Pharmacology Ch. 47 Lipid Lowering Agents

Adverse effects of Cholesterol Absorption Inhibitors (Ezetimibe)

-Abdominal pain and diarrhea -Headache, dizziness, fatigue, URI, back pain -Muscle aches and pain

Liproproteins

transport fats in the blood -Chylomicrons made in small intestine wall

MOA of Bile Acid Sequestrants (cholestyramine)

Binds bile acids in the intestine, allows excretion in feces instead of reabsorption and serum cholesterol levels to fall

Hyperlipidemia

High levels of lipids in the blood

What does grapefruit juice do?

INTERFERES WITH FIRST PASS MECHANISM and ENHANCES ABSORPTION of the drug and can lead to a toxicity 2-3x the normal therapeutic amount of the drug.

When should a statin be administered? Before breakfast With morning medications Midafternoon In the evening

In the evening

When would you administer HMG-CoA reductase inhibitors (statins)?

before bed or in the evening

What is the peak production time for the liver?

between 4-5 am

Do you want high or low fasting blood sugar levels in your blood?

low

Breakdown of muscle could be life-threatening. This relates to...

rhabdomyolysis

Which is a bile acid sequestrant? Colestipol Lovastatin Evolocumab Lomitapide

Colestipol

Which is a modifiable risk factor for coronary artery disease? Age Family history Diabetes Menopause

Diabetes

What is HMG-CoA?

an enzyme in the liver that produces LDL cholesterol

Which juice should be avoided when taking a statin? Orange Apple Grapefruit Pineapple

Grapefruit

Which is considered "neutral fat"? High-density lipoprotein Low-density lipoprotein Phospholipids Triglycerides

Triglycerides

MOA of Fenofibric acid (Trilipix)

Activates hepatic receptors to increase the breakdown of lipids, elimination of triglyceride-rich particles from plasma, reduction in production of an enzyme that inhibits lipid breakdown.

Indications of HMG-CoA reductase inhibitors (statins)

-Adjunct to diet and exercise to treat increased cholesterol, triglycerides, and LDL unresponsive to dietary restrictions -Slow progression of ASCVD -Assist with the prevention of MI, stroke, and revascularization procedures in patients with multiple ASCVD risk factors (plague and clotting buildup in vessels) -hyperlipidemia

Cholesterol

-Base unit for formation of steroid hormones -Basic unit in formation and maintenance of cell membranes

Name classifications of Lipid-Lowering Agents

-Bile acid sequestrants -HMG-CoA reductase inhibitors -Cholesterol absorption inhibitor -PCSK9 inhibitors -Others that do not fall into these classes but are approved in combination with changes in diet and exercise

drug-drug interactions of Cholesterol Absorption Inhibitors (Ezetimibe)

-Bile acid sequestrants, Statins, Cyclosporine and fibrates, Fenofibrate -Warfarin

Causes of hyperlipidemia

-Excessive dietary intake of fats -Genetic alterations in fat metabolism -Dietary modifications are usually a successful treatment. -Drug therapy is needed if the cause is genetically linked to alterations in lipid levels or if dietary limits do not decrease serum levels adequately. -Excessive dietary intake of fats -Genetic alterations in fat metabolism lead to a variety of elevated fats in the blood -Hypercholesterolemia, hypertriglyceridemia, alterations in LDL and HDL concentrations

Unmodifiable Risk Factors for CAD

-Genetic Predisposition -Age -Gender

Name the three fibrates

Fenofibrate (Tricor and others) Gemfibrozil (Lopid) Fenofibric acid (Trilipix)

Hyperlipidemia is considered to be a... normal finding in adult males. condition related to stress levels. treatable ASCVD risk factor. side effect of cigarette smoking.

treatable ASCVD risk factor.

Modifiable Risk Factors for CAD

-Gout -Cigarette smoking -Sedentary lifestyle -Unhealthy diet -High-stress levels -Hypertension -High blood cholesterol levels -Obesity -Diabetes -Other factors that if untreated may contribute to ASCVD

MOA of Vitamin B3 (Niacin [Niacor, Niaspan])

-Inhibits release of free fatty acids from adipose tissue -Increases rate of triglyceride removal from plasma -Generally reduces LDL and triglyceride levels and increases HDL levels -May decrease levels of apoproteins needed to form chylomicrons -this med has many drug-drug interactions, so check the reconciliation list -very cheap, inexpensive, OTC

What type of Lipoproteins are produced in the liver?

-Very-low-density lipoproteins (VLDLs) -Intermediate-density lipoproteins (IDLs) -Low-density lipoproteins (LDLs) -High-density lipoproteins (HDLs)

Specific nursing interventions for Bile Acid Sequestrants (cholestyramine)

-comes in fluid form and mixed with fluid, otherwise no chewing, crushing, or scoring pills -must check dosage directions on the label

A patient who recently started taking a statin reports new muscle cramps and weakness. What is the nurse's priority intervention? Encourage stretching and weight lifting. Assess for rhabdomyolysis. Review previously documented strength assessments. Increase the dose of the statin since it is not working.

Assess for rhabdomyolysis.

Atorvastatin (Lipitor) is an example of which? PCSK9 inhibitor Cholesterol absorption inhibitor Fibrate HMG-CoA reductase inhibitor

HMG-CoA reductase inhibitor

MOA of HMG-CoA reductase inhibitors (statins)

Block HMG-CoA from completing synthesis of cholesterol, decreasing LDL levels and slightly increasing HDL levels -May have protective CV effects on blood vessels -vasodilation

Can Cholesterol Absorption Inhibitors (Ezetimibe) be combined or taken alone?

