CH 37: ANTILIPEMICS
ezetimibe
(Zetia)- cholesterol absorption inhibitor
FLAX- indications
*Atherosclerosis, hypercholesterolemia, hypertriglyceridemia,* GI distress (especially constipation), menopausal Sx, bladder inflammation
When teaching the nursing student about coronary heart disease, which statement will the nurse include in the session? 1. "Coronary heart disease occurs due to the formation of atherosclerotic plaques." 2. "Coronary heart disease cannot be prevented by changing lifestyle modifications." 3. "Coronary heart disease is due to decreases in the cholesterol levels to below 200 mg/dL." 4. "Coronary heart disease is nonlethal and cannot be prevented by antilipemic medications."
1. "Coronary heart disease occurs due to the formation of atherosclerotic plaques." Coronary heart disease (CHD) occurs due to the formation of atherosclerotic plaques inside the walls of the coronary arteries. The risk of CHD also increases with an unhealthy lifestyle, which should be modified. Cholesterol levels above 200 mg/dL increase the risk for developing coronary artery disease. CHD is lethal and can be prevented by antilipemic medications that lower the serum cholesterol levels, if diagnosed early. Antilipemic therapy is used as primary prevention in patients with known risk factors for CHD.
The nurse provides teaching to a patient who will take atorvastatin at home. Which patient teaching is most likely to help maintain the antilipemic medication dosage at the lowest level possible? Lovaza 1. Take atorvastatin at bedtime. 2. Engage in moderate exercise. 3. Avoid all alcoholic beverages. 4. Adhere to the blood test schedule.
2. Engage in moderate exercise. The nurse instructs the patient to engage in moderate-intensity exercise to improve cardiovascular conditioning. Exercise helps increase metabolism and promote collateral circulation. Taking atorvastatin at bedtime, avoiding alcoholic beverages, and adhering to the blood test schedule all help manage adverse effects and aid in the early detection of serious adverse effects; however, these reasonable nursing interventions for patient teaching are less likely to affect the dosage of atorvastatin.
The nurse is caring for a patient who has undergone kidney transplantation. The patient's laboratory reports show hyperlipidemia. Which antihyperlipidemic drug would be most beneficial for the patient? 1. Fluvastatin 2. Cyclosporin 3. Colesevelam 4. Cholestyramine
3. Colesevelam Colesevelam is better tolerated by high-risk patients who have intolerance to other antilipemic medications. It can be prescribed for patients who have undergone organ transplantation or have serious liver or kidney disease. Fluvastatin is not used in patients who have had an organ transplantation, because it may increase the risk of rhabdomyolysis. Cyclosporin is an immunosuppressant drug, not an antihyperlipidemic drug. Cholestyramine is used for constipation and has more side effects than colesevelam; it is therefore not as beneficial as colesevelam.
A patient will be discharged to continue treatment with simvastatin. The nurse will teach the patient to report which symptom? 1. Fatigue 2. Headache 3. Muscle pain 4. Nausea and vomiting
3. Muscle pain Muscle pain must be reported because it could signify rhabdomyolysis, the uncommon but serious adverse effect that is associated with statin drugs like simvastatin. Fatigue, headache, and nausea and vomiting are also adverse effects of statin drugs, but they are generally not severe.
The nurse is teaching a medication regimen to a patient who has type II hyperlipoproteinemia and who has been prescribed cholestyramine. Of what will the nurse inform the patient during the teaching? 1. Include milk in the diet while taking this medication. 2. Avoid doing deep breathing exercises after taking the medication. 3.Avoid taking vitamin A supplements while taking the medication. 4. Take other medications 1 hour before the administration of cholestyramine.
4. Take other medications 1 hour before the administration of cholestyramine. Bile acid sequestrants such as cholestyramine should not be taken along with other medications because of reduced absorption. Other drugs must be taken at least 1 hour before or 4 to 6 hours after taking the bile acid sequestrant. Milk reduces peristalsis and is therefore not included in the diet. Cholestyramine does not impair pulmonary function, so the patient does not need to avoid practicing deep breathing exercises. Cholestyramine reduces the absorption of fat-soluble vitamins (A, D, E, K); therefore, to prevent a vitamin A deficiency, the nurse suggests that the patient take vitamin A supplements.
Gemfibrozil + oral anticoagulants
additive anticoagulant effect
fibric acid derivatives- DRUGS
gemfibrozil fenofibrate
fibric acid derivatives- CONTRAINDICATIONS
severe liver or kidney disease, cirrhosis, gallbladder disease
Patient groups to be treated with statin
• Clinical atherosclerotic cardiovascular disease (CVD) • LDL cholesterol levels >190 mg/dL • Diabetes who are 40 to 75 years of age with LDL levels 70 to 189 mg/dL and no evidence of CVD • No evidence of CVD or diabetes but who have LDL levels between 70 and 189 mg/dL and a 10-year risk for CVD >7.5%
FLAX- contraindications
Not recommended during pregnancy
statins + gemfibrozil
Potentiation- Increased risk for myopathy
hydroxymethylglutaryl-coenzyme A (HMG-CoA) reductase inhibitors- DRUGS
atorvastatin (Lipitor), fluvastatin (Lescol), lovastatin (Mevacor), pravastatin (Pravachol), simvastatin (Zocor), rosuvastatin (Crestor), and pitavastatin (Livalo)
bile acid sequestrants- CONTRAINDICATIONS
biliary or bowel obstruction phenylketonuria (PKU)
B vitamin niacin + statin
likelihood of myopathy development is increased
hydroxymethylglutaryl-coenzyme A (HMG-CoA) reductase inhibitors- CONTRAINDICATIONS
pregnancy, liver disease, liver enzyme elevation
GARLIC- pharmacology
(Allium sativum) Pharmacologic effects from the active ingredient allicin.
