Chapter 47: Lipid-Lowering Agents
An older adult client's most recent physical assessment and diagnostic workup reveal the presence of dyslipidemia. The client is a candidate for monotherapy with a statin, and she will soon begin treatment with atorvastatin. The nurse should anticipate what prescription from the health care provider?
"Atorvastatin 10 mg PO daily" Explanation: Atorvastatin is normally administered PO 10 to 80 mg daily in a single dose. The other options present twice or thrice daily administration and total dosages of 150 mg or 300 mg.
A client who is receiving cholestyramine also takes digoxin. The nurse teaches the client about the drug and administration. The client demonstrates understanding of the teaching when stating:
"I will take the digoxin about an hour before the cholestyramine." Explanation: The absorption of digoxin can be decreased or delayed with cholestyramine, a bile acid sequestrant. Therefore, the digoxin should be taken 1 hour before for 4 to 6 hours after the cholestyramine.
A 58-year-old man has recently been prescribed atorvastatin (Lipitor) in an effort to reduce his cholesterol levels. The man has acknowledged the potentially harmful effects of hyperlipidemia and is motivated to make changes to resolve this health problem. What advice should the nurse give to this client?
"It's a good idea to keep your intake of saturated fat to a bare minimum." Explanation: Statins should be accompanied by a low-cholesterol diet that is also low in saturated fats. Reduction of sodium intake is a useful health-promotion measure but is not particular to treatment with statins. Plant sources of fat are typically lower in saturated fat than animal sources and it is unnecessary to prioritize protein intake over carbohydrates.
A client who is receiving colestipol is also taking a thiazide diuretic. Which instruction would be most appropriate for the nurse to give?
"Take the thiazide diuretic about 1 hour before the colestipol." Explanation: The absorption of thiazide diuretic can be decreased or delayed with colestipol, a bile acid sequestrant. Therefore, the diuretic should be taken 1 hour before or 4 to 6 hours after the colestipol.
The nurse is providing education to an older adult client who has been prescribed atorvastatin. How should the nurse describe the common adverse effects of the drug?
"The most common side effects of atorvastatin include some mild gastrointestinal upset." Explanation: Statins like atorvastatin are usually well tolerated. The most common adverse effects (nausea, constipation, diarrhea, abdominal cramps or pain, headache, skin rash) are usually mild and transient. Chest pain, joint stiffness, and bleeding are not common adverse effects.
A female client is taking a large dose of nicotinic acid to treat hyperlipidemia. She calls the clinic and reports that her face, neck, and chest are red. Which would be an appropriate response by the nurse?
"This is an expected adverse effect of the drug. It should subside in time." Explanation: Large doses of nicotinic acid produce peripheral vasodilation, mostly in the cutaneous vessels of the face, neck, and chest. Vasodilation results in flushing of the skin and is usually transient. The vasodilation is due to the histamine release caused by the medication. A nurse would never tell a client not to worry and to stop taking the medication, unless the prescriber told her to. The flushing should subside and will not be present for the duration of the course of the drug.
A client with primary hypercholesterolemia has been prescribed 10 mg of ezetimibe per day by a health care provider. The provider has instructed the nurse to continue the drug therapy for 3 days. The drug is available in 10-mg capsules. How many capsules of the drug should the nurse administer to the client during the entire therapy?
3 capsules Explanation: The nurse should administer 3 capsules of ezetimibe to the client during the therapy.
A client who had a total cholesterol-to-HDL cholesterol ratio of 5.3 has been losing weight and participating in an exercise program. His total cholesterol-to-HDL ratio is now 3.9. What LDL reading is also important to further decrease his risk of coronary artery disease?
95 mg/dL Explanation: In conjunction with an acceptable total cholesterol-to-HDL ratio, it is also important for the LDL reading to be between 80 and 100 mg/dL to further decrease the risk of coronary artery disease.
A client diagnosed with metabolic syndrome is encouraged to implement nonpharmacologic measures to improve existing risk factors. What actions demonstrate an understanding of appropriate measures? Select all that apply.