Both Use as an adjunct with statin may help lower total and LDL cholesterol Also used as an adjunct with a fenofibrate for familial hyperlipidemia Can also be used as monotherapy

Which diagnosis is often an indication for a prescription for a statin? Hypertension Coronary artery disease Atrial fibrillation Ventricular tachycardia

Coronary artery disease

Adverse effects of Bile Acid Sequestrants (cholestyramine)

Headache, fatigue, and drowsiness Direct GI irritation - Nausea, constipation Increased bleeding times Fecal impaction Obstruction of bowel Vitamin A and E deficiencies Muscle aches and pains (in large muscles, ex. shoulders, buttocks, thighs, etc.)

When would you mainly hold HMG-CoA reductase inhibitors (statins)?

If any pain is present.

Rule of thrumb for choosing a Omega-3-Fatty Acid

EPA + DHA - 500mg-2G qday combined -If you add EPA and DHA amount, you want it no less than 500 mg in total, or else you wont feel any therapeutic effects

Which of the following descriptions accurately reflects how the body uses cholesterol? Production of water-soluble vitamins Formation of steroid hormones Mineralization of bones Development of dental plaques

Formation of steroid hormones

Adverse effects of HMG-CoA reductase inhibitors (statins)

GI symptoms: Flatulence, abdominal pain, cramps, nausea, vomiting, and constipation CNS: Headache, dizziness, blurred vision, insomnia, fatigue -Liver failure -Rhabdomylosis

Patients taking "statins" should be advised to completely avoid which because it alters the metabolism of the drugs? Grapefruit juice Tomatoes Bananas Cranberry juice

Grapefruit juice

MOA of Fenofibrate (Tricor and others)

Increases lipolysis and elimination of triglycerides Increases uric acid secretion

MOA of Gemfibrozil (Lopid)

Inhibits peripheral breakdown of lipids Reduces production of triglycerides and LDLs Increases HDL concentrations

When does combination therapy occur?

Initiated if the patient shows no response to strict dietary modification, exercise, and lifestyle changes with the use of one agent. Example: bile acid sequestrant combined with niacin -Decreases synthesis of LDLs; lower serum levels of LDLs -Thought to help the progression of ASCVD Care must be taken not to combine agents that raise the risk of rhabdomyolysis.

Why do many patients not like taking Bile Acid Sequestrants (cholestyramine)?

It is usually because they don't want to worry about using the toilet several times a day since it increases GI motility. -constipation and/or diarrhea

What do lipid lowering agents do overall to the body?

Lower serum levels of cholesterol and various lipids

Indications of Cholesterol Absorption Inhibitors (Ezetimibe)

Lower serum total cholesterol levels

Drug-drug interactions of Bile Acid Sequestrants (cholestyramine)

Malabsorption of fat-soluble vitamins -Thiazide diuretics, digoxin, warfarin, thyroid hormones, and corticosteroids (good HDL fat may not be fully absorbed-check labs)

Drug-drug interactions of HMG-CoA reductase inhibitors (statins)

Medications that suppress CYP3A4, fibrates, ezetimibe -Grapefruit juice

Which would alert the nurse to suspect that a patient receiving HMG-CoA reductase inhibitors is developing rhabdomyolysis? Flatulence and abdominal bloating Increased bleeding and bruising Development of cataracts and blurred vision Muscle pain and weakness

Muscle pain and weakness

Which would the nurse expect the health care provider to prescribe for a patient who has high lipid levels and cannot take fibrates or HMG-CoA reductase inhibitors? Nicotine Vitamin C PCSK9 inhibitor Nitrates

PCSK9 inhibitor

Which lab values does not need to be assessed routinely when a patient is on a statin? High-density lipoprotein (HDL) Low-density lipoprotein (LDL) Liver function tests Partial thromboplastin time (PTT)

Partial thromboplastin time (PTT)

Indications of Bile Acid Sequestrants (cholestyramine)

Reduces elevated serum cholesterol in patients with primary hypercholesterolemia, pruritus associated with partial biliary obstruction

Most important nursing intervention of Cholesterol Absorption Inhibitors (Ezetimibe)

Watch LDL levels and look for a positive response in the body that it imposes. -if the med blocks absorption in small intestine, defer which nutrients it might be blocking, then provide supplements or further interventions.

MOA of Cholesterol Absorption Inhibitors (Ezetimibe)

Works in the brush border of the small intestine to inhibit the absorption of cholesterol

The formation of atheromas in blood vessels precedes the signs and symptoms of... hepatitis. atherosclerotic cardiovascular disease. diabetes mellitus. chronic obstructive pulmonary disease (COPD).

atherosclerotic cardiovascular disease.

Omega-3-acid ethyl esters (Lovaza): Omega-3-Fatty Acids

combination of omega-3 fatty acids and an activator that inhibits liver enzyme systems to decrease the synthesis of triglycerides

Omega-3-carboxylic acids (Epanova): Omega-3-Fatty Acids

fish oil mixture of free fatty acids approved as an adjunct to diet to reduce triglyceride levels in adults with severe hypertriglyceridemia

Diet high in saturated fat ______cholesterol production in liver.

increases

When teaching a patient about HMG-CoA reductase inhibitors, the nurse would include that the patient will not have a heart attack. will not develop ASCVD. might develop cataracts as a result. might stop absorbing fat-soluble vitamins.

might develop cataracts as a result.

The bile acid sequestrants are absorbed into the liver. take several weeks to show an effect. have no associated adverse effects. prevent bile salts from being reabsorbed.

prevent bile salts from being reabsorbed.

HMG-CoA reductase inhibitors work in the process of bile secretion. process of cholesterol formation in the cell. intestinal wall to block fat absorption. kidney to block fat excretion.

process of cholesterol formation in the cell.