chp 10 drug therapy for dyslipidemia pharm

PREVENTING INTERACTIONS: Cholestyramine may decrease absorption of many oral medications like:

-digoxin -folic acid -glipizide -propranolol -tetracyclines -thiazide diuretics -thyroid hormones -fat-soluble vitamins -warfarin

Herbs and Foods That Increase the Effects of Atorvastatin:

-grapefruit juice -pomegranate juice -red yeast rice -sitostanol -vitamin B3

Ezetimibe (Zetia) adverse effects:

-headache -diarrhea -hypersensitivity reactions such as rash, and nausea.

Niacin (nicotinic acid) contraindications:

-hypersensitivity -active hepatic disease -unexplained hepatic dysfunction -active peptic ulcer

Fenofibrate (TriCor) contraindications:

-hypersensitivity to fibrates -hepatic or (severe) renal impairment -preexisting gallbladder disease -primary biliary cirrhosis -persistent liver function abnormalities of unknown origin.

Red Yeast Rice:

-Total and LDL cholesterol: decreased. -Triglycerides: no significant effect. -Dosage standardization is a concern, and information about long-term safety is unavailable.

Ezetimibe (Zetia) contraindications:

-pregnancy and lactation -hypersensitivity to ezetimibe or concomitant use with a statin in people with active hepatic disease.

Atorvastatin (Lipitor) contraindications:

-pregnant women -lactation, because the drugs are secreted in breast milk, and hypersensitivity to statins.

Atorvastatin (Lipitor) pharmacokinetics:

-rapidly absorbed following oral administration -metabolism : liver, which results in low levels of drug available for general circulation. -Peak effect occurs in 1 to 2 hours. -Food decreases the rate and extent of absorption. -excreted in feces & urine

chp 10 drug therapy for dyslipidemia page 171

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Assessing for adverse effects of Fenofibrate (TriCor):

-GI disturbances as well as elevated liver function tests are common. -Reportedly, hypersensitivity reactions, myopathy, rhabdomyolysis, blood dyscrasias, hepatotoxicity, cholelithiasis, cholestatic jaundice, pancreatitis, and reduced libido also occur -Risk of myopathy increases with concomitant use of statins.

Cholesterol Absorption Inhibitor: Whats the prototype? Describe this class.

-Act in the small intestine to inhibit absorption of cholesterol and decrease the delivery of intestinal cholesterol to the liver, resulting in reduced hepatic cholesterol stores and increased clearance of cholesterol from the blood. -This distinct mechanism is complementary to that of HMG-CoA reductase inhibitors, producing synergistic cholesterol-lowering effects when these drugs are used in combination. -Ezetimibe reduces total cholesterol and triglycerides and increases HDL cholesterol. -PROTOTYPE: Ezetimibe (Zetia)

Drugs That Increase the Effects of Niacin:

-Alcohol -Leflunomide -Statins and zidovudine

HMG-CoA Reductase Inhibitors.. whats the prototype? Describe this class. THEY ALL END IN STATIN.

-Atorvastatin (Lipitor), one of the most widely used drugs in the United States, is the prototype of the class of drugs called the hydroxymethylglutaryl-coenzyme A (HMG-CoA) reductase inhibitors, or statins. -By decreasing production of cholesterol, the statins decrease total serum cholesterol, LDL cholesterol, VLDL cholesterol, and triglycerides. -They reduce LDL cholesterol within 2 weeks and reach maximal effects in approximately 4 to 6 weeks. -HDL cholesterol levels remain unchanged or may increase

Atorvastatin (Lipitor) use:

-Atorvastatin and the other statins are indicated for the treatment of hypercholesterolemia and reducing cardiovascular events in people with multiple risk factors. -The statins are the most powerful drug class for reduction of LDL cholesterol. -They result in an 18% to 55% decrease in LDL levels, as well as a 5% to 15% increase in HDL levels and a 7% to 30% decrease in triglycerides.

Atorvastatin (Lipitor) administering the medication:

-Because the bulk of cholesterol synthesis appears to occur at night, administration of statins normally takes place in the evening or at bedtime. -However, atorvastatin has a long half-life, and evidence suggests that the drug can be given without regard to time of day. -There is no definitive global recommendation for the entire class; thus, the timing of administration of statins should be based on manufacturer recommendations.

