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/ 

Metoprolol Mnemonics and Beta Blockers

Metoprolol Mnemonic and Other Betablockers

Metoprolol tartrate is short acting and usually given BID.  

Metoprolol succinate is long acting. and usually given once a day.

BETA BLOCKERS

These medications prevent norepinephrine and epinephrine from attaching to beta receptors on nerves. By inhibiting these neurotransmitters, they lower heart rate and blood pressure by dilating blood vessels.

Uses:

• Manage hypertension, heart failure, arrhythmias, and angina (not for immediate relief).
• Treat glaucoma (when used as eye drops).
• Prevent future heart attacks in patients who have had a heart attack.
• Prevent migraine headaches.

The generic names of beta blockers typically end in "lol." 

Beta blockers are also used to reduce brain activity, helping to alleviate palpitations during panic attacks, reduce essential tremors, and ease situational anxiety. They may also help reduce migraine headaches in some individuals.

Really Important to Know  

Warning! Patients should consult their physician before stopping their medication. Suddenly discontinuing beta blockers can lead to severe worsening of angina, heart attacks, or sudden death.

Examples

acebutolol (Sectral)

atenolol* (Tenormin)

betaxolol (Kerlone)

bisoprolol* (Zebeta)

carteolol (Cartrol)

carvedilol* (Coreg)

! esmolol (Brevibloc)

! labetalol (Trandate)

! metoprolol* (Lopressor, Toprol-XL)

nadolol (Corgard)

nebivolol* (Bystolic)

penbutolol (Levatol)

pindolol (Visken)

propranolol (Inderal)

sotalol (Betapace)

timolol (Timoptic)

One of the top 200 most commonly prescribed medications. 
! high alert drug

Beta blockers can be cardio selective or non-cardio selective. 

Cardio selective beta blockers act on Beta 1 receptors which are found in the heart.                

Beta 1=1 heart

Non cardio selective beta blockers act on Beta 2 receptors found in the lungs.                       

Beta 2=2 lungs

                                  

Nurses must check heart rate and blood pressure before and after administration of beta blockers. 

Beta blockers can mask the symptoms of hypoglycemia

Use with caution when giving betablockers to COPD and asthma patients because of the potential for causing bronchospasms and wheezing. 

Pradaxa (dabigatran etexilate mesylate) Capsules Storage Instructions From the FDA

Pradaxa (dabigatran etexilate mesylate) Capsules 

Storage Instructions From the FDA

Pradaxa capsules should only be dispensed and stored in their original bottle or blister package, and patients should follow specific handling requirements.

Facts about Pradaxa

• Pradaxa is an anticoagulant (blood thinner) known as a direct thrombin inhibitor, which prevents the formation of blood clots.
• It is used to help prevent strokes or serious blood clots in people with non-valvular atrial fibrillation (an irregular heartbeat), a condition that increases the risk of clot formation and stroke.
• Between October 2010 and January 2011, around 128,000 Pradaxa prescriptions were dispensed, with approximately 86,000 patients filling these prescriptions at outpatient retail pharmacies in the U.S.
• The Pradaxa label and Medication Guide provide information on special storage and handling requirements, but the FDA is concerned that these guidelines are not widely known or followed by Pradaxa users and pharmacies.

Many consumers use pill boxes or organizers to help them remember to take their medications. 

However, due to the risk of product degradation and potency loss Pradaxa should not be stored in any container other than its original manufacturer packaging. Keeping Pradaxa capsules in pillboxes can cause it to lose potency increasing the risk of stroke for the patients.

Pharmacists should also dispense Pradaxa capsules only in the original packaging to prevent moisture-related breakdown. Pradaxa bottles contain a 30-day supply with a desiccant (drying agent) in the cap to protect the capsules from moisture. Pradaxa capsules are also available in blister packages, which offer similar protection.

Source: FDA Drug Safety Communication: Special storage and handling requirements must be followed for Pradaxa (dabigatran etexilate mesylate) capsules | FDA

Anticoagulants in NCLEX and Warfarin Education for Patients

Anticoagulants 

 Examples

! heparin (generic)

! warfarin* (Coumadin)

Indirect factor Xa inhibitor

! fondaparinux (Arixtra)

LMWH

! dalteparin (Fragmin)

! enoxaparin (Lovenox)

! tinzaparin (Innohep)

Thrombin inhibitors

! argatroban (generic)

! bivalirudin (Angiomax)

! dabigatran* (Pradaxa)

! desirudin (Iprivask)

! lepirudin (rDNA)

*One of the top 200 most commonly prescribed medications. 
! high alert drug

These medications impede the synthesis of clotting factors, inhibit thrombin, or interfere with the formation of blood platelets.

Uses: They are utilized to prevent or manage blood clots associated with conditions such as stroke, heart attack, heart valve disease, coronary artery disease, heart failure, arrhythmia, atrial fibrillation, deep vein thrombosis, and pulmonary embolism.

Nice To Know: Foods high in vitamin K (such as leafy green vegetables) may diminish the effectiveness of anticoagulant drug therapy.

Good To Know: Clients should be asked about their use of herbal remedies as Ginseng and St. John's wort can decrease PT/INR, while Ginkgo biloba, garlic, chamomile, and licorice root can increase PT/INR.

Really Important To Know: The therapeutic range of effectiveness for most anticoagulants is typically 1.5-2 or 2.5 times the "normal" lab values. It's crucial to know the client's lab results before administering anticoagulants.

Warfarin Education for Patients

Antidotes for Drugs and Toxins (NCLEX)

 

Toxin Antidotes

Toxin	Antidote / Treatment
Acetaminophen (Paracetamol)	N-acetylecysteine
Salicylates	Alkalinize urine, dialysis
Anticholinesterases, organophosphates	Atropine, Pralidoxime
Antimuscarinic, anticholinergic agents	Physostigmine salicylate
Beta blockers	Glucagon
Digitalis	Stop digitalis, normalize K; lidocaine, anti-dig FAB fragments ( Digitoxin) Digitalis Immune FAB
Iron (Ferrous Sulfate)	Deferoxamine
Lead	CaEDTA, dimercaprol, succimer, penicillamine
Arsenic, mercurym gold	Dimercaprol (BAL), succimer
Copper, arsenic, gold	Penicillamine
Cyanide	Nitride, Hydroxocobalamin
Methemoglobin	Methelyn blue
Carbon Monoxide	100% O2, hyperbaric O2
Methanol, ethylene glycol (antifreeze)	Ethanolm dialysism fomepizole
Opioids, Narcotic Analgesics: Demerol and Morphine Sulfate	Naloxone Hydrochloride (Narcan), Naltrexone
Benzodiazepines	Flumazenil (Romazicon)
Tricyclic antidepressants (Anafranil, Tofranil)	NaHCO3 (nonspecific)
Anticoagulant: Heparin	Protamine Sulfate
Anticoagulant: Warfarin	Vitamin K, fresh frozen plasma
Thrombolytics: t-PA, (Streptokinase, Urokinase)	Aminocaproic Acid ( Amicar)
Lithium Carbonate (Eskalith)	Sodium Bicarbonate
Calcium Channel Blocker (Verapamil)	Calcium
Magnesium Sulfate	Calcium Gluconate