atorvastatin
(Lipitor)- Lowers total and LDL cholesterol levels, & triglyceride levels. Raises HDL levels. Dosed once daily, usually with the evening meal or at bedtime. Bedtime dosing provides peak drug levels in a time frame that correlates better with the natural diurnal (daytime) rhythm of cholesterol production in the body. Pregnancy category X
gemfibrozil
(Lopid)- decreases synthesis of apolipoprotein B and lowers VLDL. Also increases HDL. Effective for lowering plasma triglyceride levels. Tx of type IV and V hyperlipidemia, and, in some cases, type IIb.
cholestyramine
(Questran) INDICATIONS: pruritus associated with partial biliary obstruction
colesevelam
(Welchol)- may be better tolerated by higher-risk Pts who are intolerant of o/ antilipemic therapy: organ transplant recipients, liver/ kidney disease.
simvastatin
(Zocor)- Lowers total and LDL cholesterol levels, & triglyceride levels. Modestly raises HDL levels. Pregnancy category X CONTRAINDICATIONS: use w/ itraconazole, ketoconazole, posaconazole, erythromycin, clarithromycin, HIV protease inhibitors, nefazodone, femfibrozil, cyclosporine, danazol CAUTION: Don't start on 80 mg. Use w/ verapamil & diltiazem- don't exceed Simvastatin 10 mg. Use w/ amiodarone, amlodipine, ranolazine- don't exceed 20 mg.
fibric acid derivatives- ACTION
(fibrates)- Activates lipoprotein lipase, an enzyme responsible for the breakdown of cholesterol. This enzyme cleaves off a triglyceride molecule from VLDL or LDL, leaving behind lipoproteins. Also suppress the release of free fatty acid from adipose tissue, inhibit the synthesis of triglycerides in the liver, and increase the secretion of cholesterol into bile. Reduce triglyceride levels and serum VLDL and LDL concentrations. Can also induce changes in blood coagulation. This involves a tendency toward a decrease in platelet adhesiveness. Can also increase plasma fibrinolysis, the process that causes clots to be broken down.
hydroxymethylglutaryl-coenzyme A (HMG-CoA) reductase inhibitors- ACTION
(statins)- Lower blood cholesterol level by decreasing the rate of cholesterol production. The liver requires HMG-CoA reductase to produce cholesterol. The statins inhibit this enzyme. Liver increases the number of LDL receptors to recycle LDL from the circulation back into the liver.
B vitamin niacin- ACTION
(vitamin B3, nicotinic acid, Nicobid)- Inhibits lipolysis in adipose tissue, decreases esterification of triglycerides in the liver, and increases activity of lipoprotein lipase. Reduction of the metabolism or catabolism of cholesterol and triglycerides. May produce vasodilatation that is limited to the cutaneous vessels, induced by prostaglandins. Also causes the release of histamine, which results in an increase in gastric motility and acid secretion. May also stimulate the fibrinolytic system to break down fibrin clots.
ezetimibe- INDICATIONS
*Effective in reducing the risk for vascular events in Pts with moderate to severe chronic kidney disease.*
hydroxymethylglutaryl-coenzyme A (HMG-CoA) reductase inhibitors- INDICATIONS
*First-line drug therapy for hypercholesterolemia (especially elevated levels of LDL cholesterol), the most common & dangerous form of dyslipidemia.* Type IIa and IIb hyperlipidemia and have been shown to reduce the plasma concentrations of LDL by up to 50%. Cholesterol-lowering properties are dose dependent.
B vitamin niacin- ADVERSE EFFECTS
*Small doses of aspirin or nonsteroidal antiinflammatory drugs (NSAIDs) may be taken 30 minutes before the niacin dose to minimize the cutaneous flushing.* GI: Abdominal discomfort Integumentary: Cutaneous flushing, pruritus O/: Blurred vision, glucose intolerance, hepatotoxicity
A patient with a serum cholesterol level of 275 mg/dL is prescribed simvastatin. What instructions should the nurse provide to the patient? Select all that apply. 1. "Avoid taking the drug with grapefruit juice." 2. "Take aspirin 30 minutes before taking simvastatin." 3. "Notify your health care provider if your urine becomes discolored." 4. "Notify your health care provider if muscle pain occurs within 1 day." 5. "Notify your health care provider if muscle pain occurs after 3 days."
1. "Avoid taking the drug with grapefruit juice." 3. "Notify your health care provider if your urine becomes discolored." 5. "Notify your health care provider if muscle pain occurs after 3 days." Simvastatin is an HMG-CoA reductase inhibitor that causes rhabdomyolysis as an adverse effect. Grapefruit juice inhibits the enzyme CYP3A4 that is required for the metabolism of simvastatin. This will increase levels of the drug in the body, resulting in rhabdomyolysis. Rhabdomyolysis is associated with the breakdown of muscle proteins, which are excreted in the urine, changing the color of the urine. Simvastatin starts acting after 3 days of administration and can cause muscle pains. These should be reported to the health care provider, because the condition may progress to rhabdomyolysis if simvastatin administration is not stopped. Taking a small dose of aspirin is suggested before taking antilipemic drugs to reduce the incidence of cutaneous flushing. Muscle pain after 1 day may be due to some other cause and not the drug.
