Lilley: Chapter 27 Antilipemic Drugs

Bile Acid Sequestrants aka bile acid-binding resins and ion-exchange resins

(second line drugs after the more potent statins) cholestyramine colestipol colesevelam *some are in powder forms and inconvenient to use . Colestipol is also available in tablet form. Colesevelam is available only in tablet form

HMG-CoA Reductase Inhibitors (Statins): Adverse Effects

*Abdominal pain, rash, and headache are most common *Elevations in liver enzyme levels may occur *Serum creatine phosphokinase (CPK) concentrations may be increased to more than 10 times the normal level *dizziness, blurred vision, fatigue, insomnia constipation, diarrhea, nausea, myalgia

Important to Note:

*bile acid sequestrants often come in powder form and must be mixed thoroughly with food or fluids (at least 4 to 6 ounces of fluid) The powder may not mix completely at first, but patients need to be sure to mix the dose as much as possible and then dilute any undissolved portion with additional fluid. The powder needs to be dissolved for at least 1 full minute. Powder and/or granule dosage forms are never to be taken in dry form. It is important that colestipol and any of these drugs be taken 1 hour before or 4 to 6 hours after any other oral medication or meals because of the high risk for drug-drug and drug-food interactions. Bile acid sequestrants do interfere with the absorption of other medications. Colestipol is also available in tablet form and may cause constipation that may be prevented with high fiber and an increase in fluid intake Cholestyramine is to be taken just before meals or with meals. Never give this drug to a patient with phenylketonuria (PKU) because cholestyramine contains aspartame (see previous discussion). Aspartame, an artificial sweetener, breaks down into phenylalanine and so is to be avoided in patients with PKU

Bile Acid Sequestrants: Adverse Effects

*colesevelam is reported to have fewer gastrointestinal adverse effects and drug interactions *constipation is a common problem and may be accompanied by heartburn, nausea, belching, and bloating. These adverse effects tend to disappear over time. *headache, tinnitus, burnt odor of urine take the drugs with meals to reduce the adverse effects *increasing dietary fiber intake or taking a fiber supplement such as psyllium (Metamucil and others), as well as increasing fluid intake, may relieve constipation and bloating. These drugs may also cause mild increases in triglyceride levels

Fibric Acid Derivatives (Fibrates): Indications

*decrease the triglyceride level and increase the HDL cholesterol level by as much as 25% *decrease the LDL concentrations in patients with type IIa and IIb hyperlipidemia but increase the LDL levels in patients with type IV and V hyperlipidemia *indicated for the treatment of type III, IV, and V hyperlipidemia, and in some cases the 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

Gemfibrozil (Lopid)

*fibric acid derivative that decreases the synthesis of apolipoprotein B and lowers the VLDL level *it can also increase the HDL level. *effective for lowering plasma triglyceride levels *indicated for the treatment of type IV and V hyperlipidemia, and, in some cases, the type IIb form

HMG-CoA Reductase Inhibitors (Statins): Indications

*first-line therapy for hypercholesterolemia (esp elevated LDL) *treatment of type IIa and IIb hyperlipidemia and have been shown to reduce the plasma concentrations of LDL cholesterol by up to 50% *dose dependent *Atorvastatin appears to be more effective in lowering triglyceride levels than other HMG-CoA reductase inhibitors. Combined drug therapy with more than one class of antilipemic drug may be necessary for desired results. The statins are often combined with niacin or fibrates for this purpose, though this combination can increase the risk for adverse drug effects

Fibric Acid Derivatives (Fibrates)

*gemfibrozil *fenofibrate (both are prescription only) *primarily affect the triglyceride levels but may also lower the total cholesterol and LDL cholesterol levels and raise the HDL cholesterol level *often collectively referred to as fibrates

Fibric Acid Derivatives (Fibrates): Interactions

*gemfibrozil can enhance the action of oral anticoagulants, so careful adjustment of the dosage of warfarin is required *risk for myositis, myalgias, and rhabdomyolysis is increased when either gemfibrozil or fenofibrate is given with a statin *combining gemfibrozil with a statin is generally not recommended due to an increased risk for rhabdomyolysis *enofibrate may raise the blood level of ezetimibe if the two are taken concurrently.