Adhering to a low-fat diet Walking for 30 minutes several times a week Eating a high-fiber diet Avoiding tobacco products Maintaining a healthy weight Explanation: Metabolic syndrome is a cluster of risk factors that includes central adiposity, elevated triglycerides, reduced HDL cholesterol, elevated blood pressure, and elevated fasting glucose. All the options will decrease weight, increase cardiovascular health, and reduce risk factors of metabolic syndrome.
A client with atrial fibrillation who is receiving oral anticoagulant therapy is receiving atorvastatin. The nurse would monitor this client for:
Bleeding Explanation: Increased serum levels and resultant toxicity can occur if a statin is combined with warfarin, an oral anticoagulant. This would increase the client's risk for bleeding. Abdominal pain and cataract development are related to the use of atorvastatin alone. Liver failure also is associated with atorvastatin use alone.
A patient with atrial fibrillation is receiving warfarin therapy. The patient is also prescribed ezetimibe. The nurse would instruct the patient to watch for:
Blood in urine or stool Explanation: Warfarin levels increase with ezetimibe, increasing the patient's risk for bleeding. Abdominal pain is a common adverse effect of ezetimibe and is unrelated to the combination therapy. Yellowing of the skin suggests liver dysfunction, which is not associated with the combination therapy. Blurred vision is not associated with the combination therapy.
A nurse is caring for a patient who is receiving lovastatin. Which assessment by the nurse would indicate that there is possible damage to the patient's skeletal muscle as a result of the drug therapy?
Brownish colored urine Explanation: Prolonged use of lovastatin may damage skeletal muscle; the increased bilirubin from the dead cells changes the color of the urine from amber to brown. Tanned and reddish color skin indicates photosensitivities caused by the drug and are general adverse effects.
A client who has been taking a statin has seen an improvement in his cholesterol laboratory values; however, the low-density lipoprotein remains elevated. What medication will be added to the medical regime?
Cholestyramine Explanation: Cholestyramine is administered to clients to reduce LDL cholesterol in clients who are already taking a statin drug. Digoxin is not given to lower LDL cholesterol. Vitamin D is not given to lower LDL cholesterol. Calcium carbonate is not given to lower LDL cholesterol.
Which would be classified as a bile acid sequestrant?
Cholestyramine Explanation: Cholestyramine is classified as a bile acid sequestrant. Lovastatin is a HMG-CoA reductase inhibitor. Ezetimibe is a cholesterol absorption inhibitor. Gemfibrozil is classified as a fibrate.
A client asks the nurse what the atorvastatin (Lipitor) prescribed for the client will do. What is an expected outcome for this client?
Decrease in serum cholesterol and LDL levels Explanation: Atorvastatin is a HMG-CoA reductase inhibitor and should lower serum cholesterol and LDL levels as well as prevent a first MI and slow the progression of CAD. A decrease in serum cholesterol alone would result from the use of a bile acid sequestrant. A cholesterol absorption inhibitor would also decrease sitosterol and campesterol levels as well as decrease levels of serum cholesterol and LDL.
Elevated blood lipids are a major risk factor for atherosclerosis and vascular disorders. From where are blood lipids derived?
Diet Explanation: Blood lipids, which include cholesterol, phospholipids, and triglycerides, are derived from the diet or synthesized by the liver and intestine. Medications, exercise, and the kidneys do not play a role in synthesis.
As part of a routine physical examination, a 60-year-old client's primary care provider has ordered blood work that includes cholesterol levels. What result would strongly suggest the need for an antihyperlipidemic drug?
Elevated LDL levels Explanation: Elevated LDL levels are considered a risk factor for coronary artery disease. Elevated HDL levels, low VLDL levels, and a high ratio of HDL to LDL are associated with a decreased risk of heart disease.
A nurse is caring for a client prescribed nicotinic acid for hyperlipidemia. The nurse would assess the client for which findings as a possibility?
Flushing of the skin Explanation: The nurse should inform the client prescribed nicotinic acid that flushing of the skin is generally experienced by clients during this treatment. Weakness, tachycardia, and dyspnea are not adverse reactions associated with nicotinic acid.
A patient with hyperlipidemia is prescribed ezetimibe. Which ongoing assessment should the nurse perform during treatment?
Frequently monitor blood cholesterol. Explanation: The nurse should frequently monitor blood cholesterol as part of the ongoing assessment for a patient receiving ezetimibe. Taking a dietary history of the patient and inspecting the skin and eyelids for evidence of xanthomas are the pre-administration assessments that a nurse should perform for a patient receiving ezetimibe. The nurse obtains the reports of fasting blood sugar for a diabetic patient.
