Pharm exam 3 - Drugs to lower Cholesterol and Triglyceride levels

Lipids

umbrella term for all the fats in the blood

Cholesterol

a fatty substance used to build cell membranes and hormones

Lipoprotein

a particle that carries cholesterol and fat through the blood

LDL

“bad” cholesterol that deposits in artery walls

Low-Density Lipoprotein

HDL

“good” cholesterol that carries cholesterol back to the liver

High-Density Lipoprotein

VLDL

Very Low-Density Lipoprotein (transports triglycerides)

Triglycerides

fats stored for energy; high levels raise risk

High LDL and triglycerides

Can lead to atherosclerosis, ASCVD

What is the goal HDL and LDL for lower cardiovascular risk

High HDL / Low LDL

Atherosclerosis

plaque buildup that narrows and stiffens arteries

ASCVD

atherosclerotic cardiovascular disease (heart attack, stroke)

Hyperlipidemia

high levels of lipids in the blood

HMG-CoA reductase

the liver enzyme statins block to make less cholesterol

Hepatotoxicity

liver damage from a drug; monitored with LFTs

Myopathy

muscle pain or weakness caused by a drug

Rhabdomyolysis

severe muscle breakdown; dark urine is a warning sign

CK (creatine kinase)

a blood enzyme that rises when muscle is breaking down

Cholesterol

• Component of all cell membranes
• Required for hormone synthesis and fat absorption
• Mostly manufactured by the liver (more than from diet)
• Decrease dietary saturated fats to lower levels

What are HMG-CoA reductase inhibitors usually called?

Statins

Statin prototype:

Atorvastatin

Atorvastatin MOA:

Inhibits hepatic HMG-CoA reductase → ↓ LDL, ↓ VLDL, ↓ triglycerides, ↑ HDL
Also promotes vasodilation and decreases plaque inflammation.

Atorvastatin therapeutic uses:

• Hypercholesterolemia
• Primary/secondary prevention of coronary events
• Prevention of MI & stroke (esp. with diabetes)

Atorvastatin adverse effects:

• Hepatotoxicity: ↑ AST; monitor LFTs q6mo
• Interactions:
• Myopathy/Rhabdomyolysis: report muscle pain, dark urine
• Teratogenicity: contraindicated in pregnancy & lactation
• Avoid grapefruit juice
• ↑ risk with fibrates, ezetimibe, CYP3A4 inhibitors
• Use lower dose in renal impairment; rosuvastatin caution (Asian descent)

Atorvastatin administration:

• Evening dosing preferred (cholesterol synthesized at night)
• Lovastatin: with evening meal

Atorvastatin client teaching:

• Avoid alcohol, report muscle pain or jaundice, use contraception

Fibrates (Fibric Acid Derivatives) prototype:

Gemfibrozil

Gemfibrozil MOA:

• Fibrates switch on the body’s natural fat-clearing system
• ↑ lipoprotein lipase activity
• ↓ hepatic VLDL production → ↓ triglycerides
• ↑ HDL (↑ Apo A-I/A-II synthesis)

Gemfibrozil therapeutic uses:

• High triglycerides (VLDL) not controlled by lifestyle or other meds
• Modest ↑ HDL

Gemfibrozil key risks/ adverse effects:

• Myopathy / rhabdomyolysis (↑ risk with statins)
• Hepatotoxicity
• Gallstones (↑ biliary cholesterol)
• GI upset (usually mild)

Gemfibrozil major interactions:

• Warfarin displacement (highly protein-bound) → ↑ INR/bleeding
• Statins (gemfibrozil inhibits statin metabolism/transport) → ↑ myopathy risk

Gemfibrozil contraindications / cautions:

• Active liver disease, severe renal impairment, gallbladder disease
• Use caution in older adults; avoid in pregnancy/breastfeeding if possible

Gemfibrozil nursing actions / teaching:

• Baseline & periodic: lipid panel, LFTs, CK
• If on warfarin → check INR more frequently at start and dose changes
• Report RUQ pain/fat intolerance (gallstones), muscle pain/weakness, dark urine, jaundice

Gemfibrozil administration:

Gemfibrozil 600 mg BID, 30 min before breakfast & dinner (formulation-specific for fenofibrate)

What are the two Nicotinic Acid & Cholesterol Absorption Inhibitors?

