Antilipemic Agents UNIT 4 chapter 23 MEDICATIONS AFFECTING THE CARDIOVASCULAR SYSTEM Chapter 23 Antilipemic Agents Overview ●● ●● ●● ●● Antilipemic agents work in different ways to help lower low-density lipoprotein (LDL cholesterol) levels, raise high-density lipoprotein (HDL cholesterol) levels, and possibly decrease very low-density lipoprotein (VLDL) levels. Use these medications along with lifestyle modifications such as regular activity, reduced cholesterol and fat, and diet and weight control. Prior to starting these medications, obtain baseline levels of total cholesterol, LDL cholesterol level, HDL cholesterol, and triglycerides (TGs). Monitor these blood values periodically throughout the course of therapy. In addition, obtain baseline liver and renal function tests and monitor periodically throughout the course of therapy. Classifications include: ◯◯ Fibrates ◯◯ HMG CoA reductase inhibitors (Statins) ◯◯ Cholesterol absorption inhibitors ◯◯ Bile-acid sequestrants ◯◯ Nicotinic acid MEDICATION CLASSIFICATION: FIBRATES ●● Select Prototype Medication – Gemfibrozil (Lopid) ●● Other Medications – Fenofibrate (TriCor, Lofibra), clofibrate (Atromid-S) Purpose ●● Expected Pharmacological Action ◯◯ ◯◯ ●● 278 Decrease in triglyceride levels (increase in VLDL excretion for clients unable to lower triglyceride levels with lifestyle modification) Increase in HDL levels by promoting production of precursors to HDLs Therapeutic Uses ◯◯ Reduction of plasma triglycerides (VLDL) ◯◯ Increased levels of HDL PN PHARMACOLOGY FOR NURSING Antilipemic Agents Complications SIDE/ADVERSE EFFECTS NURSING INTERVENTIONS/CLIENT EDUCATION Gastrointestinal (GI) distress (nausea, abdominal pain, and diarrhea) • Usually mild and self-limiting Gallbladder stones (right upper quadrant pain, fat intolerance, bloating) • Advise clients to observe for symptoms of gallbladder disease (right upper quadrant pain, fat intolerance, bloating). • Advise clients to notify the provider if symptoms occur. Myopathy (muscle tenderness, pain) • Obtain baseline creatine kinase (CK) level. • Monitor CK levels periodically during treatment. • Monitor symptoms of muscle aches, pain, and tenderness, and notify the provider if symptoms occur. • Withhold medication if CK levels are elevated. Hepatotoxicity (anorexia, vomiting, nausea, jaundice) • Obtain baseline liver function tests and monitor periodically. • Advise clients to observe for symptoms of liver dysfunction and notify the provider if symptoms occur. • Withhold medication if liver function tests are abnormal. Contraindications/Precautions ●● Pregnancy Risk Category C ●● Contraindicated in clients with liver disorders, severe renal dysfunction, and gallbladder disease Interactions MEDICATION/FOOD INTERACTIONS NURSING INTERVENTIONS/CLIENT EDUCATION With concurrent use, warfarin (Coumadin) increases the risk of bleeding • Obtain the client’s baseline and INR, and perform periodic monitoring. • Advise clients to report signs of bleeding (bruising, bleeding gums), and notify the provider if symptoms occur. • Tell clients the provider may decrease the dosage. Concurrent use with statins increases the risk of myopathy. • • • • Bile acid sequestrants such as cholestyramine interfere with absorption. • Advise clients to take gemfibrozil 1 hr before or 4 hr after taking bile sequestrants. PN PHARMACOLOGY FOR NURSING Obtain baseline (CK) level. Monitor CK levels periodically during treatment. Advise clients to report symptoms of muscle aches and pain, Avoid concurrent use. 279 Antilipemic Agents Nursing Administration ●● Administer by oral route. ●● Advise clients to take medication 30 min prior to breakfast and dinner. MEDICATION CLASSIFICATION: HMG COA REDUCTASE INHIBITORS (STATINS) ●● Select Prototype Medication – Atorvastatin (Lipitor) ●● Other Medications: ◯◯ Simvastatin (Zocor) ◯◯ Lovastatin (Mevacor) ◯◯ Pravastatin sodium (Pravachol) ◯◯ Rosuvastatin (Crestor) ◯◯ Fluvastatin (Lescol, Lescol XL) Purpose ●● Expected Pharmacological Action ◯◯ Decrease manufacture of LDL cholesterol ◯◯ Decrease manufacture of very low-density lipoproteins (VLDL) ◯◯ Increase manufacture of high-density lipoproteins (HDL) ◯◯ ●● 280 Besides affecting lipid levels, other beneficial effects include: promotion of vasodilation, decrease in plaque site inflammation, and decreased risk of thromboembolism. Therapeutic Uses ◯◯ Primary hypercholesterolemia ◯◯ Prevention of coronary events ◯◯ Protection against MI and stroke for clients with diabetes ◯◯ Increasing levels of HDL in clients with primary hypercholesterolemia PN PHARMACOLOGY FOR NURSING Antilipemic Agents Complications SIDE/ADVERSE EFFECTS NURSING INTERVENTIONS/CLIENT EDUCATION • Hepatotoxicity (anorexia, vomiting, nausea, jaundice, increase in serum