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Chapter 8: Dyslipidemia

Terms in this set (43)

Dyslipidemia (Hyperlipidemia)
-Elevated total serum cholesterol
-Elevated levels of LDL cholesterol
-Reduced levels of HDL cholesterol
-Elevated levels of triglycerides
-Total Cholesterol to HDL cholesterol Ratio ≥ 4
(predicts risk of developing atherosclerosis)
Normal Ranges of Cholesterol
-Total serum cholesterol: Less than 200mg/dl
-LDL cholesterol: Less than 100mg/dl
-HDL cholesterol: High (desirable) > 60mg/dl; Protective level = 40-60mg/dl
-Triglycerides: Less than 150mg/dl
-Total Cholesterol to HDL cholesterol Ratio: Less than 4
Lipid Profile (Labs)
-Total serum cholesterol
-HDL (high-density lipoprotein)
-LDL (low-density lipoprotein)
-Triglycerides: For accurate interpretation of triglycerides, pt must fast for 12 hrs before blood draw
Metabolic Syndrome
-A group of cardiovascular risk factors linked with obesity
-Symptoms: Central adiposity (increased waist circumference), Elevated triglycerides, Reduced HDL cholesterol, Elevated BP, and Elevated fasting glucose
-Could lead to: cardiovascular, cerebrovascular, and peripheral vascular disease
First-line Treatment
Lifestyle Modifications:
-Low-fat diet
-"Mediterranean diet": Monounsaturated & polyunsaturated fats (canola oil, olive oil, sunflower oil)
-Increase intake of soluble fiber
-Weight-reduction if overweight
-Aerobic exercise - 30 min 3x/week
-Smoking cessation
-Hormone replacement therapy (HRT) if menopausal (increases HDL; lowers LDL)
-Dietary supplements, especially soy
-Reduces LDL and total cholesterol
Second-line Treatment
Cholesterol medication (usually among other medications)
Treatment
Unless lipid levels are SEVERELY elevated, 6 months of intensive diet therapy and lifestyle modification may be undertaken before drug therapy is considered
Statins
-Inhibit the enzyme (HMG-CoA Reductase) required for hepatic synthesis of cholesterol
-Atorvastatin (Lipitor)
-Simvastatin (Zocor)
-Rosuvastatin (Crestor)
Bile Acid Sequestrants
-Meds bind to bile acids in intestine leading to bile acid excreted in feces leading to no re-circulation to liver leading to liver stimulated to make more bile acids from cholesterol leading to serum cholesterol moves to liver leading to serum cholesterol lowered (mostly LDL)
-Cholestyramine (Prevalite, Questran)
-Others pg. 139
Fibrates
-Increases oxidation of fatty acids in liver and muscle tissue decreased liver production of triglycerides, decreases VLDL, increases HDL
-Fenofibrate (TriCor)
-Gemfibrozil (Lopid)
Cholesterol Absorption Inhibitor
-Blocks cholesterol absorption w/o affecting absorption of fat-soluble vitamins (A, D, E, K) & triglycerides
-Ezetimibe (Zetia)
Misc. Dyslipidemic Agent
-Decreases LDL; increases HDL cholesterol
-Nicotoinic acid (Niacin)
Atorvastatin (Lipitor) Statins
USES
-Most effective drug class in reducing major types of dyslipidemia
-Reduces cardiovascular events in people with multiple risk factors
-MOST POWERFUL drugs for reduction in LDL cholesterol
Atorvastatin (Lipitor) Statins
ADVERSE EFFECTS
May have GI symptoms (n/v, constipation, abd cramping)
Myopathy - muscle aches/weakness
Statins can injure muscle tissue
Atorvastatin (Lipitor) Statins
CONTRAINDICATIONS
-Pregnancy: teratogenic (category X)
-Lactation
-Precautions/Interactions: Grapefruit juice- increases effects of drug
Atorvastatin (Lipitor) Statins
NURSING IMPLICATIONS
-Assess for decreased levels of total serum cholesterol, LDL, triglycerides; increased levels of HDL
-Monitor LFTs- drug metabolized by liver
-Assess for muscle pain/weakness: Myopathy is side effect of drug