Drugs That Decrease the Effects of Niacin:

-Bile acid sequestrant drugs

Drugs That Decrease the Effects of Atorvastatin:

-Cholestyramine -Colestipol

Bile Acid Sequestrants: Whats the prototype?

-Cholestyramine (Prevalite, Questran) -This drug 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. -There is no evidence that cholestyramine can be used as monotherapy, but it can play a role as an add-on drug with statins or niacin in combination therapy.

Assessing for adverse effects of Atorvastatin (Lipitor):

-Common adverse effects include nausea, diarrhea, abdominal pain, dyspepsia, and elevated liver function tests. -The nurse monitors for signs or symptoms of muscle pain or weakness, mainly during the first months of therapy and when dosages are adjusted upward. -If unexplained severe muscle symptoms, fatigue, or cola-colored urine develop, the statin should be held and the prescriber notified to address the possibility of rhabdomyolysis.

Fenofibrate (TriCor) pharmacokinetics:

-Fenofibrate is administered orally and is highly protein bound, primarily to albumin. -Time-to-peak effect is 6 to 8 hours. -Metabolism occurs in the liver and excretion is by urinary elimination.

Herbs and Foods That May Decrease the Effects of Atorvastatin:

-Fibers such as oat bran and pectin

FIBRATES: Describe this class, whats the prototype?

-Fibrates are derivatives of fibric acid and are similar to endogenous fatty acids. -Prototype is: Fenofibrate (TriCor)

Fenofibrate (TriCor) use in patients with renal impairment:

-Fibrates are excreted mainly by the kidneys; they accumulate in the serum of patients with renal impairment. -Fenofibrate is contraindicated in patients with severe renal impairment, and the recommended starting dose is 67 mg/d in pts w a creatinine clearance of less than 50 mL/min. -It is necessary to evaluate the effects of this dose effects on renal function and to check triglyceride levels before increasing this dose. -Fibrates may cause a reversible elevated serum creatinine. -Patients with diabetes require close monitoring because renal disease is a serious complication in this population.

Fenofibrate (TriCor) use:

-Fibrates are the most effective drugs for reducing serum triglyceride values, and their main indication for use is high serum triglycerides -They are also helpful for patients with low HDL cholesterol levels -Fibrates are the drug of choice for hypertriglyceridemia associated with diabetes, gout, gastritis, or ulcer disease (niacin may worsen these conditions). -There are no specific recommendations for use of these drugs in patients who are critically ill; drug interactions and adverse effects may restrict their use in critical illness.

Fenofibrate (TriCor) use in patients with hepatic impairment:

-Fibrates may cause hepatotoxicity. -Abnormal elevations of serum aminotransferases have occurred with both gemfibrozil and fenofibrate, but they usually subside after the drug is discontinued. -Contraindications to fenofibrate include severe hepatic impairment, including primary biliary cirrhosis, and persistent elevations in liver function tests and preexisting gallbladder disease.

Administering Niacin (nicotinic acid):

-Formulations of niacin (immediate release, timed release) are not interchangeable. -It is necessary to give immediate-release niacin with meals because it may cause gastric irritation. -In contrast, patients may take timed-release niacin without regard to meals.

Nursing: Administering Cholestyramine (Prevalite, Questran) :

-It is necessary to mix cholestyramine powder with water or other fluids, soups, cereals, or fruits such as applesauce and to follow with more fluid. -The nurse ensures that the drug is not taken in a dry form. -It is essential that cholestyramine not be given with other drugs; to minimize altered absorption, people should take the other drugs 1 hour before or 4 to 6 hours after cholestyramine.

Soy:

-LDL cholesterol: benefit at most small. -Triglycerides: no significant effect. -Intake of soy proteins may have other beneficial vascular effects

Garlic:

-LDL cholesterol: no significant effect. -Triglycerides: no significant effect. -Bleeding may be increased when garlic is combined with anticoagulants, and insulin doses may need to be decreased as a result of the hypoglycemic effect of garlic

Herbs and Foods Reported to Have Evidence-Based Effects on Cholesterol and Triglyceride Levels. Flaxseed:

-Low-density lipoprotein (LDL) cholesterol: decreased with flaxseed and flaxseed lignans; no apparent decrease with flaxseed oil. -Triglycerides: no apparent effect. -Absorption of all medications may be decreased when taken with flax, resulting in a less than therapeutic effect.