The nursing instructor is teaching nursing students about niacin therapy for the treatment of different types of hyperlipidemia. What will the nursing instructor include in this teaching? Select all that apply. 1. Always check the patient's medical history for gout. 2. Always check the patient's medical history for diabetes. 3. Always check the patient's white blood cell count before administering the drug. 4. It is always preferable to give the extended-release dosage form of the drug to the patient. 5. It is always preferable to give the sustained-release dosage form of the drug to the patient.
1. Always check the patient's medical history for gout. 2. Always check the patient's medical history for diabetes. 4. It is always preferable to give the extended-release dosage form of the drug to the patient. The nurse should check the patient's medical history for gout and diabetes, because these conditions may worsen with niacin therapy and should be avoided in such patients. Extended-release dosage forms dissolve more slowly than immediate-release forms, but faster than sustained-release forms. To minimize the adverse effect profiles of the medication, such as hepatotoxicity and flushing of the skin, an extended-dosage form of the drug must be given to the patient. Because the drug doesn't alter the number of leukocytes, it is not required to check the white blood cell count before administering the medication. Giving sustained-release dosage forms may not be as effective as extended-release dosage forms in preventing adverse effects of the drug.
A patient with hyperlipidemia is prescribed atorvastatin; however, the patient does not want to take a pill and prefers powder form. What alternative medication available in powder form would be most beneficial for the patient? 1. Colestipol 2. Fluvastatin 3. Colesevelam 4. Cholestyramine
1. Colestipol Colestipol is a bile acid sequestrant, also available in powder form. The patient must be instructed to mix the powder thoroughly with food or fluids (at least 4 to 6 ounces of fluid). This drug is considered second-line after the more potent statins. Fluvastatin and colesevelam are available only in tablet form and cannot be prescribed for the patient who has a fear of taking pills. Cholestyramine is also available in powder form, but it is not beneficial to the patient; it is used for relieving constipation.
The nurse would question an order for colesevelam if the patient has which condition in the medical history? 1. Impaction 2. Glaucoma 3. Renal disease 4. Hepatic disease
1. Impaction Colesevelam binds with bile in the intestinal tract to form an insoluble complex. It can also bind to other substances and lead to intestinal obstruction. Glaucoma, renal disease, and hepatic disease are not contraindications for taking colesevelam.
What are the common side effects of fenofibrate, a fibric acid derivative? Select all that apply. 1. Impotence 2. Constipation 3. Cutaneous flushing 4. Nausea and abdominal pain 5. Increase in gallstone formation
1. Impotence 4. Nausea and abdominal pain 5. Increase in gallstone formation Impotence, nausea, abdominal pain, and an increase in gallstone formation are the adverse effects produced by fenofibrate. Diarrhea, not constipation, is a common side effect of fibric acid derivatives. Cutaneous flushing is an adverse effect produced by niacin. Constipation and cutaneous flushing are not associated with fenofibrate.
When will the nurse administer hydroxymethylglutaryl-coenzyme A (HMG-CoA) reductase inhibitors (statins)? 1. In the evening 2. With breakfast 3. With an antacid 4. On an empty stomach
1. In the evening The liver produces the majority of cholesterol during the night. Thus, it is best to give HMG-CoA reductase inhibitors (statins), which work to decrease this synthesis, during the evening so that blood levels are highest coinciding with this production. Since the liver produces the majority of cholesterol during the night, the drug is not ideally given during breakfast. An antacid is generally given to prevent stomach upset. Because this drug has a tendency to elevate the liver enzyme level, it may not be advisable to take the drug on an empty stomach.
The primary health care provider prescribes niacin (nicotinic acid) for a patient who has hyperlipidemia. For what will the nurse assess while caring for this patient? 1. Symptoms of pruritus 2. Symptoms of muscle pain 3. Symptoms of constipation 4. Symptoms of nausea and vomiting
1. Symptoms of pruritus The nurse should monitor the patient for adverse effects of antilipemic drugs, such as abdominal discomfort, cutaneous flushing and pruritus. Muscle pain is the most serious adverse effect of statins. Constipation is an adverse effect produced by HMG-CoA reductase inhibitors and bile acid sequestrants. Nausea and vomiting are adverse effects of HMG-CoA reductase inhibitors and bile acid sequestrants.
The nurse is caring for a patient who has hyperlipidemia and who has been prescribed gemfibrozil. On reviewing the medical history of the patient, the nurse learns that the patient is taking warfarin. What does the nurse anticipate after reviewing the patient's medical history? 1. The patient has an increased risk of bleeding. 2. The patient has an increased risk of infection. 3. The patient has an increased risk of bowel obstruction. 4. The patient has an increased risk of vitamin K toxicity.
1. The patient has an increased risk of bleeding. Gemfibrozil can bind with vitamin K in the intestinal tract, reducing the absorption of vitamin K. Vitamin K is the antidote for warfarin, so the lack of vitamin K increases the anticoagulant effect of warfarin, causing an increased risk of bleeding. Hyperlipidemic drugs do not cause immune suppression; the patient would not have an increased risk of infection. There may be an increased risk of bowel obstruction when bile acid sequestrants bind to other substances in the intestinal tract, but not with this combination of drugs. Because the hyperlipidemic drug gemfibrozil reduces absorption of vitamin K, the patient may have a vitamin K deficiency rather than a vitamin K toxicity.
The nurse is assessing a patient with diabetes who has hyperlipidemia. The patient asks the nurse to suggest either an herbal medication or a dietary modification to reduce cholesterol levels. Which suggestion, given by the nurse would be most beneficial to the patient? 1. "Include flaxseeds in your food." 2. "Eat foods rich in omega-3 fatty acids." 3. "Consume excessive amounts of garlic." 4. "Take 20 mg of St. John's wort regularly."
