c h a p t e r

43
Antihyperlipidemic Drugs

Key Terms Chapter Objectives

atherosclerosis hyperlipidemia On completion of this chapter, the student will:
bile acid sequestrants lipids ● Discuss cholesterol, HDL, LDL, and triglyceride levels and how they con-
catalyst lipoprotein tribute to the development of heart disease.
cholesterol low-density ● Discuss therapeutic life changes and how they affect cholesterol levels.
high-density lipoproteins (LDL) ● Discuss the general actions, uses, adverse reactions, contraindications,
lipoproteins (HDL) rhabdomyolysis precautions, and interactions of antihyperlipidemic drugs.
HMG-CoA reductase triglycerides ● Discuss important preadministration and ongoing assessment activities
inhibitors the nurse should perform on the patient taking an antihyperlipidemic
drug.
● List some nursing diagnoses particular to a patient taking an antihyper-
lipidemic drug.
● Discuss ways to promote an optimal response to therapy, how to man-
age common adverse reactions, and important points to keep in mind
when educating patients about the use of an antihyperlipidemic drug.

Hyperlipidemia is an increase (hyper) in the lipids plaque formation. Elevation of the LDL increases the risk
(lipi), which are a group of fats or fatlike substances in for heart disease. High-density lipoproteins (HDL) take
the blood (demia). Cholesterol and the triglycerides cholesterol from the peripheral cells and bring it to the
are the two lipids in the blood. Elevation of one or both liver, where it is metabolized and excreted. The higher the
of these lipids is seen in hyperlipidemia. Serum choles- HDL, the lower the risk for development of atherosclero-
terol levels above 240 mg/dL and triglyceride levels sis. Therefore, it is desirable to see an increase in the HDL
above 150 mg/dL are associated with atherosclerosis. (the “good” lipoprotein) because of the protective nature
Atherosclerosis is a disorder in which lipid deposits of its properties against the development of atherosclerosis
accumulate on the lining of the blood vessels, eventually and a decrease in the LDL. A laboratory examination of
producing degenerative changes and obstruction of blood lipids, called a lipoprotein profile, provides valuable
blood flow. Atherosclerosis is considered to be a major information on the important cholesterol levels, such as:
contributor in the development of heart disease.
• Total cholesterol
Triglycerides and cholesterides are insoluble in water
• LDL (the harmful lipoprotein)
and must be bound to a lipid-containing protein (lipopro-
• HDL (the protective lipoprotein)
tein) for transportation throughout the body. Although
• Triglycerides
several lipoproteins are found in the blood, this chapter
will focus on the low-density lipoproteins (LDL), the high- Table 43-1 provides an analysis of cholesterol levels.
density lipoproteins (HDL), and cholesterol. Low-density HDL cholesterol protects against heart disease, so the
lipoproteins (LDL) transport cholesterol to the periph- higher the numbers the better. An HDL level less than
eral cells. When the cells have all of the cholesterol they 40 mg/dL is low and considered a major risk factor for
need, the excess cholesterol is discarded into the blood. heart disease. Triglyceride levels that are borderline
This can result in an excess of cholesterol, which can pen- (150–190 mg/dL) or high (above 190 mg/dL) may need
etrate the walls of the arteries, resulting in atherosclerotic treatment in some individuals.