After teaching a group of students about fats and biotransformation, the instructor determines that the teaching was successful when the students identify what as the storage location of bile acids?
Gallbladder Explanation: The presence of fatty acids, lipids, and cholesterol in the duodenum stimulates contraction of the gallbladder and the release of bile, which contains bile acids. Once their action is completed, they are reabsorbed and recycled to the gallbladder, where they remain until the gallbladder is stimulated again.
After reviewing information about antihyperlipidemic drugs, a group of nursing students demonstrate understanding when they identify which medication as a fibric acid derivative (fibrate)?
Gemfibrozil Explanation: Gemfibrozil is a fibric acid derivative. Colesevelam is a bile acid resin. Niacin is classified as a miscellaneous antihyperlipidemic. Ezetimibe is a miscellaneous antihyperlipidemic.
The nurse instructs a client to take the prescribed pravastatin at bedtime based on understanding that:
Greater drug effectiveness is achieved at this time. Explanation: The drug is administered at bedtime because the highest rates of cholesterol synthesis occur between 12 and 5 AM, and the drug should be taken when it will be most effective.
The nurse is evaluating the effectiveness of drug therapy in a client with hyperlipidemia. Effective therapy is best demonstrated by which laboratory values?
HDL 58 LDL 96 Cholesterol 178 Explanation: Normal HDL should be greater than 40 mg/dl, LDL should be less than 100 mg/dl, and total cholesterol should be less than 200 mg/dl.
Which drug is most effective in reducing most major types of dyslipidemia in patients at risk or who have already developed CAD?
HMG-CoA reductase inhibitors Explanation: HMG-CoA reductase inhibitors are the first drug of choice in the treatment of hypercholesterolemia in patients who are at risk for, or who have already developed, coronary artery disease. HMG-CoA reductase inhibitors (statins) lower LDL cholesterin within 2 weeks and reach maximal effects in approximately 4 to 6 weeks.
A 54-year-old client has a cholesterol level of 240 mg/dL (6.2064 mmol/L). What serum concentration of cholesterol would this client have?
High Explanation: High is rated at >240 mg/dL (6.2064 mmol/L). The other options are incorrect.
Which lipid level would the nurse interpret as being high?
LDL cholesterol of 190 mg/dL Explanation: LDL level of 190 mg/dL would be considered high. A total cholesterol level of 200 mg/dL would be considered borderline high. A triglyceride level of 160 would be borderline high. HDL level of 48 would be considered low to optimal. Levels about 60 mg/dL would be considered high.
A client diagnosed with hyperlipidemia is prescribed a statin. The nurse is reviewing the client's history and would notify the client's health care provider if which condition was noted in the client's history?
Liver disease Explanation: Statins are contraindicated in clients with liver disorders. They are used cautiously in clients with a history of hypotension, infection, and myopathy.
An elderly client with dyslipidemia has had fenofibrate added to the existing medication regimen. In addition to having the lipid profile drawn on a regular basis, the nurse should educate the client about the need for what ongoing laboratory testing during therapy?
Liver panel Explanation: Because of the risk for hepatotoxicity, clients taking fenofibrate require serial testing of liver enzyme levels. There is no specific need for follow-up with CBCs, coagulation tests, or reticulocyte counts.
A client is taking lovastatin. Which are noted as the most common adverse effects?
Nausea, flatulence, and constipation Explanation: The most common adverse effects of statins are nausea, constipation, diarrhea, abdominal cramps or pain, headache, and skin rash. The client will not experience increased appetite and blood pressure as adverse effects of statins. The client will not experience fatigue and mental disorientation as adverse effects of statins. The client will not experience hiccups, nasal congestion, and dizziness as adverse effects of statins.
A client who is receiving a bile acid sequestrant is being prescribed an additional agent to lower lipid levels. Which agent would the nurse most likely expect the provider to order?
Niacin Explanation: Although any combinations may be used, niacin is often combined with bile acid sequestrants for increased effects.
A female client presents to the health care provider's office with recurrence of her "hot flashes." The nurse understands that the client is taking what drug to treat her dyslipidemia?