2. "Eat foods rich in omega-3 fatty acids." The patient has diabetes and hyperlipidemia; therefore, the nurse should suggest that the patient include foods rich in omega-3 fatty acids, such as fish oil, in her diet. They are also available as fish oil products under the brand name Lovaza. This reduces cholesterol levels without altering blood glucose levels. Flax intake should not be suggested to a diabetic patient, because it may have potential hypoglycemic effects due to drug interactions. Garlic is contraindicated in diabetic patients; the nurse should not suggest that the patient eat an excessive amount of garlic. St. John's wort is an herb used to treat depression and the symptoms associated with depression, such as anxiety, loss of appetite, and insomnia. This is not helpful in reducing the cholesterol level.
The nurse teaches the nursing student about statin drugs. Which statements by the student indicate effective learning? Select all that apply. 1. "Statins can be used along with gemfibrozil." 2. "Fluvastatin with warfarin increases the risk of bleeding." 3. "Simvastatin is the least potent inhibitor of the CYP3A4 enzyme." 4. "Atorvastatin with cyclosporine decreases the risk of rhabdomyolysis." 5. "Pravastatin is not as effective as simvastatin for the inhibition of CYP3A4."
2. "Fluvastatin with warfarin increases the risk of bleeding." 5. "Pravastatin is not as effective as simvastatin for the inhibition of CYP3A4." Fluvastatin increases the risk of bleeding when taken along with warfarin. This effect is observed due to an increase in the concentration of warfarin in the presence of statins. Pravastatin inhibits CYP3A4 to a much lesser extent than simvastatin because it is less potent than other statins. Statins should not be taken along with gemfibrozil, because the combination increases the risk of rhabdomyolysis. Simvastatin is the most potent inhibitor of the CYP3A4 enzyme. Atorvastatin taken with cyclosporine increases the risk of rhabdomyolysis due to drug interaction.
A patient is receiving clofibrate. A careful adjustment of the dosage of warfarin is required for patients taking this medication because of the risk of which condition? 1. Clotting 2. Bleeding 3. Vitamin K toxicity 4. Deep vein thrombosis
2. Bleeding Clofibrate can bind with vitamin K in the intestinal tract, reducing vitamin K absorption. Because vitamin K is the antidote for warfarin, a lack of vitamin K increases the anticoagulant effect of warfarin and thus the risk for bleeding. Warfarin is an anticoagulant, so it will not increase the risk of clotting.
Which antilipemic medication reduces serum cholesterol by inhibiting its absorption in the small intestine? 1. Niacin 2. Ezetimibe 3. Rosuvastatin 4. Cholestyramine
2. Ezetimibe Ezetimibe, the only cholesterol absorption inhibitor on the U.S. market, is effective in lowering total cholesterol, low-density lipoprotein (LDL) cholesterol, apolipoprotein B, and triglyceride levels. Niacin is a vitamin administered in large doses to lower serum cholesterol levels. Rosuvastatin is a hydroxymethylglutaryl-coenzyme A (HMG-CoA) reductase inhibitor that lowers serum cholesterol levels. Cholestyramine is a bile acid sequestrant. Topics
Which are positive risk factors for coronary heart disease (CHD)? Select all that apply. 1. Blood pressure of 130/85 mm Hg 2. Family history of premature CHD 3. Blood pressure higher than 140/90 mm Hg 4. Serum triglyceride level of 150 mg/dL or more 5. High-density lipoprotein level of 60 mg/dL or higher
2. Family history of premature CHD 3. Blood pressure higher than 140/90 mm Hg The positive risk factors for CHD include a family history of premature CHD, such as myocardial infarction. The sudden death of a patient's father before 55 years of age, or the sudden death of the patient's mother before 65 years of age, also indicates a CHD risk. Hypertension is characterized by an increase in blood pressure, which may be higher than 140/90 mm Hg, indicating that the individual has a CHD risk. A blood pressure of 130/85 mm Hg and a serum triglyceride level of 150 mg/dL or more are identifying features of metabolic syndrome but are not risk factors for CHD. A high-density lipoprotein (HDL) cholesterol level of 60 mg/dL or higher is a negative risk factor for CHD.
A patient with hypercholesterolemia has been prescribed simvastatin. Which action should the nurse perform while caring for the patient? 1. Instruct the patient to take aspirin for pain relief. 2. Inform the patient that this drug may cause nausea. 3. Inform the patient that allergies are a side effect of the drug. 4. Instruct the patient to discontinue the drug in case of muscle pain.
2. Inform the patient that this drug may cause nausea. Patients who are treated with simvastatin may have adverse effects such as nausea, vomiting, and fever. The nurse should teach the patient about the possible adverse effects of the drug therapy and instruct him or her to immediately report any signs of toxicity, including muscle soreness, changes in urine color, fever, malaise, nausea, or vomiting. The nurse should not instruct the patient to administer aspirin for pain relief. Any pain should be reported, because it can indicate rhabdomyolysis, which may cause renal failure and even death. Simvastatin is contraindicated in patients with a known drug allergy. The nurse should not advise the patient to discontinue the medication without consulting the health care provider.
A patient is taking pravastatin sodium. Which assessment finding requires immediate action by the nurse? 1. Headache 2. Muscle pain 3. Constipation 4. Slight nausea
2. Muscle pain Patients who experience severe muscle pain while taking pravastatin sodium need to report the findings right away because this may be indicative of rhabdomyolysis, a muscle disintegration that can become fatal. Headache and nausea are not common side effects. Constipation is a possible adverse effect but does not warrant immediate action.