transaminase) • Obtain the client’s baseline liver function. • Monitor liver function tests after 12 weeks and then every 6 to 12 months. • Advise clients to observe for symptoms of liver dysfunction and notify the provider if symptoms occur. • Advise clients to avoid alcohol. • Tell clients the provider may discontinue the medication if liver function tests are abnormal. • Myopathy (muscle aches, pain, and tenderness) • May progress to myositis, or rhabdomyolysis. • Obtain baseline CK level. • Monitor CK levels while on treatment periodically. • Advise clients to report symptoms. • Tell clients the provider may discontinue the medication if CK levels are elevated. • Peripheral neuropathy (weakness, numbness, tingling, and pain in the hands and feet) • Advise clients to observe for signs and symptoms, and to notify the provider if symptoms occur. Contraindications/Precautions ●● ●● ●● ●● Statins are Pregnancy Risk Category X. These medications are contraindicated in clients who have hepatitis induced by viral infection or alcohol. Avoid use of rosuvastatin for clients of Asian descent. Use cautiously in older adult clients, clients in debilitated condition, and those with chronic renal disease. PN PHARMACOLOGY FOR NURSING 281 Antilipemic Agents Interactions MEDICATION/FOOD INTERACTIONS NURSING INTERVENTIONS/CLIENT EDUCATION Fibrates (gemfibrozil, fenofibrate) and ezetimibe (Zetia) increase the risk of myopathy • Obtain baseline CK level. • Monitor the client’s CK levels periodically during treatment. • Tell clients the provider may discontinue the medication if CK levels are elevated. Medications that suppress CYP3A4, such as erythromycin and ketoconazole, can increase levels of statins when taken concurrently. • Atorvastatin, lovastatin, and simvastatin should be avoided. • Level of statin may need to be decreased. • Advise clients to inform the provider of all medications currently taken. Grapefruit juice suppresses CYP3A4 and can increase levels of statins. • Advise clients to limit the amount of grapefruit juice consumed each day. Clients should not drink more than 240 mL (8 oz) a day. Nursing Administration Administer statins by oral route. ●● Instruct clients to take lovastatin with evening meal. Tell clients to take other statins with or without food, but evening dosing is best. ●● Administer atorvastatin or fluvastatin to clients with renal insufficiency. ●● Advise clients to obtain baseline cholesterol levels, HDL, LDL, and triglycerides, and monitor periodically while taking the medication. ●● Advise clients to obtain baseline liver, renal function tests, and monitor periodically during treatment. ●● MEDICATION CLASSIFICATION: CHOLESTEROL ABSORPTION INHIBITOR ●● Select Prototype Medication – Ezetimibe (Zetia) Purpose ●● Expected Pharmacological Action ◯◯ ●● 282 Ezetimibe inhibits absorption of cholesterol secreted in the bile and from food. Therapeutic Uses ◯◯ As an adjunct with dietary medications to help lower LDL cholesterol ◯◯ Use alone or in combination with a statin medication. PN PHARMACOLOGY FOR NURSING Antilipemic Agents Complications SIDE/ADVERSE EFFECTS NURSING INTERVENTIONS/CLIENT EDUCATION Hepatitis (anorexia, vomiting, nausea, jaundice) • Obtain the client’s baseline liver function. • Advise clients to observe for symptoms of liver dysfunction and notify the provider if symptoms occur. • Advise clients to avoid alcohol. • Tell clients the provider may discontinue the medication if liver function tests are abnormal. Myopathy (muscle aches and pains) • • • • Obtain baseline CK level. Monitor CK levels while on treatment periodically. Advise clients to notify the provider if symptoms occur. Tell clients the provider may discontinue the medication if CK levels are elevated. Contraindications/Precautions ●● Ezetimibe is Pregnancy Risk Category X. ●● Use cautiously in women who are breastfeeding. ●● This medication is contraindicated in clients who have renal dysfunction. ●● Use caution in clients with liver disease. Interactions MEDICATION/FOOD INTERACTIONS NURSING INTERVENTIONS/CLIENT EDUCATION Bile acid sequestrants, such as cholestyramine, interfere with absorption. • Advise clients to take ezetimibe 1 hr before or 4 hr after taking bile sequestrants. Statins, such as atorvastatin, can increase the risk of liver dysfunction and/or myopathy. • Obtain baseline liver function tests and monitor periodically. Advise clients to report signs of liver damage to the provider, who may discontinue the medication. • Advise clients to notify the provider of symptoms such as muscle aches and pains. • Tell clients the provider may discontinue the medication if CK levels are elevated. Concurrent use with fibrates, such as gemfibrozil, increases the risk of gallstone development and myopathy. • Avoid