Drugs That Increase the Effects of Atorvastatin:

-Magnesium- and aluminum-containing antacids -Amiodarone and colchicine -Azole antifungals -Cyclosporine, CYP3A inhibitors, diltiazem, fibric acid derivatives, niacin, and verapamil -Erythromycin, macrolide antibiotics, nefazodone, and protease inhibitors

Atorvastatin (Lipitor) adverse effects:

-Most common adverse effects (nausea, constipation, diarrhea, abdominal cramps or pain, headache, skin rash) are usually mild and transient. -Hepatic dysfunction has been a source of concern, although the actual risk appears to be small. -Myopathies are important adverse effects and can range from discreet muscle pain to rhabdomyolysis. -Statins can injure muscle tissue, resulting in muscle ache, pain, or weakness.

Miscellaneous Dyslipidemic Agent: What is the prototype? Describe this class.

-Niacin (nicotinic acid) is a vitamin that decreases LDL and increases HDL cholesterol, and it serves as the prototype. -Over-the-counter preparations of niacin are not federally regulated in the United States, and preparations that are marketed as causing "no flush" may have no free nicotinic acid and are therefore ineffective in treating dyslipidemia. -Some formulations of sustained-release OTC niacin have been associated with an increased risk of hepatotoxicity.

Niacin (nicotinic acid) use:

-Niacin the most effective drug for increasing the concentration of HDL cholesterol, is most helpful in preventing heart disease when used in combination with another dyslipidemic drug such as a bile acid sequestrant or a fibrate. -Serious concerns have been raised about its safety and efficacy in combination with statin therapy. -No specific recommendations exist for use of niacin in patients who are critically ill, although drug interactions and adverse effects may restrict its use in these patients.

Niacin (nicotinic acid) adverse effects:

-Poor tolerability often limits the advantages of niacin; the high doses required for dyslipidemic effects result in adverse effects -skin flushing -pruritus -gastric irritation -tachycardia -hypotension -dizziness -hyperglycemia -hyperuricemia -elevated liver aminotransferases -hepatitis

Fenofibrate and other fibric acid derivatives may enhance the hypoprothrombinemic effect of warfarin-type oral anticoagulants, increasing the risk of bleeding. Patients receiving warfarin concurrently require a substantially decreased dosage of warfarin because fibrates displace warfarin from binding sites on serum albumin. Drugs That Increase the Effects of Fenofibrate:

-Statins -Cyclosporine

Fenofibrate (TriCor) adverse effects:

-The main adverse effects are GI discomfort and diarrhea, which may occur less often with fenofibrate than with other fibrates. -Fibrates may also increase cholesterol concentration in the biliary tract and formation of gallstones.

Assessing for therapeutic effects of Fenofibrate (TriCor):

-The nurse assesses for decreased levels of total serum cholesterol, LDL cholesterol, and triglycerides and increased levels of HDL cholesterol. -With fibrates, effects occur in approximately 1 month

Assessing for therapeutic effects of Niacin (nicotinic acid):

-The nurse assesses for decreased levels of total serum cholesterol, LDL cholesterol, and triglycerides, as well as increased levels of HDL cholesterol. -Effects occur in approximately 1 month.

Assessing for therapeutic effects of Atorvastatin (Lipitor):

-The nurse monitors lipid response to therapy, looking for decreased levels of total serum cholesterol, LDL cholesterol, and triglycerides, as well as increased levels of HDL cholesterol. -Effects occur in 1 to 2 weeks, with maximum effects in 4 to 6 weeks.

Niacin (nicotinic acid) use in the older adults:

Although niacin is effective in older adults, these patients do not tolerate the adverse effects of the drug well.

Atorvastatin (Lipitor) use in the older adults:

As in younger adults, diet, exercise, and weight control should be tried first to reduce cholesterol levels. When drug therapy is required, statins are effective for lowering LDL cholesterol and usually are well tolerated by older adults.

What are the other drugs in this class?