The nurse is assessing a patient who has hyperlipidemia and who is prescribed gemfibrozil. For which condition will the nurse assess in the patient before administering the drug? Select all that apply. 1. Muscle reflexes 2. Renal dysfunction 3. Gallbladder disease 4. Hepatic dysfunction 5. Level of consciousness
2. Renal dysfunction 3. Gallbladder disease 4. Hepatic dysfunction Gemfibrozil is contraindicated in patients with renal and hepatic dysfunction and in patients with gallbladder disease, because the drug can worsen these conditions. Muscular function and the level of consciousness are not affected by the drug; therefore, the nurse need not check these.
The nurse assesses a patient who has hyperlipidemia and who is on antihyperlipidemic therapy and informs the primary health care provider that the patient has keratomalacia. Which drug does the nurse expect to be included in the patient's treatment regimen? 1. Niacin 2. Retinol 3. Ezetimibe 4. Fluvastatin
2. Retinol Retinol is a vitamin A supplement. Absorption of fat-soluble vitamins such as A, D, E, and K is decreased upon long-term usage of antihyperlipidemics. A vitamin A deficiency causes keratomalacia; a vitamin A supplement like retinol must be included in the patient's prescription when treating keratomalacia. Ezetimibe, fluvastatin, and antilipemic drugs are antihyperlipidemic medications. These medications do not help prevent vitamin A deficiency and cannot be included in the patient's prescription. Niacin is a B vitamin.
An older adult patient with hypertension and hyperlipidemia who has been prescribed a statin medication comes for a follow-up visit after 4 months of therapy. The patient's lab reports show elevated blood cholesterol levels, and the urine examination reveals rhabdomyolysis. What could be the reasons for this condition? Select all that apply. 1. The patient is not responding to the treatment. 2. The patient is taking verapamil along with statins. 3. The patient is taking amiodarone along with statins. 4. The patient is eating fiber-rich food along with statins. 5. The patient is taking grapefruit juice along with statins.
2. The patient is taking verapamil along with statins. 3. The patient is taking amiodarone along with statins. 5. The patient is taking grapefruit juice along with statins. Verapamil, amiodarone, and grapefruit juice inhibit the metabolic protein CYP3A4 and thus decrease the metabolism of the statins. This leads to sustained blood levels of unmetabolized statins and rhabdomyolysis. Because statins are not metabolized completely, less of the drug is available in the patient to decrease the blood cholesterol levels; the patient still shows elevated blood cholesterol levels with rhabdomyolysis. Statins are highly effective in reducing cholesterol levels, and it is unlikely that the patient is not responding to the therapy. Fiber intake does not affect the metabolic protein CYP3A4. It is unlikely that these symptoms are caused by the intake of fiber-rich food.
Laboratory reports indicate that a patient's serum cholesterol concentration is 250 mg/dL and triglyceride levels are 450 mg/dL. The health care provider prescribes gemfibrozil to lower cholesterol levels. What is the desired effect of the drug on the patient's lipoprotein levels? 1. There would be a decrease in low-density lipoprotein (LDL) levels. 2. There would be an increase in low-density lipoprotein (LDL) levels. 3. There would be a decrease in high-density lipoprotein (HDL) levels. 4. There would be an increase in very-low-density lipoprotein (VLDL) levels.
2. There would be an increase in low-density lipoprotein (LDL) levels. The serum cholesterol level of 250 mg/dL and the triglyceride levels of 450 mg/dL indicate that the patient has type IV hyperlipidemia. These patients have elevated VLDL levels. Gemfibrozil activates the enzyme lipoprotein lipase, an enzyme responsible for the breakdown of cholesterol. This drug decreases the very-low-density lipoproteins and increases the levels of LDL. A decrease in LDL levels occurs upon further continuation of the drug. Gemfibrozil increases HDL levels by converting LDL to HDL. However, in this case HDL remains unchanged at the time of serum test. The serum levels of VLDL are decreased by gemfibrozil due to the activation of the enzyme lipoprotein lipase, which converts VLDL to LDL.
The nurse is caring for a patient who has hypercholesterolemia and who has been prescribed atorvastatin. Which instruction will the nurse receive from the primary healthcare provider for the safe administration of the medication? 1. "Administer 2 mg of atorvastatin orally." 2. "Administer 60 mg of atorvastatin orally." 3. "Administer 10 mg of atorvastatin orally." 4. "Administer 40 mg of atorvastatin orally."
3. "Administer 10 mg of atorvastatin orally." The nurse should ensure safe administration of medication by educating the patient on taking the right dose as prescribed. To provide effective treatment, the primary healthcare provider would instruct the nurse to administer 10 mg of atorvastatin orally. The oral administration of 2 mg of atorvastatin may not be effective due to lower concentration of drug at the site of action. The oral administration of 60 mg and 40 mg of atorvastatin may lead to adverse effects due to overdosage of the drug.
Which statement made by the patient indicates an understanding of discharge instructions on antihyperlipidemic medications? 1. "I will stop taking the medication if it causes nausea and vomiting." 2. "It is important to double my dose if I miss one in order to maintain therapeutic blood levels." 3. "I will continue my exercise program to help increase my high-density lipoprotein serum levels." 4. "Antihyperlipidemic medications will replace the other interventions I have tried to decrease my cholesterol."
3. "I will continue my exercise program to help increase my high-density lipoprotein serum levels." Antihyperlipidemic medications are an addition to, not a replacement for, the therapeutic regimen used to decrease serum cholesterol levels. Patients should not stop taking the medication without consulting the provider. The dose should never be doubled if one is missed or stopped because of side effects.
