Cholesterol Lowering Drugs

These medications are used for patients with hyperlipidemia, dyslipidemia, and hypercholesterolemia. The first line of treatment for increased cholesterol level is still dietary therapy, lifestyle changes, weight loss, and exercise.

1. Bile acid sequestrants lower LDL cholesterol by binding to bile acids, preventing cholesterol absorption in the small intestine. 

They benefit patients with Type 2 diabetes by reducing blood sugar levels and can quickly lower plasma thyroid hormones, making them useful for refractory thyrotoxicosis. Additionally, they can raise HDL-C levels and are used to manage pruritus in patients with cholestatic disease and incomplete biliary obstruction. 

However, these medications can cause gastrointestinal side effects like nausea, bloating, cramping, and increased liver enzymes. Dyspepsia and bloating can be mitigated if cholestyramine is fully suspended in liquid hours before ingestion. Bile acid sequestrants can also inhibit the absorption of fat-soluble vitamins such as vitamin K, leading to potential clotting issues.

Examples: 

cholestyramine (Questran)

colesevelam (Welchol)

colestipol (Colestid)

2. Fibric Acids- prevent cardiovascular disease in patients with elevated triglycerides and low HDL when diet and lifestyle changes are unsuccessful. Fibrate commonly causes dyspepsia and has also been shown to produce fatigue, vertigo, pancytopenia, and elevation of serum transaminases.

Examples: 

fenofibrate (Tricor)

fenofibric acid (Trilipix)

Gemfibrozil (Lopid)

3. HMG CoA Reductase Inhibitors- inhibit the enzyme in the liver (HMG-CoA reductase) responsible for making cholesterol. 

Examples: 

atorvastatin (Lipitor)

pitavastatin (Livalo)

pravastatin (Pravachol)

osuvastatin (Crestor)

simvastatin (Zocor)

lovastatin (Mevacor)

4. Other

Ezetimibe (Zetia) is a synthetic 2-azetidinone agent that lowers cholesterol by inhibiting its absorption in the intestines, unlike other cholesterol-lowering agents that increase bile acid excretion or inhibit cholesterol synthesis in the liver. It can be taken with meals and safely used with statins or fibrates. When taken with bile acid sequestrants, it should be dosed at least 2 hours before or 4 hours after. Side effects of ezetimibe include fatigue, diarrhea, headache, runny nose, body aches, back pain, chest pain, joint pain, sore throat, and elevated serum transaminases.

ezetimibe & simvastatin (Vytorin)

MORE ON STATINS

Statins, also known as HMG-CoA Reductase Inhibitors, reduce low-density lipoproteins (LDL) or "bad" cholesterol but typically do not affect high-density lipoprotein (HDL) or "good" cholesterol. They work by inhibiting the liver enzyme HMG-CoA reductase, which is responsible for cholesterol production. Statins also stabilize and shrink fatty plaques, prevent their rupture, inhibit clot formation, and reduce inflammation. Statins usually have the suffix "-statin."

When taken correctly, statins can lower the risk of coronary artery disease and the risk and recurrence of stroke. However, they can cause side effects such as nausea, headache, blurred vision, muscle pain, rashes, flushing, and gastrointestinal disturbances. Additionally, some patients may experience elevated liver enzymes, hyperglycemia, and hyperuricemia.

Lab Values to Watch Out for When on Statins

Normal Liver Function Test

ALT 7-55 units per liter (U/L)

AST 8-48 U/L

ALP 45- 115 U/L

Albumin 3.5-5 grams per deciliter (g/dL)

Total protein 6.3-7.9 g/dL

Bilirubin 0.1 to 1 mg/dL

GGT 9-48 U/L

LD 122-222 U/L

PT 9.5-13.8 seconds

Normal random blood glucose: 70-140 mg/dl

BUN 7-20 mg/dL

Nursing Precautions and Recommendations for Statins

1. Advise your client to take this during evening meal. Most cholesterol synthesis occurs at night, reflecting the fasting state. Thus, prompting the statins to be administered at evening or bedtime.

2. Assess and monitor the increase in muscle pain and liver enzyme

3. Annual eye exam should be facilitated so as to monitor for the formation of cataracts

4. Never give to clients with preexisting gallbladder disease

5. Patients should avoid taking grapefruit juice since it may increase drug toxicity and adverse effects

References: 

Bansal AB, Cassagnol M. HMG-CoA Reductase Inhibitors. [Updated 2023 Jul 3]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2024 Jan-. Available from: https://www.ncbi.nlm.nih.gov/books/NBK542212/

Chhetry M, Jialal I. Lipid-Lowering Drug Therapy. [Updated 2023 Aug 28]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2024 Jan-. Available from: https://www.ncbi.nlm.nih.gov/books/NBK541128/

Duong H, Bajaj T. Lovastatin. [Updated 2023 Mar 20]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2024 Jan-. Available from: https://www.ncbi.nlm.nih.gov/books/NBK540994/

Sizar O, Nassereddin A, Talati R. Ezetimibe. [Updated 2023 Aug 28]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2024 Jan-. Available from: https://www.ncbi.nlm.nih.gov/books/NBK532879/