Atorvastatin (Lipitor) Pravastatin (Pravachol) Rosuvastatin (Crestor) Simvastatin (Zocor) Lovastatin (Mevacor) Fluvastatin (Lescol)

Atorvastatin (Lipitor) use in hepatic patients:

Atorvastatin and other statins, which are metabolized in the liver, may accumulate in patients with impaired hepatic function. they are contraindicated in patients with active liver disease or unexplained elevations of serum aspartate aminotransferase or alanine aminotransferase. These drugs should be used cautiously, in reduced dosages, for patients who ingest substantial amounts of alcohol or who have a history of liver disease.

To lower triglycerides, whats used?

gemfibrozil, ezetimibe, a cholesterol absorption inhibitor, or niacin may be given.

Fenofibrate (TriCor) use in home care:

Because liver enzyme tests are recommended, patients who are housebound may need assistance in obtaining blood tests (like lipids, liver function tests). The nurse advises patients to notify their health care provider if unexplained muscle pain or tenderness occurs. Increasing availability of home cholesterol-monitoring devices will require additional patient teaching about technique and interpretation of the results.

Atorvastatin (Lipitor) use in patients receiving home care:

Because liver enzymes may be elevated during atorvastatin use, patients need liver function tests and repeat lipid profile testing on a routine basis. Increasing availability of home cholesterol-monitoring devices will require additional patient teaching about technique and interpretation of the results. Patients should notify their health care provider if unexplained muscle pain or tenderness occurs

Drugs That Decrease the Effects of Ezetimibe:

Bile acid sequestrant drugs

Drugs That Decrease the Effects of Fenofibrate:

Bile acid sequestrant drugs

Fenofibrate (TriCor) use in older adults:

Caution is warranted with dosage determination. For fenofibrate, lower starting dosages are recommended (67 mg/d)

Cholestyramine (Prevalite, Questran) use in older adults:

Cholestyramine and other bile acid sequestrants are effective in older adults, although these individuals do not tolerate the adverse effects well.

Cholestyramine (Prevalite, Questran) action:

Cholestyramine binds bile acids in the intestinal lumen, causing the bile acids to be excreted in feces, preventing recirculation to the liver. Loss of bile acids stimulates hepatic synthesis of more bile acids from cholesterol. As more hepatic cholesterol is used to produce bile acids, more serum cholesterol moves into the liver to replenish the supply, thereby lowering serum cholesterol (primarily LDL).

Cholestyramine (Prevalite, Questran) use in hepatic impairment:

Cholestyramine can further raise serum cholesterol. Therefore, its use in people with primary biliary cirrhosis warrants caution.

Cholestyramine (Prevalite, Questran) contraindications:

Cholestyramine is contraindicated in people with complete biliary obstruction, because bile is not secreted into the intestine. The drug can bind with vitamin K; therefore, use in individuals with any coagulopathy requires caution.

Adverse effects of Cholestyramine (Prevalite, Questran):

Cholestyramine is not absorbed systemically, so the main adverse effects are GI ones like abdominal fullness, flatulence, diarrhea, and constipation -Constipation is especially common, and a bowel program may be necessary to control this problem.

Cholestyramine (Prevalite, Questran) pharmacokinetics:

Cholestyramine is not absorbed when taken orally. Therefore, the drug is excreted in feces essentially unchanged.

Cholestyramine (Prevalite, Questran) use:

Cholestyramine reduces LDL cholesterol levels (15%-30%) and also produces a minimal elevation in HDL cholesterol (3%-5%)

Ezetimibe (Zetia) use in patients with hepatic impairment:

Dosage adjustment of ezetimibe is necessary in patients with mild hepatic impairment. The drug is not recommended in patients with moderate to severe hepatic impairment.

Drugs That Increase the Effects of Ezetimibe:

Cyclosporine

Cholestyramine (Prevalite, Questran) use in renal impairments:

Extended use of cholestyramine in patients with renal impairment requires caution because the drug releases chloride. This effect can increase the risk of hyperchloremic metabolic acidosis.

Ezetimibe (Zetia) action:

Ezetimibe blocks biliary and dietary cholesterol absorption at the brush border of the intestine without affecting absorption of fat-soluble vitamins and triglycerides.