Bile Acid Sequestrants: MOA

*increase destruction of LDL *bind bile and prevent the resorption of the bile acids from the small intestine *an insoluble bile acid and resin (drug) complex is formed and then excreted in the bowel movement *bile acids are necessary for the absorption of cholesterol from the small intestine and are also synthesized from cholesterol by the liver *this is one natural way that the liver excretes cholesterol from the body. The more that bile acids are excreted in the feces, the more the liver converts cholesterol to bile acids. This reduces the level of cholesterol in the liver and thus in the circulation as well. *the liver then attempts to compensate for the loss of cholesterol by increasing the number of LDL receptors on its surface. Circulating LDL molecules bind to these receptors to be taken up into the liver, which has the benefit of reducing circulating LDL in the bloodstream

Niacin: MOA

*inhibit lipolysis in adipose tissue, decrease esterification of triglycerides in the liver, and increase the activity of lipoprotein lipase *drug effects are primarily limited to : reduction of the metabolism or catabolism of cholesterol and triglycerides. *in large doses, it may produce vasodilation that is limited to the cutaneous vessels which seems to be induced by prostaglandins. *it 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

Niacin (Nicotinic Acid)

*lipid lowering drug AND a vitamin (B3) *not usually recommended for first line routine use for antilipemic treatment

Niacin: Indications

*lower lipid levels including triglyceride, total serum cholesterol, and LDL cholesterol levels *increases HDL cholesterol levels *lower the levels of lipoprotein(a), except in patients with severe hypertriglyceridemia *can be used in the treatment of type IIa, IIb, III, IV, and V hyperlipidemia *the effects on triglyceride levels begin to be noticed after 1 to 4 days of therapy, with the maximum effects seen after 3 to 5 weeks of continuous therapy *recent data indicate that niacin has no effect on cardiovascular outcomes in patients taking statins, but is associated with numerous adverse effects.

HMG-CoA Reductase Inhibitors (Statins): another very important adverse effect : myopathy (muscle pain)

*may progress to a serious condition known as rhabdomyolysis. Rhabdomyolysis is the breakdown of muscle protein accompanied by myoglobinuria, which is the urinary elimination of the muscle protein myoglobin. This can lead to acute renal failure and even death. It appears to be dose dependent and is more common in patients receiving a statin in combination with cyclosporine, gemfibrozil (a fibrate), or erythromycin. When recognized reasonably early, rhabdomyolysis is usually reversible with discontinuation of the statin drug. Risk factors for myopathy include: age older than 65 years, hypothyroidism, renal insufficiency, and drug interactions. Instruct patients to immediately report any signs of toxicity, including muscle soreness or changes in urine color.

Niacin: Interactions

*minimal *when niacin is taken with an HMG-CoA reductase inhibitor, the likelihood of myopathy development is increased

Patient Teaching

*notify the prescriber if there are any new or troublesome symptoms or if there is persistent gastrointestinal upset, constipation, gas, bloating, heartburn, nausea, vomiting, abnormal or unusual bleeding, or yellow discoloration of the skin Another symptom to report is muscle aches and pain Advise the patient to keep these and all medications out of the reach of children and protected with childproof lids. Emphasize the importance of keeping a daily journal of fluid intake and dietary practices

Simvastatin (Zocor)

*one of the first statins to become generic and is one of the most commonly used drugs in this class *as with all statins, it is used primarily to lower total and LDL cholesterol levels as well as triglyceride levels *it can also modestly raise levels of HDL, the "good" cholesterol *pregnancy category X drug. *drug interactions can be significant with simvastatin *FDA imposed prescribing restrictions on simvastatin, stating "Physicians should limit using the 80-mg dose unless the patient has already been taking the drug for 12 months and there is no evidence of myopathy. *Simvastatin 80 mg should not be started in new patients, including patients already taking lower doses of the drug." *simvastatin is not to be used with certain other drugs including itraconazole, ketoconazole, posaconazole, erythromycin, clarithromycin, HIV protease inhibitors, nefazodone, femfibrozil, cyclosporine, and danazol. *for patients taking verapamil and diltiazem, the dose of simvastatin is not to exceed 10 mg. In patients taking amiodarone, amlodipine, and ranolazine, the dose is not to exceed 20 mg.