The nurse plans which intervention to decrease flushing associated with niacin? 1. Administer niacin with an antacid. 2. Apply cold compresses to the head and neck. 3. Administer aspirin 30 minutes before nicotinic acid. 4. Administer diphenhydramine hydrochloride with the niacin.
3. Administer aspirin 30 minutes before nicotinic acid. Administration of an antiinflammatory agent such as aspirin has been shown to decrease the flushing reaction associated with niacin. Antacids do not prevent cutaneous flushing. Applying cold compresses to the patient's head and neck may not diminish flushing. H1 antagonists, including drugs such as diphenhydramine hydrochloride, are of greatest value in the treatment of nasal allergies, particularly seasonal hay fever.
On assessment of a patient with hyperlipidemia, the nurse learns that the patient has recently undergone a liver transplantation. Which antihyperlipidemic drug does the nurse expect to be excluded from the patient's prescription? 1. Ezetimibe 2. Gemfibrozil 3. Atorvastatin 4. Cholestyramine
3. Atorvastatin The patient who has undergone organ transplantation uses immunosuppressants such as cyclosporine to minimize graft rejection. Antihyperlipidemic drugs such as atorvastatin interact with the immunosuppressants like cyclosporine and increase the risk of myopathy. Atorvastatin should not be prescribed to the patient. Ezetimibe is a cholesterol absorption inhibitor, gemfibrozil is a fibric acid derivative, and cholestyramine is a bile acid sequestrant. These medications can be given to the patient who has undergone an organ transplant because these drugs do not cause serious side effects; nor do they interact with the immunosuppressant.
The nurse is caring for a patient who has elevated triglyceride levels and is unresponsive to HMG-CoA reductase inhibitors. What does the nurse expect the primary health care provider to prescribe to the patient? 1. Colestipol 2. Simvastatin 3. Gemfibrozil 4. Cholestyramine
3. Gemfibrozil Gemfibrozil can be prescribed to the patient, because it promotes catabolism of triglycerides and is highly effective in lowering plasma triglyceride levels. Colestipol lowers the cholesterol level, in particular the LDL cholesterol level, by increasing the destruction of LDL; it is not as effective as statins. Simvastatin is used primarily to lower total and LDL cholesterol levels as well as triglyceride levels. It cannot be used in the patient, because the patient is unresponsive to statins. Cholestyramine lowers the cholesterol level, in particular the LDL cholesterol level. It is used for constipation.
Before the nurse administers simvastatin, which baseline data are collected to help prevent adverse effects of therapy? Select all that apply. 1. Uric acid 2. Potassium 3. Muscle pain 4. Renal function 5. Liver enzymes 6. Gastric distress
3. Muscle pain 4. Renal function 5. Liver enzymes 6. Gastric distress Simvastatin is a hydroxymethylglutaryl-coenzyme A (HMG-CoA) reductase inhibitor, or statin, which is used to decrease the serum low-density lipoprotein cholesterol by decreasing its synthesis in the liver. The nurse checks the patient for muscle pain and assesses renal function, because serious adverse effects of therapy involving the muscles can result in renal dysfunction. The nurse assesses the liver enzymes, because adverse effects of statin therapy include myositis, rhabdomyolysis, and liver dysfunction. Gastric distress is also assessed to establish baseline data about nausea and vomiting, which are potential adverse effects of a statin. Assessments of the serum uric acid and serum potassium levels are reasonable nursing interventions before the administration of medication; however, these parameters are unrelated to the adverse effects of statin therapy.
A patient with metabolic syndrome requires antilipemic therapy after a myocardial infarction. Which antilipemic medication is the best choice to reach this patient's treatment goals? 1. Ezetimibe 2. Pravastatin 3. Nicotinic acid 4. Cholestyramine
3. Nicotinic acid Metabolic syndrome is a set of risk factors that includes hypertriglyceridemia and a low concentration of high-density lipoprotein. Nicotinic acid is the best choice to decrease serum triglyceride levels and to increase HDL levels in this patient because it decreases triglycerides by 30% to 70% and increases HDLs by 20% to 35%. The only antilipemic agent that affects the triglycerides and HDLs more favorably than nicotinic acid is a fibric acid derivative such as gemfibrozil. Ezetimibe and pravastatin are indicated to lower serum concentrations of triglycerides and low-density lipoprotein (LDL) cholesterol. Cholestyramine is indicated to reduce the serum LDL cholesterol level but is likely to increase serum triglyceride levels.
A patient with hyperlipidemia is treated with atorvastatin. On the follow-up visit, the nurse discovers that the patient has had no improvement in cholesterol levels. What could be the reason for this? 1. The patient has a history of rhabdomyolysis. 2. The patient took atorvastatin with gemfibrozil. 3. The patient is taking the medication in the morning. 4. The patient consumed more than 8 ounces of grapefruit juice per day.