Ezetimibe (Zetia) pharmacokinetics:

Ezetimibe is significantly protein bound, is metabolized in the small intestine and liver, and is excreted predominately in feces. The time-to-peak effect is 4 to 12 hours

Ezetimibe (Zetia) use:

Ezetimibe is used together with dietary management for treatment of primary dyslipidemia. It can be used as monotherapy on in combination with a statin. When given as monotherapy (without a statin), ezetimibe does not require dosage reduction in geriatric patients.

Administering Ezetimibe (Zetia):

Ezetimibe may be administered with or without food. The patient takes the drug: -At the same time each day -At night if used in combination with a statin (Ezetimibe may be given at the same time as a statin.) -Either 2 hours before or 4 hours after bile sequestrants to prevent altered absorption

Fenofibrate (TriCor) action:

Fenofibrate and other fibrates increase the oxidation of fatty acids in liver and muscle tissue. Therefore, they decrease hepatic production of triglycerides, decrease VLDL cholesterol, and increase HDL cholesterol.

Assessing for adverse effects of Niacin (nicotinic acid):

Flushing of the face and neck, pruritus, and skin rash may occur. Other adverse effects include tachycardia, hypotension, and dizziness.

__________, rather than niacin, is usually preferred for people with diabetes because niacin increases blood sugar.

Gemfibrozil

Atorvastatin (Lipitor) use in renal patients:

In renal impairment, plasma levels are not affected, and dosage reductions are not necessary.

Adminsitering Fenofibrate (TriCor):

It is necessary to give fenofibrate with food to increase drug absorption

Niacin (nicotinic acid) action:

Niacin inhibits mobilization of free fatty acids from peripheral tissues, thereby reducing hepatic synthesis of triglycerides and secretion of VLDL, which leads to decreased production of LDL cholesterol. The drug also raises HDL levels by reducing lipid transfer of cholesterol from HDL to VLDL and by delaying clearance of HDL.

Niacin (nicotinic acid) pharmacokinetics:

Niacin is rapidly absorbed from the GI tract, with peak effect in about 45 minutes. Minimal metabolism occurs through the liver, and the majority of the drug is excreted unchanged in the urine.

Niacin (nicotinic acid) use in renal impairments:

Niacin may cause hepatotoxicity; thus, it is contraindicated in patients with hepatic impairment.

Niacin (nicotinic acid) use in patients wit renal impairments:

Niacin should be used with caution in patients with renal impairment.

REMEMBER THIS : LABS. REMEMBER THESE ARE YOUR LADIES. TOTAL SERUM CHOLSTEROL : LDL: HDL: TRIGLYCERIDES:

TOTAL SERUM CHOLSTEROL : 200 (if greater its bad, if lower its good) LDL: below 100 (is good kind of) HDL: (above 40 but below 60 = good) TRIGLYCERIDES: below 150 good LDL is bad cholerstrol HDL is good cholsterol, we can control this by exercising

Assessing for adverse effects of Cholestyramine (Prevalite, Questran) :

The most common adverse effect is constipation. Other conditions relate to GI effects: abdominal discomfort or pain, nausea, vomiting, flatulence, diarrhea, anorexia, and steatorrhea. Increased bleeding tendencies may result from vitamin K malabsorption

What should you teach your patients about Cholestyramine (Prevalite, Questran) ?

The nurse assesses the adequacy of levels of fat-soluble vitamins A, D, E, and K; supplementation may be required. Good dental hygiene is important because holding the mixture in the mouth can damage the teeth. Some products may contain aspartame or sugar, so caution is necessary in patients with phenylketonuria or diabetes mellitus.

Nursing implications for Ezetimibe (Zetia):

The nurse instructs patients to maintain a low-cholesterol diet during ezetimibe therapy. Patients should report side effects to their health care providers

What should you teach your patients about Fenofibrate (TriCor)?

The nurse instructs patients to report signs and symptoms of adverse effects to the health care provider. Throughout drug therapy, patients should have periodic blood tests. look at box 10.5

What should you teach your patients about Ezetimibe (Zetia)?

The nurse instructs patients to report signs and symptoms of adverse effects to the health care provider. Throughout drug therapy, patients should have periodic blood tests. See Box 10.5 for general patient information.