Niacin Explanation: Skin flushing may occur with niacin.
A nurse should be aware that use of statin drugs is contraindicated in clients with which conditions? (Select all that apply.)
Pregnancy Serious hepatic disease Lactation Explanation: Statin drugs are contraindicated in individuals with known hypersensitivity to the drugs, serious liver disease, and during pregnancy (Category X), and lactation.
HMG-CoA reductase inhibitors (statins) are classified as which pregnancy category?
Pregnancy Category X Explanation: HMG-CoA reductase inhibitors (statins) are in pregnancy category X and contraindicated during any stage of pregnancy. Medications in pregnancy category A are considered safe. Medications classified as pregnancy category B, studies have failed to demonstrate a risk to the fetus and there are no adequate and well-controlled studies in pregnant women. For pregnancy category C, studies have shown adverse effects to the fetus; however, benefit may outweigh the potential harm—the risk has not been ruled out.
A client has been largely unsuccessful in achieving adequate control of dyslipidemia through lifestyle changes and the use of a statin. As a result, the client has been prescribed cholestyramine. What change in this client's lipid profile will the nurse identify as the most likely goal of therapy?
Reduction in LDL cholesterol levels Explanation: Cholestyramine, the prototype bile acid sequestrant, has the ability to reduce LDL cholesterol. It has little or no effect on HDL cholesterol and either no effect or an increased effect on triglyceride levels.
The nurse knows that part of the education plan for a client with the diagnosis of hyperlipidemia needs to include which lifestyle changes? (Select all that apply.)
Reduction of the intake of saturated fats Weight loss Increased physical activity Explanation: The NCEP ATP IV recommends a multipronged approach in reducing LDL levels. They term this approach therapeutic lifestyle changes. These lifestyle changes include reduced intake of saturated fats, trans fats, and cholesterol; minimum intake of fatty acids; weight reduction; increased physical activity; increased intake of soluble fiber; and possibly increased intake of plant stanols and sterols.
What should the nurse suggest to assist a client to improve his cholesterol levels?
Smoking cessation Explanation: Lifestyle changes that can help improve cholesterol levels include a low-fat diet, regular aerobic exercise, losing weight, and not smoking.
A client has an elevated total serum cholesterol of 260 mg/dL (14.4 mmol/L). Which aspect of client teaching of lifestyle changes is most important for the client?
Stop smoking. Explanation: Therapeutic lifestyle changes to lower serum cholesterol, including exercise, smoking cessation, change in diet, and drug therapy, are recommended to lower serum cholesterol. The client with an elevated serum cholesterol should increase exercise and not increase rest periods. The client should consume low-fat dairy products and avoid whole milk. Organic foods are not specifically recommended.
A patient with metabolic syndrome usually has increased plasminogen activator levels.
True Explanation: Metabolic syndrome involves increase plasminogen activator levels.
Which category of blood lipids is involved in the formation of atherosclerotic plaques?
cholesterol Explanation: Blood lipids are a category of fatty acids, which are substances used within the body to perform essential functions. Cholesterol is the portion of blood lipids involved in the formation of atherosclerotic plaques. Triglycerides and phospholipids are not involved in the formation of plaque. Nitroglycerin is not a blood lipid.
A client has had cholestyramine added to his or her treatment plan for dyslipidemia. What effect will cholestyramine have on the pharmacokinetics of the thiazide diuretic that the client is currently prescribed?
decreased absorption Explanation: Cholestyramine may decrease absorption of thiazide diuretics. None of the other options are associated with cholestyramine's effect on other medications.
A client's serum cholesterol is 286 mg/dL. Lovastatin (Mevacor) is prescribed. The nurse plans care based on the fact that the action of lovastatin:
inhibits the production of cholesterol. Explanation: Statin drugs inhibit the production of cholesterol and promote the breakdown of cholesterol. Bile acid resins bind to bile acids to form insoluble substances that cannot be absorbed.
A client will begin taking atorvastatin, and the nurse is conducting relevant health education. The nurse should emphasize the need to report any new onset of:
muscle pain. Explanation: Myopathy is an important adverse effect of statins. Statins can injure muscle tissue, resulting in muscle ache or weakness; this should be reported promptly. Dry mouth, pruritus, and thirst are not reported adverse effects of statins.