3. The patient is taking the medication in the morning. Patients who take statins such as atorvastatin should be taught to take the medication in the evening to get the best effects. The drug increases the risk of rhabdomyolysis, but having a history of this disorder does not cause the drug to be ineffective. The use of gemfibrozil and statins together is not recommended due to increased risk for rhabdomylosis, not increasing cholesterol levels. Grapefruit juice increases the risk of rhabdomyolysis, but only if more than 1 quart per day is taken. Topics
The nurse is assessing a patient who is receiving antilipemic drug therapy. After 3 weeks of treatment, the nurse finds decreased levels of cognition, learning dysfunction, and behavioral changes in the patient. What does the nurse infer from this observation? Select all that apply. 1. The patient is treated with gemfibrozil drug therapy. 2. The patient has a previous history of diabetes mellitus. 3. The patient is treated with cholestyramine drug therapy. 4. The patient has a previous history of phenylketonuria (PKU). 5. The patient has consumed excess grapefruit juice with the medications
3. The patient is treated with cholestyramine drug therapy. 4. The patient has a previous history of phenylketonuria (PKU). The aspartame in the oral cholestyramine contains phenylalanine, which further increases the production of amino acid phenylalanine in phenylketonuria patients. As a result, high levels of this amino acid are converted into tyrosine in the body, affecting the central nervous system and resulting in decreased cognition, learning dysfunction, and behavioral changes. The patient is not on gemfibrozil drug therapy; it doesn't affect the central nervous system (CNS). Increased blood sugar does not cause the symptoms reported by the patient. If the patient on statin antilipemic drug therapy had consumed excess grapefruit juice, the result might have been muscle pain that progressed to rhabdomyolysis.
The nurse is teaching a group of nursing students about statin drugs and asks about the mechanism of action of lovastatin. Which response from the students indicates effective learning? 1. "It inhibits the absorption of dietary cholesterol in the small intestine." 2. "It stimulates the biliary system to increase the excretion of dietary cholesterol." 3. "It binds to bile in the intestinal tract, forming an insoluble complex that is excreted in the feces." 4. "It inhibits hydroxymethylglutaryl-coenzyme A (HMG-CoA) reductase to reduce the biosynthesis of cholesterol in the liver."
4. "It inhibits hydroxymethylglutaryl-coenzyme A (HMG-CoA) reductase to reduce the biosynthesis of cholesterol in the liver." Lovastatin is an HMG-CoA reductase inhibitor, decreasing the synthesis of cholesterol in the liver. Lovastatin does not inhibit the absorption of dietary cholesterol in the small intestine. Lovastatin does not stimulate the biliary system to increase the excretion of dietary cholesterol. Bile acid sequestrants bind bile and prevent the resorption of the bile acids from the small intestine.
The nurse knows that simvastatin exerts its action by doing what? 1. By inhibiting lipolysis in the adipose tissue 2. By activating the lipoprotein lipase enzyme 3. By preventing the reabsorption of bile acids 4. By inhibiting the enzyme HMG-CoA reductase
4. By inhibiting the enzyme HMG-CoA reductase Simvastatin exerts its action by inhibiting the enzyme HMG-CoA reductase, reducing the rate of cholesterol production. Antilipemic drugs are known to inhibit lipolysis in the adipose tissue, decrease esterification of the triglycerides in the liver, and increase the activity of lipoprotein lipase. Fibric acid drugs are believed to work by activating the lipoprotein lipase, an enzyme responsible for the breakdown of cholesterol. Bile acid sequestrants bind to bile salts and prevent the resorption of bile acids from the small intestine.
A patient with dyslipidemia has been prescribed atorvastatin. After a few days, the patient reports to the nurse that her pregnancy test is positive and that she has severe constipation. What medication does the nurse expect the provider to order for the patient? 1. Ezetimibe 2. Simvastatin 3. Cholestyramine 4. Niacin (nicotinic acid)
4. Niacin (nicotinic acid) The health care provider prescribes niacin (nicotinic acid), because it is not only a unique lipid-lowering drug but also a vitamin. It is a pregnancy A category drug; these are safe to use during pregnancy and do not produce any side effects such as constipation. Niacin (nicotinic acid) intake should not exceed the recommended dose. Ezetimibe and simvastatin are X category drugs and should not be used during pregnancy, because they have teratogenic effects and are embryocidal. Cholestyramine is used to relieve constipation, but it is a C category drug, which means that the drug has potential for teratogenicity.
ezetimibe- CONTRAINDICATIONS
Active liver disease, unexplained liver enzyme elevations.
FLAX- interactions
Antidiabetic & anticoagulant drugs
GARLIC- indications
Antispasmodic, antiseptic, antibacterial and antiviral, antihypertensive, antiplatelet, *lipid reducer*
bile acid sequestrants- ACTION
Bind bile & prevent resorption of bile acids from the small intestine. Insoluble bile acid & resin (drug) complex is formed & then excreted in BM. Bile acids are necessary for absorption of cholesterol from the small intestine & are also synthesized from cholesterol by liver. One natural way that the liver excretes cholesterol from the body. Reduces level of cholesterol in the liver & circulation as well.
hydroxymethylglutaryl-coenzyme A (HMG-CoA) reductase inhibitors- ADVERSE EFFECTS
CNS: Headache, dizziness, blurred vision, fatigue, insomnia GI: Constipation, diarrhea, nausea O/: Myalgias, skin rashes
OMEGA-3 FATTY ACIDS- indications
Cholesterol reduction
gemfibrozil- LAB INTERACTIONS
Decrease Hgb, Hct, WBC. Increase aspartate aminotransferase, lactate dehydrogenase, & bilirubin levels; activated clotting time.
Ezetimibe + bile acid sequestrants
Decreased serum ezetimibe.
GARLIC- adverse effects
Dermatitis, vomiting, diarrhea, anorexia, flatulence, antiplatelet activity
FLAX- adverse effects
Diarrhea, allergic reactions
bile acid sequestrants- INTERACTIONS
Effects absorption of concurrently administered drugs. *All drugs must be taken at least 1 hour before or 4-6 hours after administration of bile acid sequestrants.* High doses of a bile acid sequestrant decrease absorption of fat-soluble vitamins (A, D, E, and K).