Assessing for therapeutic effects of Ezetimibe (Zetia):

The nurse monitors lipid response to therapy with ezetimibe. Desired results include decreases in total cholesterol, LDL cholesterol, and triglycerides, with increases in HDL cholesterol. A therapeutic response occurs within 2 weeks of initiation of therapy and lasts as long as the drug is continued.

Assessing for therapeutic effects of Cholestyramine (Prevalite, Questran) :

The nurse observes for decreased levels of total serum cholesterol, LDL cholesterol, and triglycerides and increased levels of HDL cholesterol. Maximum effects occur in approximately 1 month.

Assessing for adverse effects of Ezetimibe (Zetia):

The nurse observes for headache, dizziness, fatigue, diarrhea, and abdominal pain.

What should you teach your patients about Niacin (nicotinic acid)?

The nurse tells patients that tablet strengths are not interchangeable and not to substitute immediate-release forms with long-acting ones. Patients should swallow sustained-release preparations whole. See Box 10.5 for general patient teaching information.

Nursing implications for Atorvastatin (Lipitor):

The statins are the most effective dyslipidemic agents for improving clinical outcomes when used for primary and secondary prevention of cardiovascular disease. The choice and use of statins are based on a number of factors, including the degree of dyslipidemia, a specific drug's actions, drug interactions, the presence of renal or liver impairment, and cost.

Atorvastatin (Lipitor) action:

The statins inhibit an enzyme (HMG-CoA reductase) required for hepatic synthesis of cholesterol. In part, metabolism involves one or more hepatic cytochrome P450 enzymes (including CYP2D6), leading to an increased risk of drug interactions and problems with certain foods like grapefruit juice.

Over the past century, evidence has shown that LDLs are the major risk factor for arteriosclerotic cardiovascular disease. In fact, in every mammalian species ever studied, elevated plasma LDL levels produce atherosclerosis. At any level of LDL, the likelihood of a myocardial infarction is increased in the presence of known cardiovascular risk factors, such as cigarette smoking and hypertension. Researchers linked the contribution of the compound 3-hydroxy-3-methylglutarate attached to coenzyme A (HMG-CoA) to the synthesis of cholesterol, which led to a revolution in the management of hypercholesterolemia.

This discovery then led to the broad use of HMG-CoA reductase inhibitors, or statins. Evidence from multiple studies regarding statins has demonstrated that the frequency of myocardial infarctions can be significantly reduced by lowering LDL even when inflammation and risk factors are present. Although these contributory factors are important, they all require LDL to initiate the lesion.

What is your teaching for Atorvastatin (Lipitor) to your patients?

Women of childbearing age should receive contraceptive counseling to enhance awareness of the risks associated with statin use. In addition, education should focus on the importance of monitoring liver function on a regular basis. Liver function tests are recommended before starting a statin, at 12 weeks after starting the drug, at every increase in dose, and then periodically. The nurse monitors patients with increased serum aminotransferases until the abnormal values resolve. If the increases are more than three times the upper limit of normal levels and persist, it is necessary to reduce the dose or change the drug.

LDL cholesterol levels decrease within a week of starting cholestyramine and other bile acid sequestrants and reach maximal reductions within a month. When the drugs are stopped, pretreatment LDL cholesterol levels return within...

a month

Dyslipidemic drugs act by altering the production, absorption, metabolism, or removal of lipids and lipoproteins. Depending on cardiovascular risk, drug therapy is initiated after 6 months of dietary and other lifestyle changes fail to decrease dyslipidemia to an acceptable level. It is also recommended for patients with signs and symptoms of coronary heart disease, a strong family history of coronary heart disease or dyslipidemia, or other risk factors for atherosclerotic vascular disease (e.g., hypertension, diabetes mellitus, cigarette smoking). Although several dyslipidemic drugs are available, none is effective in all types of dyslipidemia, so drug selection is based on the type of dyslipidemia and its severity. To lower cholesterol using a single drug, what is preferred?

a statin is preferred.

To lower cholesterol and triglycerides, what is used?

a statin, a cholesterol absorption inhibitor, gemfibrozil, a fibrate, or the vitamin niacin may be used.