The client has been taking rosuvastatin for hyperlipidemia. The client now presents with severe weakness and states barely being able to move the extremities. The nurse suspects the client has which?
rhabdomyolysis. Explanation: An adverse reaction of rosuvastatin is muscle toxicity, which may cause rhabdomyolysis. Rhabdomyolysis is the breakdown of muscle that can cause pain, weakness, nausea, and even kidney damage. Gallbladder disorders are related to the use of fibric acid derivatives. Any medication can cause pruritis, however, it is not related to weakness manifested by the use of rosuvastatin.
A client with hypertriglyceridemia is prescribed an omega 3-acid ester medication. Which teaching about this medication would the nurse emphasize with this client?
"Do not use any aspirin products when taking this medication." Explanation: Omega-3-acid ethyl esters are a combination of omega-3 fatty acids and an activator that inhibits liver enzyme systems to decrease the synthesis of triglycerides, a risk factor in metabolic syndrome, lowering serum triglyceride levels. It is approved to lower triglycerides in adults with high triglyceride levels. Because this drug may prolong bleeding time, the client should be instructed to avoid aspirin products. Constipation is not an adverse effect of this medication. This medication should be combined with dietary changes and exercise to keep overall lipid levels lower. This medication does not cause weight loss.
A male client takes cholesterol absorption inhibitors as a monotherapy without statins. He develops mild hepatic insufficiency. What would the nurse expect the health care provider to do?
Decrease the dosage of his medication Explanation: Cholesterol absorption inhibitors as monotherapy (without statins) require dosage reduction in clients with mild hepatic impairment.
Treatments for clients with dyslipidemia are determined according to blood levels of total and LDL cholesterol and risk factors for cardiovascular disease. What does the impact of existing cardiovascular disease have on treatment recommendations?
Decreases target serum LDL level Explanation: Existing cardiovascular disease lowers the target LDL serum level in these clients.
In addition to being synthesized in the liver and intestine, from where are blood lipids derived?
diet Explanation: Blood lipids, which include cholesterol, phospholipids, and triglycerides, are derived from the diet or synthesized by the liver and intestine. None of the remaining options are capable of synthesizing or even stimulating the synthesis of blood lipids.
A 39-year-old nulliparous woman has been taking atorvastatin for 2 years and has now decided that she would like to become pregnant. What health education should the nurse provide to this client?
"It's important that you stop taking atorvastatin before you stop using contraception." Explanation: Statins like atorvastatin are potentially teratogenic (pregnancy category X). In a very few cases, potential benefits warrant use of these drugs in pregnant women, but this is exceptional. It is also contraindicated during breastfeeding. None of the other statements describe accurate educational information about atorvastatin and conception.
A 50-year-old female client expresses concern about developing atherosclerotic cardiovascular disease (ASCVD). What statement made by the client suggests an understanding of the information the nurse presented on minimizing the risk?
"Losing those 25 lb (11.4 kg) and keeping it off for the last 10 years has done a lot to minimize my risk." Explanation: Obesity increases the heart's workload and contributes to the risk of developing ASCVD. Being within the normal weight range for height will help minimize the client's risk. The risk of ASCVD is related to the duration and amount of smoking. The client's years and amount of smoking pose a significant risk. Cessation of smoking reduces risk immediately, but it may take 20 years or more to completely reverse the risk. Males are more likely than premenopausal females to have ASCVD; however, the incidence is almost equal in males and postmenopausal females, possibly because of a protective effect of estrogens.
A nurse is caring for a client receiving cholestyramine to improve his blood lipid profile at a home care setting. What adverse reactions to cholestyramine should the nurse monitor in the client?
Constipation Explanation: The nurse should monitor for constipation in the client receiving cholestyramine. Rash, vertigo, and cholelithiasis should be monitored by the nurse when caring for a client receiving gemfibrozil.
The physician is caring for a client who is a 2-year kidney transplant survivor. The nurse would expect the physician to order what drug for the client's hyperlipidemia?
Fluvastatin Explanation: Fluvastatin is cleared hepatically, and less than 6% of the dose is excreted in urine; therefore, dosage reduction for mild to moderate renal impairment is unnecessary. Use caution with severe impairment. Recent randomized, controlled clinical trials have demonstrated the drug's safety in kidney transplant recipients.