Atorvastatin (Lipitor)

*one of the most commonly used drugs in this class *it is used to lower total and LDL cholesterol levels as well as triglyceride levels *has also been shown to raise levels of "good" cholesterol, the HDL component. *all statins are 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

HMG-CoA Reductase Inhibitors (Statins): Interactions

*oral anticoagulants(warfarin)-->risk for bleeding *erythromycin, azole antifungals, quinidine, verapamil, diltiazem, HIV and hepatitis C protease inhibitors, amiodarone, and grapefruit juice, cyclosporin, clarithromycin, amlodipine, may lead to the development of rhabdomyolysis *limit grapefruit juice to less than 1 quart daily *gemfibrozil and statins together is not recommended due to increased risk for rhabdomyolysis

Cholestyramine (Questran)

*prescription-only Bile Acid Sequestrate *contraindicated in patients with a known hypersensitivity to it and in those who have complete biliary obstruction or PKU *may interfere with the distribution of proper amounts of fat-soluble vitamins to the fetus or nursing infant of a pregnant or nursing woman taking the drug *now being used for its constipating effect, often given as needed for loose bowel movements *available as a dry powder and poses a choking hazard if not diluted before administering

Bile Acid Sequestrants: Indications

*treat type II hyperlipoproteinemia *often used along with statins to reduce LDL *cholestyramine is used to relieve the pruritus associated with partial biliary obstruction. *colesevelam may be better tolerated by higher-risk patients who are intolerant of other antilipemic therapy, including organ transplant recipients and those with serious liver or kidney disease

niacin

*used alone or in combination with other lipid-lowering drugs, niacin (nicotinic acid, vitamin B3) (Nicobid) is an inexpensive medication that may have effects on LDL cholesterol, triglyceride, and HDL cholesterol levels *drug therapy is usually initiated at a small daily dose taken with or after meals to minimize the adverse effects. *liver dysfunction has been 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, including less hepatotoxicity and flushing of the skin *contraindicated in patients with a known hypersensitivity to it; in those with peptic ulcer, hepatic disease, or hemorrhage; and in lactating women. It is also not recommended for patients with gout *available over the counter and by prescription.

Fibric Acid Derivatives (Fibrates): MOA

*work by activating lipoprotein lipase, an enzyme responsible for the breakdown of cholesterol. *this enzyme cleaves off a triglyceride molecule from VLDL or LDL, leaving behind lipoproteins *fibric acid derivatives 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 *they have been shown to reduce triglyceride levels and serum VLDL and LDL concentrations. *independent of their lipid-lowering actions, fibric acid derivatives can also induce changes in blood coagulation. this involves a tendency toward a decrease in platelet adhesiveness *they can also increase plasma fibrinolysis, the process that causes clots to be broken down

foam cells

, the characteristic precursor lesion of atherosclerosis, also known as a fatty streak

major classes of antilipemics include :

1. HMG-CoA reductase inhibitors 2. bile acid sequestrants 3. niacin 4. fibric acid derivatives 5. cholesterol absorption inhibitors

Flax :

Adverse Effects : Diarrhea, allergic reactions Potential Drug Interactions : Antidiabetic drugs and anticoagulant drugs Contraindications: Not recommended during pregnancy

moderate intensity statins

Atorvastatin 10 mg Rosuvastatin 10 mg Simvastatin 20-40 mg Pravastatin 40 mg Lovastatin 40 mg Fluvastatin 40 mg bid lowers LDL by approx 30%-<50%

High intensity statins

Atorvastatin 40-80 mg Rosuvastatin 20mg lowers LDL by approx 50%

Ezetimibe (Zetia)

Cholesterol Absorption Inhibitor (miscellaneous antilipemic) unique MOA--> selectively inhibits absorption of cholesterol and related sterols in the small intestine *the result is a reduction in several blood lipid parameters: total cholesterol level, LDL cholesterol level, apolipoprotein B level, and triglyceride level *serum levels of HDL cholesterol, the so-called good cholesterol, have been shown to increase with the use of ezetimibe *beneficial effects of ezetimibe appear to be further enhanced when given with a statin drug. *may also be used as monotherapy *can be used with moderate to severe chronic kidney disease, as studies showed it was effective in reducing the risk for vascular events in such patients

flax and garlic are often used by patients to reduce lipids, it is important to know their contraindications and interactions

Garlic : Adverse Effects : Dermatitis, vomiting, diarrhea, anorexia, flatulence, antiplatelet activity Potential Drug Interactions : May interact with warfarin, diazepam, protease inhibitors. Use with nonsteroidal antiinflammatory drugs may enhance bleeding. Possible interference with hypoglycemic therapy Contraindications: patients who will undergo surgery within 2 weeks and in patients with human immunodeficiency virus infection or diabetes

when taking an HMG-CoA reductase inhibitor or statin drug, it is best taken with at least 6 to 8 ounces of water or with meals to help minimize gastric upset

It takes several weeks before therapeutic results are seen. Monitor liver and renal function laboratory studies every 3 to 6 months, as prescribed

if taking a bile acid sequestrant, advise the patient to take the medication with meals to decrease gastrointestinal upset.