Dyslipidemia:

abnormal lipid levels in the blood; associated with atherosclerosis and its many pathophysiologic effects (e.g., myocardial ischemia and infarction, stroke, peripheral arterial occlusive disease)

Central adiposity:

accumulation of abdominal fat, resulting in an increased waist circumference

Factors that increase the risk of rhabdomyolysis include :

advanced age, frail or small body frame, high dosage of statins, concomitant use of drugs that interfere with CPY3A4 including fibrates, hypothyroidism, and multiple systemic diseases such as renal insufficiency secondary to diabetic nephropathy

Also, the nurse teaches patients that these drugs are used mainly to reduce LDL cholesterol further in those who are already taking a statin drug. The inhibition of cholesterol synthesis by a statin drug makes bile acid-binding drugs more effective. In addition, the combination increases HDL cholesterol and can further reduce the risk of :

cardiovascular disorders

Metabolic syndrome:

cluster of several cardiovascular risk factors linked with obesity: -increased waist circumference -elevated triglycerides -reduced high-density lipoprotein cholesterol -elevated blood pressure -elevated fasting glucose

Cholesterol:

component of cell membrane that is produced and processed in the liver; a fat essential for the formation of steroid hormones that is produced in cells and taken in by dietary sources

Dyslipidemic drugs are used to :

decrease blood lipids, prevent or delay the development of atherosclerotic plaque, promote the regression of existing atherosclerotic plaque, and reduce morbidity and mortality from atherosclerotic cardiovascular disease (ASCVD).

Elevated blood lipids are a major risk factor for atherosclerosis and cardiovascular disorders such as coronary artery disease and stroke. Therapeutic lifestyle changes (including dietary modification, physical activity, and smoking cessation) have been the cornerstone of population-based interventions to manage dyslipidemia. However, making the commitment is often insufficient to achieve recommended treatment targets. When lifestyle changes alone do not reduce blood lipids, ________ are used in the management of patients with elevated blood lipids.

dyslipidemic drugs

In addition, hepatitis (hepatocellular, chronic active, and cholestatic) has reportedly occurred after use of fenofibrate from a few weeks to several years. It is necessary to monitor liver function during the first year of drug administration. Discontinuation of the drug is warranted if :

elevated enzyme levels persist at more than three times the normal limit.

Herbs and foods that increase the effects of cholestyramine include:

fibers such as oat bran and pectin. -No herbs and foods seem to decrease the effects of cholestyramine.

Absorption following oral administration varies depending on the drug. Lovastatin and pravastatin are poorly absorbed, and fluvastatin has the highest rate of absorption. Most of the statins undergo extensive first-pass metabolism by the liver, which results in low levels of drug available for general circulation. Patients may take pravastatin or simvastatin with or without food in the evening. They may take fluvastatin on an empty stomach or at bedtime. It is important to avoid taking them with:

grapefruit juice -Note that concurrent use of cimetidine, ranitidine, and omeprazole increases the effects of fluvastatin.

QSEN Alert: Safety When women of childbearing age are treated with drug therapy for dyslipidemia, adequate patient education is critical to minimize complications associated with pregnancy. The absolute risk of teratogenicity with the use of statins appears to be relatively small; however, the use of birth control measures with statin use is essential in sexually active women. Careful consideration should be given if potential benefits warrant use of the drug class in pregnant women despite potential risks. The nurse advocates in the patient's care.

jk

A lipid profile consists of a total cholesterol, HDL cholesterol, LDL cholesterol, and triglycerides. For accurate interpretation, blood samples for laboratory testing of triglycerides should be drawn after the patient has fasted for 12 hours. Fasting does not appear to be required for cholesterol testing. However, since triglycerides require fasting, and guidelines for interpreting nonfasting levels for evaluating cardiovascular risk have not been established; therefore, fasting is recommended prior to tests for a lipid profile.

jk.

Flushing may occur with niacin administration. This reaction can be reduced by starting with small doses, gradually increasing doses, taking doses with meals, and taking 325 mg of aspirin about 30 minutes before or 200 mg of ibuprofen about 60 minutes prior to administering niacin.

jk.

The efficacy of oral hypoglycemic agents and insulin may be diminished by niacin, which may affect glucose control. Herbs and foods that increase the effects of niacin include:

red yeast rice.