concurrent use. Levels of ezetimibe can be increased with concurrent use of cyclosporine. • Monitor clients for side effects (liver damage, myopathy). PN PHARMACOLOGY FOR NURSING 283 Antilipemic Agents Nursing Administration ●● ●● ●● ●● Advise clients to obtain baseline cholesterol levels, HDL, LDL, and triglyceride, and monitor periodically while taking the medication. Advise clients to obtain baseline liver, renal function tests, and monitor periodically during treatment. Advise clients to follow a low-fat/low-cholesterol diet and to get involved in a regular exercise regimen. Inform clients that this medication can be taken in a fixed-dose combination with simvastatin as Vytorin. MEDICATION CLASSIFICATION: BILE-ACID SEQUESTRANTS ●● Select Prototype Medication– Colesevelam (Welchol) ●● Other Medications – Cholestyramine (Questran), colestipol (Colestid) Purpose ●● Expected Pharmacological Action Decrease in LDL cholesterol ◯◯ ●● Therapeutic Use As adjunct with a HMG CoA reductase inhibitor, such as atorvastatin, and with dietary measures to lower cholesterol levels ◯◯ Complications SIDE/ADVERSE EFFECTS NURSING INTERVENTIONS/CLIENT EDUCATION Cholestyramine and colestipol may cause GI distress and decrease absorption of fat-soluble vitamins. • Administer vitamin supplements. Constipation (less with colesevelam) • Advise clients to increase the intake of high-fiber food and oral fluids, if not restricted. Contraindications/Precautions 284 ●● These medications are contraindicated in clients with biliary disease. ●● Avoid use in clients with elevated VLDL. PN PHARMACOLOGY FOR NURSING Antilipemic Agents Interactions MEDICATION/FOOD INTERACTIONS NURSING INTERVENTIONS/CLIENT EDUCATION Cholestyramine and colestipol form complexes with digoxin (Lanoxin), warfarin (Coumadin), thiazides, and tetracyclines that interfere with absorption. • Advise clients to take other medications 1 hr before or 4 hr after taking bile sequestrants. • Advise clients to inform the provider of all medications currently taken. Nursing Administration ●● ●● ●● Instruct clients to take colesevelam tablets with food or water. Instruct clients not to crush or chew colestipol tablets. Clients should take tablets 30 min before a meal. Advise clients to use an adequate amount of fluid (4 to 8 oz) to dissolve the medication when taking powder formulation of cholestyramine and colestipol. This will prevent irritation or impaction of the esophagus. OTHER MEDICATIONS: NICOTINIC ACID, NIACIN (NIACOR, NIASPAN) Purpose ●● ●● Expected Pharmacological Action ◯◯ Decrease in LDL cholesterol and triglyceride levels ◯◯ Increase in HDL cholesterol Therapeutic Uses ◯◯ For clients at risk for pancreatitis and elevated triglyceride levels ◯◯ To lower elevated LDL cholesterol and triglycerides, and to raise HDL levels (Niaspan) PN PHARMACOLOGY FOR NURSING 285 Antilipemic Agents Complications SIDE/ADVERSE EFFECTS NURSING INTERVENTIONS/CLIENT EDUCATION GI distress • Usually self-limiting. Advise client to take with food. Facial flushing • Advise client to take aspirin 30 min before each dose. May be less with extended release formation. Hyperglycemia • Monitor blood glucose levels Hepatotoxicity (anorexia, vomiting, nausea, jaundice) • Obtain baseline liver function tests and monitor periodically. • Advise clients to observe for symptoms of liver dysfunction and notify the provider if symptoms occur. • Tell clients the provider may discontinue the medication if liver function tests are abnormal. Hyperuricemia • Monitor kidney function, BUN, and creatinine, I&O. • Encourage adequate fluid intake of 2 to 3 L of water each day from food and beverage sources. • Administer allopurinol if uric acid level is elevated. Contraindications/Precautions ●● Contraindicated in clients with liver disease and gout Nursing Administration ●● Administer by oral route, either in pill or liquid form. Pill may be standard form or timereleased. ●● Administer standard form three times a day with or after meals. ●● Administer time-released formulations once in the evening. ●● Advise clients that dosage is much larger than dosage when taken as vitamin supplement. Nursing Evaluation of Medication Effectiveness ●● 286 Depending on therapeutic intent, effectiveness may be evidenced by: ◯◯ Decreased LDL cholesterol level ◯◯ Decreased triglyceride (VLDL) levels ◯◯ Increased HDL levels ◯◯ Absence of cardiovascular events such as stroke, MI, thrombosis PN PHARMACOLOGY FOR NURSING Antilipemic Agents APPLICATION EXERCISES 1. A nurse is reinforcing teaching to a client who is prescribed lovastatin (Mevacor). Which of the following should be included in the teaching? A. Take the medication with the evening meal. B. Change position slowly when rising from a chair. C. Maintain a steady intake of green leafy vegetables. D. Consume no more than 1 L of fluid/day. 2. A nurse is caring for a client who has received a prescription for gemfibrozil (Lopid). The nurse should know that which of the following lab values should be reviewed before the client begins taking the medication? (Select all that apply) RBC count Liver function tests WBC count Serum electrolytes Creatine kinase (CK) 3. A nurse is reinforcing teaching for a client who has been prescribed Ezetimibe (Zetia) for some time and now has a new prescription for cholestyramine (Questran). Both medications are to be taken once daily. How should the nurse advise the client to take these two medications in order to prevent an interaction? 