Other drugs must be taken 1 hour before or 4 to 6 hours after taking a bile acid sequestrant.

Low intensity statins

Pravastatin 10-20 mg Lovastatin 20 mg lowers LDL by approx <30%

Serum Lipid Level (normal ranges)

Serum cholesterol level: less than or equal to 200 mg/dL Triglyceride level: less than 150 mg/dL Low-density lipoprotein (LDL) cholesterol level: less than 100 mg/dL High-density lipoprotein (HDL) cholesterol level: greater than or equal to 60 mg/dL

Triglycerides and cholesterol are both water-insoluble fats that must be bound to specialized lipid-carrying proteins called apolipoproteins.

The combination of triglycerides and cholesterol with an apolipoprotein is referred to as a lipoprotein.

Cholesterol Homeostasis: Fats are taken into the body through the diet and are broken down in the small intestine to form triglycerides. Triglycerides are then incorporated into chylomicrons in the cells of the intestinal wall and are absorbed into the lymphatic system.

The primary purpose of chylomicrons is to transport lipids obtained from dietary sources (exogenous lipids) from the intestines to the liver to be used to make steroid hormones, lipid structural components for peripheral body cells, and bile acids.

Lipids and lipoproteins participate in the formation of atherosclerotic plaque, which subsequently leads to the development of CHD.

When serum cholesterol levels are elevated, circulating monocytes adhere to the smooth endothelial surfaces of the coronary vasculature

laboratory test interactions that can occur in patients taking gemfibrozil include:

a decrease in the hemoglobin level, hematocrit value, and white blood cell count, the aspartate aminotransferase level, activated clotting time, lactate dehydrogenase level, and bilirubin level can be increased

When administering niacin, the nurse needs to monitor for which adverse effect? a. Cutaneous flushing b. Muscle pain c. Headache d. Constipation

a. Cutaneous flushing

Fibric Acid Derivatives (Fibrates): Adverse Effects

abdominal discomfort diarrhea nausea headache blurred vision increased risk for gallstones prolonged prothrombin time vomiting decreased urine output hematuria dizziness rash pruritus vertigo liver function tests may also show increased enzyme levels

All statins are prescription-only drugs and are contraindicated in those with :

active liver dysfunction or elevated serum transaminase levels of unknown cause. T they are classified as pregnancy category X drugs and are to be avoided during pregnancy and lactation. There is little evidence to recommend one drug over another. However, in terms of drug interactions, lovastatin and simvastatin are the statins most commonly involved.

factors present in the decision to prescribe antilipemics

age, sex, menopausal status for women, family history, and response to dietary treatment, as well as the presence of risk factors (other than hyperlipidemia) for premature CHD and the cause, duration, and phenotypic pattern of the patient's hyperlipidemia guidelines no longer recommend specific LDL and non-HDL targets; rather they identify four groups of primary- and secondary-prevention patients on whom physicians should focus their efforts

Fat-soluble vitamins may need to be prescribed for patients taking these medications for long periods because :

antilipemics have long-term effects on the liver's production of these vitamins

Lipids and lipoproteins participate in the formation of :

atherosclerotic plaque, which leads to CHD, and it is important to understand the pathology of this disease process so that appropriate patient education may be delivered

A patient is currently taking a statin. The nurse considers that the patient may have a higher risk for developing rhabdomyolysis when also taking which product? a. NSAIDs b. A fibric acid derivative c. Orange juice d. Fat-soluble vitamins

b. A fibric acid derivative

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.