The pharmacology instructor is discussing medications used in the treatment of dyslipidemia. Which drug class would the instructor identify as the most widely used dyslipidemia drugs?
HMG-CoA reductase inhibitors Explanation: HMG-CoA reductase inhibitors (or statins) are the most widely used dyslipidemia drugs. They are useful in treating most of the major types of dyslipidemia.
A nurse is providing care to a client who has elevated levels of low-density lipoprotein (LDL). A review of the client's history reveals a sedentary lifestyle and a history of being overweight. The nurse understands that this combination of factors places the client at risk for which condition?
Heart disease Explanation: Increased levels of LDL in combination with other risk factors, such as increased weight, diet high in saturated fats, and lack of physical activity, can lead to the development of atherosclerotic heart disease. In diabetes high levels of blood glucose as well as HbA1c are seen. In clients with glaucoma, increased eye pressure causes damage to the optic nerve. Clients with hypertension left untreated can lead to kidney failure and stroke.
To effectively prevent or manage metabolic syndrome, what should the desired blood lipid profile include? (Select all that apply.)
Low triglycerides High HDL cholesterol Low LDL cholesterol Explanation: Overall, the most effective blood lipid profile for prevention or management of metabolic syndrome and its sequelae is high HDL cholesterol, low LDL cholesterol, and low total cholesterol. A low triglyceride level is also desirable.
A client being initiated on cholestyramine for the treatment of hyperlipidemia should be counseled that what can occur? (Select all that apply.)
Malabsorption of vitamin K Aggravation of hemorrhoids Flatulence Explanation: Adverse reaction reported with the use of bile acid resins, such as cholestyramine, include constipation (that can become severe), aggravation of hemorrhoids, abdominal cramps, flatulence, nausea, increased bleeding related to vitamin K malabsorption, and vitamin A and D deficiencies.
Which single class drug is known to be most effective in reducing the major types of dyslipidemia?
Statins Explanation: For single-drug therapy, a statin is preferred for the treatment of dyslipidemia. To lower cholesterol and triglycerides, a statin, a cholesterol absorption inhibitor, gemfibrozil, a fibrate, or the vitamin niacin may be used. To lower triglycerides, gemfibrozil, ezetimibe, a cholesterol absorption inhibitor, or niacin may be given.
A client has been diagnosed with moderately increased LDL, and the primary care provider wishes to start statin therapy. What is a potential disadvantage of statins that the health care provider should consider? Select all that apply.
Statins are expensive. Statins require regularly scheduled blood work. Explanation: Because liver enzymes may be elevated during atorvastatin use, clients need liver function tests and repeat lipid profile testing on a routine basis. These drugs are also expensive. They are not nephrotoxic and do not suppress the immune system. Previous MI is an indication for their use, not a contraindication.
What information would be included in a lipoprotein profile? Select all that apply:
Total cholesterol Triglycerides LDL Explanation: A lipoprotein profile is a laboratory test which reports total cholesterol, LDL, HDL, and triglycerides. AST and ALT are values that would be found reported from liver function test.
After teaching a group of students about metabolic syndrome, the instructor determines that the teaching was successful when the students identify which characteristic?
Triglyceride level above 150 mg/dL Explanation: Characteristics of metabolic syndrome include fasting blood glucose levels greater than 110 mg/dL, waist measurement over 40 inches in men and over 35 inches in women, triglyceride levels greater than 150 mg/dL or HDL levels less than 40 mg/dL in men or less than 50 mg/dL in women, blood pressure greater than 130/85 mm Hg, increased macrophages, levels of interleukin-6 and TNF, and increased plasminogen activator levels.
Several months of treatment with a statin accompanied by lifestyle modifications have failed to appreciably improve a patient's cholesterol levels. Consequently, the patient has been prescribed cholestyramine. The nurse should recognize that this drug achieves its therapeutic effect by:
oxidizing cholesterol to bile acids. Explanation: Unlike statins, which work by decreasing the synthesis of cholesterol, the bile acid sequestrants such as cholestyramine promote the oxidation of cholesterol to bile acids. Bile acid sequestrants do not promote vasodilation or bind HDL to LDL.