407
408 UNIT VI ● Drugs That Affect the Cardiovascular System

low-saturated fat and low cholesterol-eating plan that

TABLE 43-1 Cholesterol Level Analysis includes less than 200 mg of dietary cholesterol per day.
In addition, 30 minutes of physical activity each day is
TOTAL CHOLESTEROL LEVEL* CATEGORY recommended in the TLC. Walking a brisk pace for
Less than 200 mg/dL Desirable 30 minutes a day 5 to 7 days a week can help raise the
200–239 mg/dL Borderline HDL and lower LDL. Added benefits of a healthy diet
240 mg/dL and above High and exercise program include a reduction of body
weight. If TLC does not result in bringing blood lipids to
LDL CHOLESTEROL LEVEL* LDL CHOLESTEROL CATEGORY therapeutic levels, the primary health care provider may
Less than 100 mg/dL Optimal add one of the antihyperlipidemic drugs to the treat-
100–129 mg/dL Near optimal/above optimal ment plan. The TLC is continued along with the drug
130–159 mg/dL Borderline regimen.
160–189 mg/dL High In addition to control of the dietary intake of fat, par-
190 mg/dL and above Very high
ticularly saturated fatty acids, antihyperlipidemic drug
*Cholesterol levels are measured in milligrams (mg) of cholesterol
therapy is used to lower serum levels of cholesterol and
per deciliter (dL) of blood. triglycerides. The primary health care provider may use
one drug or, in some instances, more than one
antihyperlipidemic drug for those with poor response to
therapy with a single drug. Three types of antihyperlipi-
An increase in serum lipids is believed to contribute demic drugs are currently in use, as well as one
to or cause atherosclerosis, a disease characterized by miscellaneous antihyperlipidemic drug (see Summary
deposits of fatty plaques on the inner walls of arteries. Drug Table: Antihyperlipidemic Drugs for a complete list-
These deposits result in a narrowing of the lumen ing of the drugs). The various types of drugs used to treat
(inside diameter) of the artery and a decrease in blood hyperlipidemia are:
supply to the area served by the artery. When these fatty
deposits occur in the coronary arteries, the patient expe- • Bile acid sequestrants
riences coronary artery disease. Lowering blood choles- • HMG-CoA reductase inhibitors
terol levels can arrest or reverse atherosclerosis in the • Fibric acid derivatives
vessels and can significantly decrease the incidence of • Niacin
heart disease.
Hyperlipidemia, particularly elevated serum choles- The target LDL level for treatment is less that 130 mg/
terol and LDL levels, is a risk factor in the development dL. If the response to drug treatment is adequate, lipid
of atherosclerotic heart disease. Other risk factors, levels are monitored every 4 months. If the response is
besides cholesterol levels, play a role in the development inadequate, another drug or a combination of two drugs
of hyperlipidemia. Additional risk factors include: is used. Antihyperlipidemic drugs decrease cholesterol
and triglyceride levels in several ways. Although the end
• Family history of early heart disease (father before
result is a lower lipid blood level, each has a slightly dif-
the age of 55 years and mother before the age of
ferent action.
55 years)
• Cigarette smoking
• High blood pressure
• Age (men older than 45 years and women older
than 55 years) ACTIONS
●
• Low HDL levels
• Obesity Bile Acid Sequestrants
• Diabetes
Cholestyramine (Questran) and colestipol (Colestid) are
In general, the higher the LDL level and the more examples of bile acid sequestrants. Bile, which is manu-
risk factors involved, the greater the risk for heart dis- factured and secreted by the liver and stored in the gall-
ease. The main goal of treatment in patients with hyper- bladder, emulsifies fat and lipids as these products pass
lipidemia is to lower the LDL to a level that will reduce through the intestine. Once emulsified, fats and lipids
the risk of heart disease. are readily absorbed in the intestine. These drugs bind
The primary care provider may initially seek to con- to bile acids to form an insoluble substance that cannot
trol the cholesterol level by encouraging therapeutic life be absorbed by the intestine, so it is secreted in the
changes (TLC). This includes a cholesterol-lowering feces. With increased loss of bile acids, the liver uses
diet (TLC diet), physical activity, quitting smoking (if cholesterol to manufacture more bile. This is followed
applicable), and weight management. The TLC diet is a by a decrease in cholesterol levels.
 CHAPTER 43 ● Antihyperlipidemic Drugs 409

SUMMARY DRUG TABLE ANTIHYPERLIPIDEMIC DRUGS

GENERIC NAME TRADE* NAME USES ADVERSE REACTIONS DOSAGE RANGES

Bile Acid Sequestrants

cholestyramine LoCHOLEST, Hyperlipidemia, Constipation (may lead to fecal 4 g PO 1–6 times/d;

koe-less’-tir-a- Prevalite, relief of pruritus impaction), exacerbation of individualize dosage based
meen Questran, associated with hemorrhoids, abdominal pain, on response
Questran partial biliary distention and cramping,
Light, obstruction nausea, increased bleeding
generic related to vitamin
K malabsorption, vitamin A
and D deficiencies
colestipol HCl Colestid Hyperlipidemia Constipation (may lead to fecal Granules: 5—30 g/d PO
koe-les’-ti-pole impaction), exacerbation of in divided doses;
hemorrhoids, abdominal tablets: 2—16 g/d
pain, distention and cramping,
nausea, increased bleeding
related to vitamin
K malabsorption, vitamin A
and D deficiencies
colesevelam HCl Welchol Adjunctive therapy Constipation (may lead to fecal 3–6 tablets/d PO
ko-leh-sev’-eh-lam used alone or with impaction), exacerbation of
an HMG-CoA hemorrhoids, abdominal
inhibitor to decrease pain, distention and cramping,
elevated LDL nausea, increased bleeding
cholesterol related to vitamin K malabsorption,
vitamin A and D deficiencies

