Chapter 47:

Lipid-Lowering Agents

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Modifiable Risk Factors for CAD

 Gout
 Cigarette Smoking
 Sedentary Lifestyle
 High Stress Levels
 Hypertension
 Obesity
 Diabetes
 Untreated Bacterial Infections
 Treatment with Tetracycline and Fluororoentgenography

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Unmodifiable Risk Factors for CAD

 Genetic Predisposition
 Age
 Gender

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Metabolism of Fats in the Body

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Lipoproteins Produced by the Liver

 Low-Density Lipoproteins (LDL)

o Enter circulation as tightly packed cholesterol,
triglycerides, and lipids
o Carried by proteins that enter circulation; broken
down for energy or stored for future use as energy
 High-Density Lipoproteins (HDL)
o Enter circulation as loosely packed lipids
o Used for energy; pick up remnants of fats and
cholesterol left in the periphery by LDL breakdown

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Lipid Blood Level Classifications

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Causes of Hyperlipidemia

 Excessive dietary intake of fats

 Genetic alterations in fat metabolism leading to a variety
of elevated fats in the blood
o Hypercholesterolemia, hypertriglyceridemia,
alterations in LDL and HDL concentrations

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Question #1

Please answer the following statement as true or false.

Low density lipoproteins (LDL) enter circulation as a tightly

packed unit consisting of cholesterol, triglycerides, and
lipids.

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Answer to Question #1

True

Rationale: Low-density lipoproteins (LDL) enters

circulation as tightly packed cholesterol, triglycerides,
and lipids.

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Action of Lipid Lowering Agents

 Lower serum levels of cholesterol and lipids

 Prevention of CAD

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Sites of Actions of Lipid Lowering Agents

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Use of Lipid Lowering Agents Across the
Lifespan #1

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Use of Lipid Lowering Agents Across the
Lifespan #2

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Drugs Used to Treat Hyperlipidemia
 Bile Acid Sequestrants
 HMG-CoA Inhibitors
 Fibrates
 Niacin
 Cholesterol Absorption Inhibitors

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Bile Acid Sequestrants #1

 Decrease plasma cholesterol levels

o Cholestyramine (generic)
o Colestipol (Colestid)
o Colesevelam (WelChol)

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Bile Acid Sequestrants #2

 Actions
o Binds bile acids in the intestine, allows excretion in feces
instead of reabsorption, causes cholesterol to be iodized in
the liver, and serum cholesterol levels to fall
 Indications
o Reduces elevated serum cholesterol in patients with
primary hypercholesterolemia, pruritus associated with
partial biliary obstruction
 Pharmacokinetics
o Not absorbed systemically
o Excreted in the feces

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Bile Acid Sequestrants #3

 Contraindications
o Allergy
o Complete biliary obstruction
o Abnormal intestinal function
o Pregnancy and lactation

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Bile Acid Sequestrants #4

 Adverse Effects
o Headache, fatigue, and drowsiness
o Direct GI irritation – Nausea, constipation
o Increased bleeding times
o Vitamin A and E deficiencies
 Drug-to-Drug Interactions
o Malabsorption of fat-soluble vitamins
o Thiazide diuretics, digoxin, warfarin, thyroid
hormones, and corticosteroids

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Nursing Considerations for Bile Acid
Sequestrants

 Assess:
o History and Physical Exam, known allergy
o Pregnancy and lactation
o Weight, skin, neurological status, pulse, BP and LS
o BS and elimination patterns and appropriate lab
values

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Prototype Bile Acid Sequestrants

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HMG-CoA Inhibitors #1

 The early rate-limiting step in the synthesis of cellular

cholesterol involves the enzyme HMG–CoA reductase. If
this enzyme is blocked, serum cholesterol and LDL level
decrease
o Atorvastatin (Lipitor)
o Fluvastatin (Lescol)
o Lovastatin (generic)
o Pitavastatin (Livalo), pravastatin (Pravachol),
rosuvastatin (Crestor), and simvastatin (Zocor)

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HMG-CoA Inhibitors #2

 Actions
o Inhibits HMG-CoA, decreases serum cholesterol
levels, LDLs, and triglycerides, increases HDL levels
 Indications
o Adjunct to diet in the treatment of elevated
cholesterol, triglycerides, and LDL; increase HDL-C in
patients with primary hypercholesterolemia; treat
familial hypercholesterolemia and two+ risk factors
for CAD