Atorvastatin (Lipitor) Statins
PATIENT EDUCATION
-Women of child bearing age use contraceptives
-Frequent monitoring of LFTs (compliance with follow-up lab draws)
-LFTs: Before starting drug, 12 weeks after starting drug, at every increase in dose, periodically
Atorvastatin (Lipitor) Statins
SPECIAL POPULATIONS
-Children: approved only for ages 10-17; younger - lifestyle modifications
-Older Adults: well tolerated
-Hepatic Impairment: metabolized by liver may accumulate
contraindicated in pts with active liver disease; Caution with excessive etoh use or hx liver disease
-Home Care: periodic labs (lipid profile, LFTs); report unexplained muscle pain/weakness (myopathy)
Cholestyramine (Prevalite, Questran) Bile Acid Sequestrants
USES
-Mainly used to reduce cholesterol further in patients already taking a statin or niacin as combination therapy
-Reduces LDL
-Some (minimal) elevation in HDL
Cholestyramine (Prevalite, Questran) Bile Acid Sequestrants
ADVERSE EFFECTS
-GI sx: Abdominal fullness, Flatulence, Diarrhea, Constipation common
-May need bowel program to control
Cholestyramine (Prevalite, Questran) Bile Acid Sequestrants
CONTRAINDICATIONS
-Pts with biliary obstruction
-Precautions/Interactions: Pts with coagulation disorders, Drug binds with vitamin K
Cholestyramine (Prevalite, Questran) Bile Acid Sequestrants
NURSING IMPLICATIONS
-Decreases absorption of many meds (digoxin, propanolol, thiazides, Coumadin)
-May interfere with normal fat digestion and absorption: May prevent absorption of fat soluble vitamins (A, D, E, K); supplementation may be required
Cholestyramine (Prevalite, Questran) Bile Acid Sequestrants
PATIENT EDUCATION
-Powder form of drug must be mixed with water, applesauce, soup, etc.
-Tablets must NOT be crushed or split
-Do NOT take with other drugs
-Take other drugs 1-2 hrs before or 4-6 hours after taking cholestyramine
Cholestyramine (Prevalite, Questran) Bile Acid Sequestrants
SPECIAL POPULATION USE
-Children: only given to children 10 years or older
-Older Adults: safe and effective, but do not tolerate adverse effects well (constipation)
-Renal Impairment: caution with extended use; drug releases chlorides and can increase risk of hyperchloremic metabolic acidosis
-Hepatic Impairment: caution if biliary cirrhosis present; may raise serum cholesterol levels if liver unable to make bile acids
Fenofibrate (TriCor) Fibrates
USES
-Most effective in reducing serum triglyceride levels
-Drug of choice in reducing triglycerides associated with:Diabetes, Gout, Gastritis, Ulcer diseases
Fenofibrate (TriCor) Fibrates
ADVERSE EFFECTS
-GI discomfort
-Diarrhea
-Formation of gallstones
-Elevated LFTs: will return to normal when medication d/c
Fenofibrate (TriCor) Fibrates
CONTRAINDICATIONS
-Hepatic disease; persistent abnormal LFTs
-Severe renal impairment
-Gallbladder disease
-Primary biliary cirrhosis
-Interactions: Warfarin (Coumadin) - fibrates enhance absorption, causing increased anticoagulant effect and bleeding risk
Fenofibrate (TriCor) Fibrates
NURSING IMPLICATIONS
-Monitor for bleeding if taking warfarin; warfarin dose may need decreased
-Assess for improvements in Lipid Panel results
Fenofibrate (TriCor) Fibrates
PATIENT EDUCATION
-Periodic blood tests (Lipid Panel, LFTs)
Fenofibrate (TriCor) Fibrates
SPECIAL POPULATION USE
-Children: safety and efficacy not established
-Older Adults: lower starting doses recommended
-Renal Impairment: Contraindicated in severe renal impairment, Moderate to mild renal impairment; start with lower dose and monitor BUN & creatinine closely; Pts with DM, monitor closely since renal disease is common complication in pts with DM
