?

gemfibrozil

What are the most effective drugs for lowering LDLs?

HMG-CoA Reductase Inhibitors (statins)

HMG-CoA Reductase Inhibitors are also called what?

Statins

Atherosclerosis

Thickening of the coronary arteries

______ is now considered primarily a chronic inflammatory process.

atherogenesis

High-Density Lipoproteins (HDLs) promote what?

cholesterol transport back to the liver

If food comes from ____, it has cholesterol.

an animal.

How do Fibric Acid Derivatives affect HDL and LDL cholesterol?

-Can raise HDL -Little or no effect on LDL

What are the kinds of drugs used to treat atherosclerotic cardiovascular diseases?

-HMG-CoA reductase inhibitors (statins) -Nicotinic acid (niacin) -Fibrates (reduce levels of TGs, not LDLs)

What are the common adverse effects of HMG-CoA Reductase Inhibitors (statins)?

-Headache -Rash -GI Distrubances

What are the therapeutic uses of HMG-CoA Reductase Inhibitors (statins)?

-Hypercholesterolemia -Primary and secondary prevention of CV events -Post-MI (myocardial infarction) therapy -Diabetes -Potential uses

What are some drug interactions to look out for when using HMG-CoA Reductase Inhibitors (statins)?

-Most other lipid-lowering drugs (except bile acid sequestrants) -Drugs that inhibit CYP3A4 (enzyme for metabolism in liver) -NEVER use in pregnancy -Grapefruit or grapefruit juice

What are the rare adverse effects of HMG-CoA Reductase Inhibitors (statins)?

-Myopathy(weakness and pain)/rhabdomyolysis(muscle breakdown) -Hepatotoxicity -New-onset diabetes -Cataracts

What are the therapeutic uses for gemfibrozil (Lopid)?

-Reduces high levels of plasma triglycerides (VLDLs) -Treatment reserved for patients who have not responded to diet modification -Less effective than statins in reducing LDL -Can raise HDL

What are the "lipid beneficial" cardiovascular actions of HMG-CoA Reductase Inhibitors (statins)?

-Reduction of LDL cholesterol -Elevation of HDL cholesterol -Reduction of triglyceride levels

How does gemfibrozil (Lopid) affect plasma lipoproteins?

-decreases plasma TG content -Can raise HDL cholesterol

What are some risk factors for developing CHD (Coronary heart disease)?

-diabetes -atherosclerotic disease other than CHD -Framingham risk score greater than 20% page 562

What are the adverse effects of Nicotinic Acid (Niacin)?

-flushing/itching of the skin -gastrointestinal -hepatotoxicity -hyperglycemia -gouty arthritis -can raise blood levels of uric acid

What are some clinical symptoms of Metabolic syndrome (Syndrome X)?

-high blood glucose -high triglycerides (levels above 150mg/dL)*** -Low HDL cholesterol -Small LDL particles -Prothrombotic state -Proinflammatory state -Hypertension

What are the "nonlipid beneficial" cardiovascular actions of HMG-CoA Reductase Inhibitors (statins).

-promote plaque stability -reduce the risk of cardiovascular (CV) events -increased bone formation

What are some adverse effects of gemfibrozil (Lopid)?

-rashes -gastrointestinal disturbances -gallstones -myopathy -liver injury (hepatotoxic)

What are some therapeutic lifestyle changes for the treatment of a high-LDL cholesterol level?

-smoking cessation -diet changes (less red meat) -exercise

What level of triglycerides (TGs) is desirable?

150mg/dL or less.

HDLs account for how much of the cholesterol content in our bodies?

20% to 30%

All adults older than 20 years should be screened every __ years for total cholesterol, LDL cholesterol, HDL cholesterol, and TGs.

5 years

LDLs account for how much of the cholesterol content in our bodies?

60% to 70%

What level of HDL cholesterol is optimal?

60mg/dL or more is optimal

What is Nicotinic Acid also known as?

Niacin

What is the mechanism of action for gemfibrozil (Lopid)?

Appears to interact with a specific receptor subtype (PPAR alpha)

When should you administer an HMG-CoA Reductase Inhibitor (statin)?

At night

LDLs initiate and fuel development of ______.

Atherosclerosis

What is the component of all cell membranes and membranes of intracellular organelles?

Cholesterol

We're concerned with Atherosclerosis and ASCVD because why?

Damage to the vessels impacted by either Atherosclerosis or ASCVD can result in a myocardial infarction (MI), aka, a heart attack.

What is another name for Fibric Acid Derivatives?