HMG-CoA Reductase Inhibitors

atorvastatin Lipitor Hyperlipidemia, (Usually mild) headache, 10—80 mg/d PO

ah-tor’-va-stah-tin reduction of elevated flatulence, abdominal
total and LDL pain, cramps, constipation,
cholesterol levels; nausea
increase HDL-C
in patients with
hypercholesterolemia
fluvastatin Lescol, Lescol Hyperlipidemia and (Usually mild) headache, 20–80 mg/d PO
flue-va-sta’-tin XL mixed dyslipidemia, flatulence, abdominal pain,
reduction of elevated cramps, constipation, nausea
total and LDL
cholesterol levels,
to slow progression
of coronary artery
disease (CAD), along
with diet and exercise
lovastatin Mevacor Hyperlipidemia, (Usually mild) headache, 10–80 mg/d PO in single
loe-va-sta’-tin reduction of elevated flatulence, abdominal or divided doses
total and LDL pain, cramps, constipation,
cholesterol levels, nausea
to slow progression
of CAD along with
diet and excercise
pravastatin Pravachol Hyperlipidemia, (Usually mild) headache, 10–40 mg/d PO
prah-va-sta’-tin reduction of elevated flatulence, abdominal
total and LDL pain, cramps, constipation,
cholesterol levels, nausea
prevention of first MI,
to slow progression
of CAD, reduce risk
of stroke, TIA, and MI
(continued)
410 UNIT VI ● Drugs That Affect the Cardiovascular System

SUMMARY DRUG TABLE ANTIHYPERLIPIDEMIC DRUGS (Continued )

GENERIC NAME TRADE* NAME USES ADVERSE REACTIONS DOSAGE RANGES

simvastatin Zocor Hyperlipidemia, (Usually mild) headache, 5–80 mg/d PO

sim-va-stah’-tin reduction of elevated flatulence, abdominal
total and LDL pain, cramps, constipation,
cholesterol levels nausea

Fibric Acid Derivatives

clofibrate Atromid-S, Hyperlipidemia Nausea, vomiting, GI upset, 2 g/d PO in divided doses

klo-fye’-brate generic impotence, myalgia (muscle
cramping and aching),
increased or decreased
angina, cardiac arrhythmias,
fatigue, rash
fenofibrate Tricor Hyperlipidemia, Nausea, constipation, diarrhea, 54–160 mg/d PO
fen-oh-figh’-brate hypertriglyceridemia abnormal liver function tests,
respiratory problems, rhinitis,
abdominal pain, back pain,
headache, asthenia, flu
syndrome
gemfibrozil Lopid, generic Hyperlipidemia, Dyspepsia, abdominal pain, 1200 mg/d PO in 2
jem-fi’-broe-zil hypertriglyceridemia, diarrhea, nausea, vomiting, divided doses 30 min
reduction of rash, vertigo, headache before morning
coronary heart and evening meal
disease risk

Miscellaneous Preparations

niacin Niaspan Adjunctive treatment Generalized flushing sensation 1—2 g PO BID, TID;
nye’-a-sin for hyperlipidemia of warmth, severe itching and extended release:
(nicotinic acid) tingling, nausea, vomiting, 500–2000 mg/d PO
abdominal pain

*The term generic indicates the drug is available in generic form.

HMG-CoA Reductase Inhibitors VLDL and inhibiting cholesterol formation. Fenofibrate

(Tricor) acts by reducing VLDL and stimulating the
Another group of antihyperlipidemic drugs are called catabolism of triglyceride-rich lipoproteins, resulting
HMG-CoA reductase inhibitors. HMG-CoA (3- in a decrease in plasma triglyceride and cholesterol.
hydroxy-3-methyglutaryl coenzyme A) reductase is an Gemfibrozil (Lopid) increases the excretion of cholesterol
enzyme that is a catalyst (a substance that accelerates a in the feces and reduces the production of triglycerides by
chemical reaction without itself undergoing a change) in the liver, thus lowering serum lipid levels.
the manufacture of cholesterol. These drugs appear to
have one of two activities, namely, inhibiting the manu-
facture of cholesterol or promoting the breakdown of Miscellaneous Antihyperlipidemic
cholesterol. This drug activity lowers the blood levels of Drug: Niacin
cholesterol and serum triglycerides and increases blood The mechanism by which niacin (nicotinic acid) lowers
levels of HDLs. Examples of these drugs are fluvastatin blood lipids is not fully understood.
(Lescol), lovastatin (Mevacor), and simvastatin (Zocor).