-Hepatic Impairment: contraindicated in severe hepatic disease
-Home Care: routine lab work (LFTs and Lipid Profile)
Ezetimibe (Zetia) Cholesterol Absorption Inhibitor
USES
-Used in combination with dietary management for tx dyslipidemia
-Used in monotherapy or in combination with a statin: Combo therapy contraindicated if pt has hepatic disease
Ezetimibe (Zetia) Cholesterol Absorption Inhibitor
ADVERSE EFFECTS
-Headache
-Diarrhea
-Nausea
Ezetimibe (Zetia) Cholesterol Absorption Inhibitor
CONTRAINDICATIONS
Pregnancy & lactation
Combo therapy with statin in pts with hepatic disease
Ezetimibe (Zetia) Cholesterol Absorption Inhibitor
NURSING IMPLICATIONS
-If pt taking bile sequestrant, administered Zetia 2 hrs before or 4 hrs after to prevent altered absorption
-Monitor lipid response
Ezetimibe (Zetia) Cholesterol Absorption Inhibitor
PATIENT EDUCATION
Periodic blood tests (Lipid Panel)
Ezetimibe (Zetia) Cholesterol Absorption Inhibitor
SPECIAL POPULATION USE
-Children: Safety and efficacy not established in children younger than 10 years old
-Older Adults: No adjustments in dosing
-Hepatic Impairment: Dosage adjustments necessary; Not recommended in pts with moderate to severe hepatic impairment
Nicotinic acid (Niacin) Misc. Dyslipidemic Agent
USES
-Most effective drug for increasing concentration of HDL cholesterol
-In combination use with a bile sequestrant and fibrate, useful for preventing heart disease
-In combination use with a statin, lowers LDL cholesterol more than any drug used alone
-High doses required for dyslipidemic effects
Nicotinic acid (Niacin) Misc. Dyslipidemic Agent
ADVERSE EFFECTS
-Skin flushing
-Pruritus (itching)
-GI irritation
-May lead to: Tachycardia, hypotension, dizziness; Hyperglycemia (not recommended for diabetic pts); Elevated LFTs, hepatitis
Nicotinic acid (Niacin) Misc. Dyslipidemic Agent
CONTRAINDICATIONS
-Active liver disease
-Active peptic ulcer
Nicotinic acid (Niacin) Misc. Dyslipidemic Agent
NURSING IMPLICATIONS
-Do not break/crush timed release tablets
-Give immediate release tablets WITH meals to decrease gastric irritation; extended release w/o regard to meals
Nicotinic acid (Niacin) Misc. Dyslipidemic Agent
PATIENT EDUCATION
-To prevent adverse effect of flushing: Gradually increase dose; Take aspirin or ibuprofen prior to administration of med
-Tablet strengths are NOT interchangeable: Do not substitute immediate release with extended release tablets
Nicotinic acid (Niacin) Misc. Dyslipidemic Agent
SPECIAL POPULATION USE
-Children: safe, but often given for other reasons than hypercholesteremia
-Older Adults: effective, but pts do not tolerate adverse effects of drug well
-Renal Impairment: caution
-Hepatic Impairment: contraindicated; causes hepatoxicity
Combination Therapy
Not intended for INITIAL therapy
-Most effective in reducing Total Cholesterol and LDL cholesterol: *Statin* combined with *Cholesterol Absorption Inhibitor*; StatinCholesterol Absorption InhibitorCholesterol and LDL cholesterol: *Statin* combined with *Cholesterol Absorption Inhibitor*; Statin combined with *Bile Acid Sequestrant*; *Niacin* combined with Bile Acid SequestrantNiacinfective in reducing Total Cholesterol and LDL cholesterol: *Statin* combined with *Cholesterol Absorption Inhibitor*; *Statin* combined with *Bile Acid Sequestrant*; *Niacin* combined with Bile Acid Sequestrant
-Most effective in increasing HDL cholesterol: Fibrate, Cholesterol Absorption Inhibitor, OR Niacin may be used
-Combinations to AVOID: Fibrate-statin- increased risk of severe myopathy; Niacin-statin- increased risk of hepatoxicity
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