Dyslipidemia_student.pptx

Drug Therapy for Dyslipidemia MATTHEW MOEHL, PHARMD Introduction Dietary habits, Other diseases, Genetics, Medications Elevated blood lipids (dyslipidemi a) Atheroscler otic Cardiovascu lar Disease (ASCVD) Stroke, Coronary artery disease, Myocardial infarction HTTPS://WWW.HEART.ORG/EN/HEALTH-T...

Drug Therapy for Dyslipidemia MATTHEW MOEHL, PHARMD Introduction Dietary habits, Other diseases, Genetics, Medications Elevated blood lipids (dyslipidemi a) Atheroscler otic Cardiovascu lar Disease (ASCVD) Stroke, Coronary artery disease, Myocardial infarction HTTPS://WWW.HEART.ORG/EN/HEALTH-TOPICS/CHOLESTEROL/ABOUT-CHOLESTEROL/ATHEROSCLEROSIS HTTPS://NDNR.COM/CARDIOPULMONARY-MEDICINE/DIETARY-MANAGEMENT-OF-DYSLIPIDEMIA-A-REVIEW-OF-EVIDENCE-BASED-STRATEGIES/ Etiology – How does cholesterol rise to unhealthy levels? Saturated fats, Other disease states, Genetic disorders Healthy amounts of cholesterol Unhealthy amounts of cholesterol Types of Lipoproteins “Bad” ◦ Chylomicron – main transport for triglycerides ◦ VLDL ◦ IDL ◦ LDL – main transport for cholesterol ◦ Carry cholesterol to cells “Good” ◦ HDL – exact protective mechanism is unknown, but it does transport cholesterol away from blood vessels ◦ Carry cholesterol away from cells HTTPS://WWW.RESEARCHGATE.NET/FIGURE/4-THE-MAJOR-TYPES-OF-LIPOPROTEINS-ARE-CHYLOMICRONS-VERY-LOW-DENSITY-LIPOPROTEINVLDL_FIG4_304525065 LDL HDL Important Lab Values Case Study Edward Watkins, a 62-year-old man, has had elevated cholesterol and triglyceride levels at his two previous visits to the nurse practitioner. He has tried diet modification and increasing exercise; however, he remains overweight, and his lipid values remain elevated. His latest laboratory findings at this visit are total serum cholesterol 239 mg/dL, low-density lipoprotein (LDL) cholesterol 162 mg/dL, high-density lipoprotein cholesterol 40 mg/dL, and triglycerides 220 mg/dL. His nurse practitioner decides to prescribe atorvastatin 10 mg PO once daily and gemfibrozil 600 mg PO twice a day. Key Drug Classes HMG-CoA Reductase Inhibitors aka “statin’s” • Prototype: atorvastatin (Lipitor) • Nursing Considerations • Best class for lowering LDL cholesterol • Also lowers TG and • Mechanism of action: inhibits enzyme primarily responsible for hepatic synthesis of cholesterol • Use(s): • Hypercholesterolemia • Reduce risk of CV events increases HDL • • • • Pregnancy category X CYP substrates Take at evening/bedtime. Usually well tolerated, but… • Myopathy • Hepatic dysfunction • Increase blood glucose Statin side effects • Myopathy • Muscle pain/weakness associated with statin use • Can range from mild to severe • Can lower dose or try a different statin https://hughston.com/wellness/rhabdomyolysis/ • Rhabdomyolysis • Severe, potentially life-threatening side effect • Muscle is broken down, releasing enzymes which can damage the kidneys • Watch for dark, “cola-colored” urine Drugs that can increase risk of statin side effects and toxicity • Azole antifungals (fluconazole) • Macrolide antibiotics (erythromycin) • Fibric acid derivatives (fenofibrate) https://www.cancercenter.com/community/blog/ 2019/08/whats-the-deal-with-grapefruit-juiceand-certain-medications • Grapefruit juice CYP3A 4 Inhibit or Example Question A client has had their atorvastatin dose increased from 10mg daily to 20mg daily. Which statement reflects accurate teaching for the client? A. It is best to take atorvastatin in the morning. B. If you experience severe muscle pain, contact your physician. C. It is safe to continue taking this medication if you become pregnant. D. Dark-colored urine is a harmless side effect. Bile Acid Sequestrants • Prototype: cholestyramine (Prevalite, Questran) • Mechanism of action: binds to bile acids, causing them to be excreted in the feces. • Result: liver uses the excess cholesterol to make new bile acids. • Use(s): • Decreases LDL • Little to no effect on HDL and TG. • Nursing Considerations: • Decreases efficacy of statins • Decreases efficacy of many orally taken drugs • Vitamin supplementation may be required (A,D,E,K) • Most side effects are GIrelated, such as constipation, N/V/D, etc. Fibric Acid Derivatives (Fibrates) • Prototype: fenofibrate (Tricor) • Mechanism of action: decrease hepatic production of TG, decrease VLDL cholesterol, increase HDL • Use(s): • Most effective at lowering serum TG • Nursing Considerations: • Main indication is for TG > 500mg/dL • Increase risk of bleeding from anticoagulants • Contraindicated in patients with severe renal impairment or liver disease • Fibrates can cause/worsen both Cholesterol Absorption Inhibitor • Prototype: ezetimibe (Zetia) • Mechanism of action: blocks biliary and dietary cholesterol absorption • Use(s): • Dyslipidemia • (monotherapy or in combo with statin) • Nursing Considerations: • Contraindicated in pregnancy and lactation • Not recommended in patients with severe hepatic impairment PCSK9 Inhibitors • Prototype: alirocumab (Praluent) • Mechanism of action: increases activity of the receptors that clear cholesterol. • Use(s): • Adults with ASCVD • Familial hypercholesterolemia https://www.praluent.com/how-to-use-praluent/ • Nursing Considerations: • Given by Sub-Q injection • So far, seems to be well-tolerated • Very expensive Misc. dyslipidemia agent • Drug name: niacin (Niacor, Niaspan) • Use(s): • No longer recommended. • Nursing Considerations: • No longer recommended except in patients with very high TG (>500). • Data did not suggest patient outcomes improved. • Raises blood glucose • Increased risk of hepatotoxicity Case Study Edward Watkins, a 62-year-old man, has had elevated cholesterol and triglyceride levels at his two previous visits to the nurse practitioner. He has tried diet modification and increasing exercise; however, he remains overweight, and his lipid values remain elevated. His latest laboratory findings at this visit are total serum cholesterol 239 mg/dL, low-density lipoprotein (LDL) cholesterol 162 mg/dL, high-density lipoprotein cholesterol 40 mg/dL, and triglycerides 220 mg/dL. His nurse practitioner decides to prescribe atorvastatin 10 mg PO once daily and gemfibrozil 600 mg PO twice a day. Example Question A client is about to be sent home with a prescription for cholestyramine. What drug class does cholestyramine belong to? A. HMG-CoA Reductase Inhibitors B. Fibric acid derivatives C. Bile Acid Sequestrants D. PCSK9 inhibitors Nursing Considerations Statins ◦ 1st line option in most circumstances ◦ Myopathy ◦ Drug interactions Bile Acid Sequestrants ◦ Decreases efficacy of most oral medications ◦ GI side effects Fibric Acid Derivatives ◦ Mainly used if high TG > 500 ◦ Hepatic and renal monitoring ◦ Increased risk of bleeding if patient taking anticoagulants HTTPS://WWW.CDC.GOV/CHOLESTEROL/IMAGES/ CHOLESTEROL-MONSTER-1.JPG The End HTTPS://WWW.CDC.GOV/CHOLESTEROL/COMMUNICATIONSKIT.HTM