Fibrates

What is the most effective drug available for lowering TG levels?

Fibric Acid Derivatives

Of all lipoproteins, which ones make the greatest contribution to coronary heart disease (CHD)?

LDLs (Low-Density Lipoproteins)

What is a trade/brand name drug of gemfibrozil?

Lopid

Where is cholesterol produced?

Manufactured by cells primarily in the liver

What drug increases HDL levels more effectively than any other drug?

Nicotinic Acid

Which discharge instructions should the nurse include for a patient prescribed cholestyramine [Questran]? A) Mix the drug with water or juice. B) Take with all other morning medications. C) Take 325 mg of aspirin 30 minutes before each dose. D) Notify the healthcare provider if upper abdominal discomfort occurs.

The answer is A. Cholestyramine [Questran] is supplied in powdered form. Mix the powder with liquids that include water, fruit juices, and soups because swallowing it can cause esophageal irritation. Certain oral medications should be administrated 1 hour before the sequestrant or 4 hours after. Flushing can occur with niacin and can be reduced by taking 325 mg of aspirin 30 minutes before each dose. Gemfibrozil and fenofibrate increase the risk of gallstones manifested with symptoms such as upper abdominal discomfort.

Which drug is the most effective for lowering LDL cholesterol? A) Atorvastatin [Lipitor] B) Cholestyramine [Questran] C) Gemfibrozil [Lopid] D) Ezetimibe [Zetia]

The answer is A. The statin drugs, such as atorvastatin, are the most effective drugs for lowering LDL cholesterol. They are better tolerated, have fewer adverse effects, and produce better clinical outcomes than any other agents available for lowering LDL.

The nurse will teach a patient who is prescribed niacin (Niacor) to prevent flushing of the face by doing what? A) Drinking a full glass of water after taking the medication B) Taking 325mg of aspirin 30 minutes before each dose C) Ingesting a meal before taking the medication D) Increasing dietary fiber before and after each dose

The answer is B, takin 325mg of aspirin 30 minutes before each dose. Aspirin reduces flushing preventing the synthesis of prostaglandins, which mediate the flushing response.

A patient is prescribed lovastatin (Mevacor). The nurse will teach the patient to take the medication at which time? A) With any meal B) With the evening meal C) 1 hour before breakfast D) 2 hours after a meal

The answer is B, with the evening meal. Lovastatin should be taken with the evening meal to increase absorption. Cholesterol synthesis normally takes place at night; statins are most effective when given in the evening.

The nurse is caring for a patient prescribed a cholesterol-lowering drug. Which drug is least likely to cause systemic side effects? A) Simvastatin [Zocor] B) Colesevelam [Welchol] C) Nicotinic acid [Niaspan] D) Gemfibrozil [Lopid]

The answer is B. Colesevelam, a bile acid sequestrant, is a nonabsorbable resin that works directly in the gastrointestinal tract. Because it and other bile acid sequestrants (eg, cholestyramine [Questran] and colestipol [Colestid]) are not absorbed, they do not have systemic effects. The bile acid sequestrants' most common complication is constipation. The other agents have potential systemic adverse effects.

The nurse is teaching a group of patients about dietary approaches to reduce cholesterol levels. Which statement is most important to include in the teaching? A) "Lower your cholesterol to 300 mg/day." B) "Eliminate red meat and pork from your diet." C) "Read food labels and reduce your intake of saturated fats." D) "Reduce salt consumption to keep your sodium intake to 2400 mg/day."

The answer is C. An increase in dietary cholesterol intake does not produce a large increase in blood cholesterol because of the body's feedback system. When cholesterol intake increases, endogenous production decreases. However, because the body uses dietary saturated fats to make cholesterol, an increase in saturated fat intake can produce a significant increase in blood cholesterol levels. To lower blood cholesterol, it is most important to lower saturated fat intake. Although red meat and pork should be limited, it is not necessary to eliminate them from the diet. Sodium intake is not directly related to lowering cholesterol levels.

The nurse understands that cholesterol is carried through the blood by lipoproteins. Which lipoprotein is most closely associated with coronary atherosclerosis? A) Very-low-density lipoprotein (VLDL) B) Apolipoprotein B-100 C) Low-density lipoprotein (LDL) D) High-density lipoprotein (HDL)

The answer is C. Cholesterol is the primary core lipid of LDLs, which are responsible for carrying cholesterol to tissues outside the liver. Of all the lipoproteins, LDLs are the most significant contributors to coronary atherosclerosis. When pharmacologic agents are used to lower cholesterol, the primary goal is to reduce elevated LDL levels.