OMEGA-3 FATTY ACIDS
Essential fatty acids, most commonly supplied as fish oil products. Several OTC products are available, as well as a Rx product, known as Lovaza.
FLAX- pharmacology
Flowering annual found in Europe, Canada, and the U.S. Both the seed and the oil of the plant are used medicinally.
bile acid sequestrants- ADVERSE EFFECTS
GI: Constipation, nausea, belching, bloating O/: HA, tinnitus, burnt odor of urine
fibric acid derivatives- ADVERSE EFFECTS
GI: N/V/D, gallstones GU: Impotence, decreased urine output, hematuria O/: Drowsiness, dizziness, rash, pruritus, vertigo, headache, blurred vision, prolonged PTT. Increased liver enzyme levels.
gemfibrozil or fenofibrate + statin
Increased risk of myositis, myalgias, rhabdomyolysis
Ezetimibe + fibrates
Increased serum ezetimibe.
fenofibrate + ezetimibe
Increased serum levels of ezetimibe
statins + erythromycin, azole antifungals, quinidine, verapamil, amiodarone, *grapefruit juice,* HIV and hepatitis C protease inhibitors, cyclosporine, clarithromycin, diltiazem, amlodipine
Inhibit statin metabolism- increased risk for myopathy
statins + warfarin
Inhibit warfarin metabolism- increased risk for bleeding
Hyperlipidemia: Phenotype I
Lipoprotein elevated: Chylomicrons Cholesterol (mg/dL): >/= 300 Triglyceride: > 3000
Hyperlipidemia: Phenotype III
Lipoprotein elevated: IDL Cholesterol (mg/dL): > 400 Triglyceride: > 600 (1-3 times higher than cholesterol)
Hyperlipidemia: Phenotype IIa
Lipoprotein elevated: LDL Cholesterol (mg/dL): >/= 300 Triglyceride: Normal ≃ 148
Hyperlipidemia: Phenotype IIb
Lipoprotein elevated: LDL, VLDL Cholesterol (mg/dL): > 300 Triglyceride: Normal ≃ 148
Hyperlipidemia: Phenotype IV
Lipoprotein elevated: VLDL Cholesterol (mg/dL): Normal or mildly elevated, ≃ 250 Triglyceride: > 400
Hyperlipidemia: Phenotype V
Lipoprotein elevated: VLDL, chylomicrons Cholesterol (mg/dL): > 300 Triglyceride: > 2000
Niacin- drug info
Liver dysfunction observed in individuals taking sustained-release forms of niacin, but not immediate-release forms. Extended-release dosage forms, which dissolve more slowly than the immediate-release but faster than the sustained-release forms, appear to have better adverse effect profiles. Not recommended for patients with gout.
OMEGA-3 FATTY ACIDS- contraindications
Pregnancy (more information is needed), allergy to fish oil
OMEGA-3 FATTY ACIDS- adverse effects
Rash, burping, allergic reactions, possible increase in total cholesterol or LDL levels in Pts with a combined hyperlipidemia, Wt gain
bile acid sequestrants- INDICATIONS
Second-line drugs after the more potent statins. Suitable alternatives for patients intolerant of statins. Primary or adjunct drug therapy for type II hyperlipoproteinemia. Type IIa & IIb hyperlipidemia. Common to use w/ statins for additive effect in reducing LDL cholesterol levels.
ezetimibe- ACTION
Selectively inhibits absorption of cholesterol and related sterols in the small intestine. Reduces total cholesterol, LDL cholesterol, apolipoprotein B, & triglyceride. Increases HDL. *Beneficial effects of ezetimibe appear to be further enhanced when given with a statin drug.* Ezetimibe may also be used as monotherapy.
Metabolic syndrome
Set of risk factors associated with development of CVD • Waist circumference > 40" in men or 35" in women • Serum triglyceride level of 150 mg/dL or more • HDL cholesterol level of < 40 mg/dL in men or < 50 mg/dL in women • BP of 130/85 mm Hg or higher • Fasting serum glucose level > 100 mg/dL
GARLIC- contraindications
Surgery within 2 weeks HIV, diabetes
OMEGA-3 FATTY ACIDS- interactions
Theoretical risk of increased bleeding with anticoagulant drugs, but the studies to date are inconclusive.
fibric acid derivatives- INDICATIONS
Type III, IV, V hyperlipidemia. In some cases type IIb form, although other classes of antilipemics are usually tried first. The latest guidelines no longer recommend routine use of fibrates as first-line drugs.
B vitamin niacin- INDICATIONS
Used to lower lipid levels- triglyceride, total serum cholesterol, LDL. Increases HDL cholesterol levels. May also lower levels of lipoprotein(a), except in patients with severe hypertriglyceridemia. Treatment of type IIa, IIb, III, IV, and V hyperlipidemia.
GARLIC- interactions
Warfarin, diazepam, protease inhibitors. Use with NSAIDs may enhance bleeding. Possible interference with hypoglycemic therapy.
1. A nurse administering niacin would implement which action to help to reduce adverse effects? a. Give the medication with grapefruit juice. b. Administer a small dose of aspirin or an NSAID 30 minutes before the niacin dose. c. Administer the medication on an empty stomach. d. Have the patient increase dietary fiber intake.
b. Administer a small dose of aspirin or an NSAID 30 minutes before the niacin dose.
bile acid sequestrants- DRUGS
cholestyramine colestipol colesevelam
B vitamin niacin- CONTRAINDICATIONS
liver disease, peptic ulcer, presence of any active hemorrhagic process