The nurse is administering cholestyramine (Questran), a bile acid sequestrant. Which nursing intervention(s) is appropriate? (Select all that apply.) a. Administering the drug on an empty stomach b. Administering the drug with meals c. Instructing the patient to follow a low-fiber diet while taking this drug d. Instructing the patient to take a fiber supplement while taking this drug e. Increasing fluid intake f. Not administering this drug at the same time as other drugs

b. Administering the drug with meals d. Instructing the patient to take a fiber supplement while taking this drug e. Increasing fluid intake

A patient has been taking simvastatin (Zocor) for 6 months. Today he received a call that he needs to come to the office for a "laboratory check." The nurse expects which laboratory studies to be ordered at this time? (Select all that apply.) a. PT/INR b. Total cholesterol c. Triglyceride d. Liver function studies e. Complete blood count f. HDL and LDL levels

b. Total cholesterol c. Triglyceride d. Liver function studies f. HDL and LDL levels

Toxicity and Management of Overdose

because the bile acid sequestrants are not absorbed, an overdose can cause obstruction of the gastrointestinal tract. Therefore, treatment of an overdose involves restoring gut motility

gemfibrozil and fenofibrate

both drugs decrease the triglyceride levels and increase the HDL levels by as much as 25% they are good drugs for the treatment of mixed hyperlipidemias

Which point will the nurse emphasize to a patient who is taking an antilipemic medication in the "statin" class? a. The drug needs to be taken on an empty stomach before meals. b. A low-fat diet is not necessary while taking these medications. c. It is important to report muscle pain immediately. d. Improved cholesterol levels will be evident within 2 weeks.

c. It is important to report muscle pain immediately

A patient is being assessed before a newly ordered antilipemic medication is given. Which condition would be a potential contraindication? a. Diabetes insipidus b. Pulmonary fibrosis c. Liver cirrhosis d. Myocardial infarction

c. Liver cirrhosis

hydroxymethylglutaryl-coenzyme A (HMG-CoA) reductase inhibitors

competitively inhibit HMG-CoA reductase, and they are the most potent of the drugs available for reducing plasma concentrations of LDL cholesterol also known as: STATINS lovastatin, pravastatin, simvastatin, atorvastatin, fluvastatin, rosuvastatin, and pitavastatin Lipid levels may not be lowered to their maximum extent until 6 to 8 weeks after the start of therapy.

When plaque forms in the blood vessels that supply the heart with needed oxygen and nutrients, the lumens of these blood vessels will eventually :

decrease in size and the amount of oxygen and nutrients that can reach the heart (and major organs) will be reduced.

Patient Teaching

encourage a diet that is plentiful in raw vegetables, fruit, and bran Increasing intake of fluids (up to 3000 mL/day unless contraindicated) may also help prevent the constipation associated with these medications exercise is to be done in moderation and often with supervision as indicated

Niacin: Adverse Effects

flushing pruritus gastrointestinal distress blurred vision glucose intolerance hepatotoxicity *small doses of aspirin or nonsteroidal antiinflammatory drugs (NSAIDs) may be taken 30 minutes before the niacin dose to minimize the cutaneous flushing *undesirable effects can also be minimized by starting patients on a low initial dosage and increasing it gradually, and by having patients take the drug with meals

Antilipemic drugs are used to lower the :

high levels of lipids in the blood (triglycerides and cholesterol)

ezetimibe levels are increased by the fibric acid derivatives (fibrates)

it is not known whether this is harmful, but concurrent use of ezetimibe and fibrates is not recommended *the use of ezetimibe with bile acid sequestrants has been shown to reduce the serum level of ezetimibe by 55% to 80% *Ezetimibe is contraindicated in those with a known hypersensitivity to it and in those with active liver disease or unexplained elevations in serum liver enzyme levels *It may be taken with or without food, and for patient convenience it may be dosed at the same time as a statin drug, if prescribed

Bile Acid Sequestrants: Contraindications

known drug allergy biliary or bowel obstruction phenylketonuria (PKU

Niacin: Contraindications

known drug allergy liver disease peptic ulcer presence of any active hemorrhagic process-bleeding risk

Fibric Acid Derivatives (Fibrates): Contraindications

known drug allergy preexisting gallbladder disease significant hepatic or renal dysfunction primary biliary cirrhosis

HMG-CoA Reductase Inhibitors (Statins): Contraindications

known drug allergy pregnancy liver disease elevation of liver enzyme levels

monitoring for adverse effects of the antilipemics includes periodic :

liver and renal function studies

Niacin is contraindicated in those with :

liver disease, peptic ulcer disease, gout, or active bleeding Instruct patients to take niacin with meals to decrease gastrointestinal upset

HMG-CoA Reductase Inhibitors (Statins): MOA

lower the blood cholesterol level by decreasing the rate of cholesterol production. The liver requires HMG-CoA reductase to produce cholesterol. The statins inhibit this enzyme, thereby decreasing cholesterol production. When less cholesterol is produced, the liver increases the number of LDL receptors to recycle LDL from the circulation back into the liver, where it is needed for the synthesis of other required substances such as steroids, bile acids, and cell membranes.