Nicotinic Acid (Niacin)

Ezetimibe (Cholesterol Absorption Inhibitor)

Nicotinic Acid (Niacin) MOA:

↓ LDL, ↓ triglycerides, ↑ HDL

Nicotinic Acid (Niacin) therapeutic uses:

Adjunct for dyslipidemia
↓ risk of pancreatitis with hypertriglyceridemia

Nicotinic Acid (Niacin) adverse effects:

Flushing, burning, pruritus
Hyperglycemia (use caution in diabetes)
GI upset (take with food)

Nicotinic Acid (Niacin) nursing / teaching points:

Take with meals to minimize flushing
May take aspirin 30 min before dose
Report itching, dark urine, muscle pain

Both Niacin and ezetimibe do what?

improve lipid profiles

Nurses focus on safety, monitoring liver function, and teaching clients to report muscle pain or jaundice

Ezetimibe MOA:

Blocks intestinal cholesterol absorption → ↓ LDL

Ezetimibe therapeutic effects:

↓ total cholesterol, LDL, triglycerides; ↑ HDL

Ezetimibe indications:

Primary hyperlipidemia
Used alone or with statin

Ezetimibe contraindications:

pregnancy, breastfeeding, active liver disease

Ezetimibe adverse effects:

Headache, sore throat, rare rhabdomyolysis

What do we avoid using with Ezetimibe?

CYP3A4 inhibitors (e.g., cyclosporine, antifungals)

Ezetimibe nursing / teaching points:

Monitor lipid & liver function labs
Report muscle pain or dark urine
Can take with or without food

PCSK9 Monoclonal Antibody Inhibitors MOA:

• Inhibit PCSK9, preserving LDL receptors → ↑ LDL clearance
• ↓ LDL by up to 60%
• May ↓ total cholesterol

PCSK9 Monoclonal Antibody Inhibitors indications:

• Familial hypercholesterolemia
• Primary hyperlipidemia not controlled by statins
• Clients with ASCVD / high CV risk
• Evolocumab approved for ≥10 years old

PCSK9 Monoclonal Antibody Inhibitors contraindications / precautions:

• Hypersensitivity or latex allergy
• Use cautiously in those with prior severe allergic reactions

PCSK9 Monoclonal Antibody Inhibitors common side effects:

mild injection site reactions, muscle pain, flu-like symptoms

PCSK9 Monoclonal Antibody Inhibitors adverse side effects:

hypersensitivity (angioedema, vasculitis, rare anaphylaxis)

PCSK9 Monoclonal Antibody Inhibitors nursing actions:

• Administer SQ every 2–4 weeks; rotate sites
• Store refrigerated, bring to room temp before use

PCSK9 Monoclonal Antibody Inhibitors teaching:

• Report rash, swelling, or breathing difficulty
• Long-term therapy—often combined with a statin
• Insurance preauthorization usually required

What assessment findings should the nurse monitor before and during lipid-lowering therapy?

• Lipid panel

• Liver function tests (LFTs)

• Creatine kinase (CK)

Which findings require the nurse to hold a lipid-lowering medication and notify the provider?

• Muscle pain with ↑ CK (possible myopathy/rhabdomyolysis)

• Jaundice

• Dark urine (possible hepatotoxicity)

What nursing interventions help manage common adverse effects of lipid-lowering medications?

• Increase fluids and fiber for constipation

• Take aspirin before niacin to reduce flushing

What patient teaching is important for bile acid sequestrants and PCSK9 inhibitors?

• Bile acid sequestrants: Take other medications 1 hour before or 4 hours after

• PCSK9 inhibitors: Store refrigerated

What outcomes indicate lipid-lowering therapy is effective?

• ↓ LDL

• ↓ Triglycerides

• ↑ HDL

• Adheres to diet, exercise, and medications

• Knows when to report side effects