4. A nurse is reinforcing teaching for a client who is to begin taking a new prescription for niacin (Niacor). The nurse should instruct the client to expect which of the following? A. Facial flushing B. Frontal headache C. Blurred vision D. Dry mouth 5. Match each of the following cholesterol-lowering medications with its classification below: Ezetimibe (Zetia) A. Cholesterol absorption inhibitor Colesevelam HCL (Welchol) B. HMG COA reductase inhibitor (statin) Gemfibrozil (Lopid) C. Bile acid sequestrant Atorvastatin (Lipitor) D. Fibrate PN PHARMACOLOGY FOR NURSING 287 Antilipemic Agents APPLICATION EXERCISES ANSWER KEY 1. A nurse is reinforcing teaching to a client who is prescribed lovastatin (Mevacor). Which of the following should be included in the teaching? A. Take the medication with the evening meal. B. Change position slowly when rising from a chair. C. Maintain a steady intake of green leafy vegetables. D. Consume no more than 1 L of fluid/day. Instruct the client to take lovastatin with the evening meal to increase absorption. Changing positions slowly may be necessary when taking an antihypertensive. Maintaining a steady intake of green leafy vegetables would be important if taking warfarin. There is no indication for fluid restriction with statins. NCLEX® Connection: Pharmacological Therapies, Medication Administration 2. A nurse is caring for a client who has received a prescription for gemfibrozil (Lopid). The nurse should know that which of the following lab values should be reviewed before the client begins taking the medication? (Select all that apply) RBC count X Liver function tests WBC count Serum electrolytes X Creatine kinase (CK) Check the client’s liver function and creatine kinase (CK) levels before beginning the prescription for gemfibrozil. If baseline liver enzymes are elevated, hepatotoxicity may be present and would be a contraindication to beginning a fibrate medication. A baseline CK is obtained since myopathy is a possible adverse reaction to gemfibrozil. Monitor both laboratory values throughout therapy with the medication. It is not necessary to check the other laboratory values before the client begins taking gemfibrozil. NCLEX® Connection: Pharmacological Therapies, Medication Administration 3. A nurse is reinforcing teaching for a client who has been prescribed Ezetimibe (Zetia) for some time and now has a new prescription for cholestyramine (Questran). Both medications are to be taken once daily. How should the nurse advise the client to take these two medications in order to prevent an interaction? Ezetimibe should be taken 2 hr before or 4 hr following the cholestyramine. If taken together, the cholestyramine can decrease absorption of the ezetimibe. NCLEX® Connection: Pharmacological Therapies, Medication Administration 288 PN PHARMACOLOGY FOR NURSING Antilipemic Agents 4. A nurse is reinforcing teaching for a client who is to begin taking a new prescription for niacin (Niacor). The nurse should instruct the client to expect which of the following? A. Facial flushing B. Frontal headache C. Blurred vision D. Dry mouth Facial flushing occurs within a few minutes after taking Niacor. It can be prevented by taking aspirin 325 mg 30 min before the Niacor is ingested. The flushing usually decreases after several weeks. Clients who are prescribed the extended-release niacin (Niaspan) may have a much less intense flushing response. Headache, blurred vision, and dry mouth are not expected side effects of niacin. NCLEX® Connection: Pharmacological Therapies, Adverse Effects/Contraindications/Side Effects/Interactions 5. Match each of the following cholesterol-lowering medications with its classification below: A C Ezetimibe (Zetia) A. Cholesterol absorption inhibitor Colesevelam HCL (Welchol) B. HMG COA reductase inhibitor (statin) D B Gemfibrozil (Lopid) C. Bile acid sequestrant Atorvastatin (Lipitor) D. Fibrate NCLEX Connection: Pharmacological Therapies, Expected Actions/Outcomes ® PN PHARMACOLOGY FOR NURSING 289
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