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HMG-CoA Inhibitors #3

 Pharmacokinetics
o Absorbed from the GI tract, undergo first-pass
metabolism by the liver
o Excreted in urine and feces
 Contraindications
o Allergy
o Active liver disease or history of alcoholic liver
disease
o Pregnancy or lactation

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HMG-CoA Inhibitors #4

 Caution
o Impaired endocrine function
 Adverse Effects
o GI symptoms: Flatulence, abdominal pain, cramps,
nausea, vomiting, and constipation
o CNS: Headache, dizziness, blurred vision, insomnia,
fatigue
o Liver failure
o Rhabdomylosis

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HMG-CoA Inhibitors #5

 Drug-to-Drug Interactions
o Erythromycin, cyclosporine, gemfibrozil, niacina
o Digoxin or warfarin
o Estrogen
o Grapefruit juice

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Nursing Considerations for HMG-CoA
Inhibitors

 Assess:
o History and Physical Exam and known allergy
o Active liver disease or history of alcoholic liver
disease
o Pregnancy and lactation
o Weight, neurological status, VS, BS and elimination
patterns and appropriate lab values

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Prototype HMG-CoA Inhibitors

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Question #2

What would cause a drug-drug interaction with bile acid

sequestrants?
A. Loop diuretics
B. Thyroid hormones
C. Water soluble vitamins
D. Mineralocorticoids

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Answer to Question #2

b. Thyroid hormones

Rationale: Drug-to-Drug Interactions: malabsorption of

fat-soluble vitamins; thiazide diuretics, digoxin, warfarin,
thyroid hormones, and corticosteroids

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Cholesterol Absorption Inhibitors #1
 New class of drugs to lower cholesterol levels was
approved in 2003
o Ezetimibe (Zetia)

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Cholesterol Absorption Inhibitors #2

 Actions
o Works in the brush border of the small intestine to
inhibit the absorption of cholesterol
 Indications
o Lower serum cholesterol levels; treat homozygous
familial hypercholesterolemia; treat homozygous
sitosterolemia to lower sitosterol and campesterol
levels

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Cholesterol Absorption Inhibitors #3

 Pharmacokinetics
o Absorbed in the GI tract
o Metabolized in the liver, excreted in urine and feces
 Contraindications
o Allergy
o Pregnancy or lactation if combined with a statin

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Cholesterol Absorption Inhibitors #4

 Caution
o Pregnancy or lactation (monotherapy)
o Elderly patients
o Liver disease
 Adverse Effects
o Abdominal pain and diarrhea
o Headache, dizziness, fatigue, URI, back pain
o Muscle aches and pain

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Cholesterol Absorption Inhibitors #5
 Drug-to-Drug Interactions
o Cholestyramine, fenofibrate, gemfibrozil, or antacids
o Cyclosporine
o Fibrates
o Warfarin

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Nursing Considerations for Cholesterol
Absorption Inhibitors
 Assess:
o History and Physical Exam and known allergy
o Pregnancy and lactation
o Liver dysfunction, orientation and reflexes
o Respirations and LS, BS and bowel elimination
patterns
o Appropriate lab values

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Prototype Cholesterol Absorption
Inhibitors #1

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Prototype Cholesterol Absorption
Inhibitors #2

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Agents Used to Lower Lipid Levels #1

 Niacin
o Vitamin B3, inhibits release of free fatty acids from
adipose tissue
o Increases rate of triglyceride removal from plasma
 Fenofibrates
o Inhibits triglyceride synthesis in the liver – decreased
LDL
o Increased uric acid secretion – may stimulate
triglyceride breakdown

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Agents Used to Lower Lipid Levels #2

 Gemfibrozil
o Inhibits peripheral breakdown of lipids
o Reduced production of triglycerides and LDL
o Increases HDL

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Question #3

The nurse is caring for a patient taking a HMG-CoA

inhibitor. What would be an appropriate intervention for
this patient?
A. Monitor CBC blood tests before and periodically during
therapy
B. Arrange for periodic ophthalmic examinations
C. Administer the drug at breakfast
D. Monitor for adverse effects

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Answer to Question #3

B. Arrange for periodic ophthalmic examinations

Rationale: Implementation with rationale: arrange for

periodic ophthalmic examinations, to monitor for cataract
development

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