Lipoproteins:

specific proteins in plasma that transport blood lipids; contain cholesterol, phospholipid, and triglyceride bound to protein. They vary in density and amounts of lipid and protein

In a patient who is taking cholestyramine in addition to other drugs, dosage of the interactive drug may need to be changed when the bile acid sequestrant is added or withdrawn. Also, because cholestyramine binds bile acids, cholestyramine may interfere with normal fat digestion and absorption and therefore may prevent absorption of:

the fat-soluble vitamins A, D, E, and K.

Niacin(Nicotinic Acid) (Vit. B3) off notes:

• Action: Decreases both cholesterol and triglycerides • Commonly causes red skin(facial) flushing, pruritus, gastric irritation, hypotension • Other side effects- hyperglycemia, hyperuricemia, elevated hepatic enzymes, and hepatitis • Take Aspirin 30 minutes before dose or take with meals to avoid facial flushing if this is a problem.

Describe this class & drugs off notes:

• Action: Increases the oxidation of fatty acids in liver and decreases the hepatic production of triglycerides • Most effective drugs for reducing triglycerides Gemfibrozil (Lopid)—Given on empty stomach. Give 30 minutes before am and pm meal • Adverse Side Effects • GI discomforts (diarrhea), gallstones

Initial Management of Hyperlipidemia:

• Assess and treat conditions that increase blood lipids-DM, hypothyroidism • Start a low-fat diet- 30%of calories from fat. • Use "Mediterranean diet"-using more olive and canola oil. • Lose weight, regular exercise-30 minutes at least 3x/wk. • Quit smoking. • HRT (hormonal replacement therapy-might protect against heart dx but the client might get cancer—this is in question.) • 6 months of diet and exercise are usually tried before medications are started.

General Ways to Reduce Risk of Hyperlipdemia/Atherosclerosis off notes:

• Begin healthy eating habits in childhood • 3 out of 4 overweight children, will be overweight adults • Type II DM- now seen in children • Parents need to be better role models • Eat oat products • Exercise • Avoid smoking • Check cholesterol level every 5 years (earlier if have other illnesses). • Watch Glucose levels and Lipid profile • Obesity is a Major Health Problem( weight modification) • Sedentary Activities

Bile Acid Sequestrants off notes:

• Binds bile acid in the intestinal lumen • Excreted in the feces • Drugs-Cholestyramine (Questran) • Mainly used to lower LDL (usually in 1 week but if d/c the levels go right back up) • Adverse effects : bdominal fullness (bloating), flatulence, and constipation-increase dietary fiber.

Caution with Bile Acid Sequestrants off notes:

• Do not give with other drugs • Give other meds 1 hr before a bile acid sequestrant or 4-6 hours after a bile acid sequestrant.

FROM NOTES: Atherosclerosis:

• Major cause of ischemic heart disease (angina, MI, CVA) • Systemic disease characterized by fatty plaques • These plaques build up on the lining of the blood vessel • The lining becomes rough, and thrombi and necrosis can occur

What should you remember about your drug therapy for hyperlipidemia off notes?

• Monitor liver enzymes while on these meds, many of these are very toxic to the liver. • Adverse Side Effects of Statins • Nausea, constipation (most common), diarrhea, abdominal cramps, HA, skin rash • Give meds with food • Serious-hepatotoxicity-check LFT's • Teach to avoid grapefruit juice as it increases the serum drug levels • May increase sun sensitivity---Use sunscreens and wear protective clothing

Causes for Hyperlipidemia:

• Primary : genetic or familial • Secondary to dietary habits • Other disease such as DM and obesity • Medications such as beta blockers and thiazide diuretics

Drug Therapy for Hyperlipidemia: • -Statins • atorvastatin (Lipitor) • rosuvastatin (Crestor) • pravastatin (Pravachol) • simvastatin (Zocor) (take at night) describe them off notes:

• Used to decrease blood lipid levels and delay the onset of atherosclerotic plaque • Reduces LDL in 2 weeks • Reach maximum effectiveness in 4-6 weeks

Cholesterol Absorption Inhibitor (Zetia) off notes:

• Used with dietary management in treating primary hyperlipidemia • Drugs that increase effects : cyclosporine • Drugs that decrease effects : bile acid sequestrant • Take at night if combined with a statin med • Take 2 hours before or 4 hours after bile acid sequestrant