A patient with an elevated triglyceride level is prescribed a sustained-release form of nicotinic acid [Slo-Niacin]. Which laboratory value is most important for the nurse to monitor for in this patient? A) Blood urea nitrogen (BUN) B) Complete blood count (CBC) C) Alanine aminotransferase (ALT) D) Creatine kinase (CK)

The answer is C. The alanine aminotransferase (ALT or SGPT) would receive priority, because nicotinic acid is hepatotoxic and severe liver injury has been reported. Hepatotoxicity is more common with the sustained-release, controlled-release, or timed-released formulation.

The nurse is caring for a patient prescribed gemfibrozil [Lopid]. For which patient should the nurse question the use of this drug? A) A patient with cardiovascular disease and elevated triglycerides B) A patient with elevated very-low-density lipoprotein (VLDL) levels C) A patient with elevated triglycerides who has not responded to dietary changes D) A patient with history of gallstones and elevated triglycerides

The answer is D. Gemfibrozil is indicated to reduce elevated triglycerides and very-low-density lipoprotein levels primarily in patients who have not responded adequately to diet modification. It can also raise HDL but does not reduce LDL to a significant degree. Gemfibrozil increases the risk of gallstone formation and should not be used in patients with preexisting gallbladder disease.

A patient with cardiovascular disease is taking rosuvastatin [Crestor]. The nurse is monitoring for potential adverse effects. Which finding indicates a potential adverse effect of this drug? A) Blood pressure of 140/90 mm Hg B) Wheezing and shortness of breath C) Platelet count of 100 × 103/mm3 D) Muscle pain and tenderness

The answer is D. The statins typically are well tolerated; however, in rare cases they can cause the serious adverse effect of myopathy and rhabdomyolysis. If unexplained muscle pain and tenderness develop, the prescriber should be notified. The other effects would not likely be caused by rosuvastatin.

Which are beneficial effects that can be derived from simvastatin [Zocor] and other drugs in this class? (Select all that apply.) A) Reduction of LDLs B) Elevation of HDLs C) Stabilization of the plaque in coronary arteries D) Reduction of risk of cardiovascular events E) Improvement of liver function

The correct choices are A, B, C, D. The statin drugs have many benefits, the most important being reduction of LDLs. They also promote an increase in HDLs, stabilization of atherosclerotic plaque, and reduced inflammation at the plaque site. Among other benefits, they also slow progression of coronary artery calcification. The statins reduce the overall risk of cardiovascular events. They can have serious adverse effects on the liver, but these are relatively rare.

Nicotinic Acid (Niacin) is which vitamin?

Vitamin B3

The healthcare provider prescribes lovastatin [Mevacor] for a patient discharged from the hospital post-myocardial infarction. Which instructions are most appropriate for the nurse to include in the patient's teaching plan? (Select all that apply.) A) "Do not start any new medications without first talking to your healthcare provider." B) "Before starting this medication a blood test will be done to check your total cholesterol level and to measure liver enzymes." C) "Take your medication in the morning, with a full glass of water for best results." D) "Take one 325-mg aspirin 30 minutes before your dose to lessen the problem of flushing and itching that can occur with this drug." E) "Lower the total fat and saturated fat in your diet by increasing your intake of fresh fruits and vegetables and whole grains."

The correct choices are A, B, E. Lovastatin, simvastatin, and atorvastatin levels may be elevated when these drugs are combined with other drugs that inhibit CYP3A4. If these drugs are combined, caution is warranted. Before starting a statin, obtain a baseline lipid profile that includes total cholesterol and obtain baseline LFTs. The statins are taken once daily with food. It is recommended to take them with the evening meal because endogenous cholesterol synthesis increases during the night. The statins do not typically cause flushing and itching; that effect occurs with niacin. A diet low in total fat and saturated fat is recommended when antilipemic drugs are prescribed.

Atherosclerotic Cardiovascular Disease (ASCVD)

Thickening of the coronary arteries, vessels of the heart, as well as the brain.

What is the main goal of cholesterol-lowering drugs?

To reduce elevated LDL levels

What level of LDL cholesterol is optimal?

less than 100mg/dL is desirable.

Fibric Acid Derivatives (Fibrates) can increase the risk of what in patients taking statins?

rhabdomyolysis

Lipoproteins

structures that transport lipids (cholesterol and triglycerides [TGs] in blood)

Fibric Acid Derivatives (Fibrates) can increase the risk for bleeding in patients taking what?

warfarin (a blood thinner)