The statins have gained much attention for their adverse effects of :

muscle aches and pain due to breakdown of muscle tissue some patients experience irreversible renal damage and severe pain and may have to alter dosages or change drugs as ordered by the prescriber

With the HMG-CoA reductase inhibitors or statin drugs, any of these symptoms must be reported to the prescriber immediately:

muscle soreness, change in color of the urine, fever, nausea, vomiting, and/or malaise

Drug and food interactions associated with the statin drugs that must be avoided include:

oral anticoagulants, erythromycin, verapamil, some antifungal drugs, and grapefruit juice.

with antilipemics assess for the presence of any positive risk factors for the detection of cholesterol disorders and other coronary heart disease (CHD) including the following:

prior coronary heart disease peripheral heart disease stroke, age gender family history cigarette smoking high blood pressure diabetes mellitus obesity physical inactivity

HDL Cholesterol

produced in the liver and intestines and is also formed when chylomicrons are broken down. Lipids that are not used by peripheral cells are transferred as cholesterol esters to HDL. HDL then transfers the cholesterol esters to IDL to be returned to the liver. HDL is responsible for the "recycling" of cholesterol. HDL is sometimes referred to as the good lipid (or good cholesterol) because it is believed to be cardioprotective. If the liver has an excess amount of cholesterol, the number of LDL receptors on the liver decreases, which results in an accumulation of LDL in the blood. One explanation for hypercholesterolemia (cholesterol in the blood), therefore, is downregulation (reduced production) of hepatic LDL receptors. A major function of the liver is to manufacture cholesterol, a process that requires acetyl coenzyme A (CoA) reductase. Inhibition of this enzyme thus results in decreased cholesterol production by the liver.

Bile Acid Sequestrants: Interactions

significant drug interactions associated with the use of bile acid sequestrants are limited to effects on the absorption of concurrently administered drugs *all drugs must be taken at least 1 hour before or 4 to 6 hours after the administration of bile acid sequestrants *high doses of a bile acid sequestrant decrease the absorption of fat-soluble vitamins (A, D, E, and K)

which organ is the major organ where lipid metabolism occurs?

the liver

phenotyping

the process of characterizing the patient's specific lipid profile by identifying patterns of hyperlipidemia

antilipemics are highly protein bound and are therefore associated with many drug interactions, including drugs that a dentist may prescribe.

these drugs may alter clotting if taken on a long-term basis This information is also important for the patient to share with the dentist

The risk for CHD in patients with cholesterol levels of 300 mg/dL is :

three to four times greater than that in patients with levels of less than 200 mg/dL.

Lipoproteins (function)

transport lipids via the blood

two primary forms of lipids:

triglycerides and cholesterol 1. Triglycerides function as an energy source and are stored in adipose (fat) tissue. 2. Cholesterol is primarily used to make steroid hormones, cell membranes, and bile acids.

Omega-3 Fatty Acids/Lovaza

used for cholesterol reduction Adverse Effects: Rash, burping, allergic reactions, possible increase in total cholesterol or LDL levels in those patients with a combined hyperlipidemia, weight gain Potential Drug Interactions : Anticoagulant drugs: May prolong bleeding time. There is a theoretical risk of increased bleeding with anticoagulant drugs, but the studies to date are inconclusive. Contraindications: Pregnancy, allergy to fish oil

LDL cholesterol

very-low-density lipoprotein (VLDL) produced by the liver from both endogenous and exogenous sources The major role of VLDL is the transport of endogenous lipids to peripheral cells. Once VLDL is circulating, it is enzymatically cleaved by lipoprotein lipase and then loses triglycerides. This creates intermediate-density lipoprotein (IDL), which is soon also cleaved by lipoprotein lipase to create low-density lipoprotein (LDL). Cholesterol is almost all that remains in LDL after this process. Any tissues that require LDL, such as endocrine cells, have LDL receptors. LDL and about half of IDL are reabsorbed from the circulation into the liver by means of LDL receptors on the liver.

Patients who need to be prescribed a 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%

Metabolic Syndrome : Identifying Features

• Waist circumference greater than 40 inches in men or 35 inches in women • Serum triglyceride level of 150 mg/dL or more • High-density lipoprotein cholesterol level of less than 40 mg/dL in men or less than 50 mg/dL in women • Blood pressure of 130/85 mm Hg or higher • Fasting serum glucose level higher than 100 mg/dL