Fibric Acid Derivatives USES

●
Fibric acid derivatives, the third group of antihyperlipi-
Bile Acid Sequestrants
demic drugs, work in a variety of ways. Clofibrate
(Atromid-S), acts to stimulate the liver to increase break- The bile acid sequestrants are used as adjunctive ther-
down of very–low-density lipoproteins (VLDL) to low- apy for the reduction of elevated serum cholesterol in
density lipoproteins (LDL), decreasing liver synthesis of patients with hypercholesterolemia who do not have an
 CHAPTER 43 ● Antihyperlipidemic Drugs 411

adequate response to a diet and exercise program. headache. A rare, but more serious, adverse reaction is
Cholestyramine may also be used to relieve pruritus rhabdomyolysis.
associated with partial biliary obstruction.
Fibric Acid Derivatives
HMG-CoA Reductase Inhibitors The adverse reactions associated with fibric acid deriv-
These drugs, along with a diet restricted in saturated fat atives include nausea, vomiting, gastrointestinal upset,
and cholesterol, are used to treat hyperlipidemia when and diarrhea. Clofibrate, fenofibrate, and gemfibrozil
diet and other nonpharmacologic treatments alone have may increase cholesterol excretion into the bile, leading
not resulted in lowered cholesterol levels. to cholelithiasis (stones in the gallbladder) or cholecys-
titis (inflammation of the gallbladder). If cholelithiasis
is found, use of the drug is discontinued. Fenofibrate
Fibric Acid Derivatives may also result in abnormal liver function tests, respi-
While the fibric acid derivatives have antihyperlipi- ratory problems, back pain, and headache. Gemfibrozil
demic effects, their use varies depending on the drug. may cause dyspepsia, skin rash, vertigo, and headache.
For example, Clofibrate (Atromid-S) and gemfibrozil See the Summary Drug Table: Antihyperlipidemic
(Lopid) are used to treat individuals with very high Drugs for additional adverse reactions.
serum triglyceride levels who present a risk of abdomi-
nal pain and pancreatitis and who do not experience a Miscellaneous Antihyperlipidemic
response to diet modifications. Clofibrate is not used for Drug: Niacin
the treatment of other types of hyperlipidemia and is
Nicotinic acid may cause nausea, vomiting, abdominal
not thought to be effective for prevention of coronary
pain, diarrhea, severe generalized flushing of the skin, a
heart disease. Fenofibrate (Tricor) is used as adjunctive
sensation of warmth, and severe itching or tingling.
treatment for the reduction of LDL, total cholesterol,
and triglycerides in patients with hyperlipidemia.
CONTRAINDICATIONS, PRECAUTIONS,
Miscellaneous Antihyperlipidemic AND INTERACTIONS
●
Drug: Niacin
Niacin is used as adjunctive therapy for the treatment of Bile Acid Sequestrants
very high serum triglyceride levels in patients who pre- The bile acid sequestrants are contraindicated in
sent a risk of pancreatitis (inflammation of the pancreas) patients with known hypersensitivity to the drugs. Bile
and who do not experience an adequate response to acid sequestrants are also contraindicated in those with
dietary control. complete biliary obstruction. These drugs are used cau-
tiously in patients with a history of liver or kidney dis-
ease. Bile acid sequestrants are used cautiously during
ADVERSE REACTIONS pregnancy (Pregnancy Category C) and lactation
● (decreased absorption of vitamins may affect the infant).
Bile Acid Sequestrants The bile acids sequestrants, particularly cholestyra-
mine, can decrease the absorption of numerous drugs.
A common problem associated with the administration For this reason, the bile acid sequestrants should be
of the bile acid sequestrants is constipation. Constipation administered alone and other drugs given at least 1 hour
may be severe and may occasionally result in fecal before or 4 hours after administration of the bile acid
impaction. Hemorrhoids may be aggravated. Additional sequestrants. There is an increased risk of bleeding
adverse reactions include vitamin A and D deficiencies, when the bile acid sequestrants are administered with
bleeding tendencies (including gastrointestinal bleeding) oral anticoagulants. The dosage of the anticoagulant is
caused by a depletion of vitamin K, nausea, abdominal usually decreased. The bile acid sequestrants may bind
pain, and distention. with digoxin, thiazide diuretics, penicillin, propranolol,
tetracyclines, folic acid, and the thyroid hormones,
HMG-CoA Reductase Inhibitors resulting in decreased effects of these drugs.

HMG-CoA reductase inhibitors are usually well toler-

HMG-CoA Reductase Inhibitors
ated. Adverse reactions, when they do occur, are often
mild and transient and do not require discontinuing ther- The HMG-CoA reductase inhibitors are contraindicated
apy. The more common adverse reactions include nausea, in individuals with hypersensitivity to the drugs, seri-
vomiting, constipation, abdominal pain or cramps, and ous liver disorders, and during pregnancy (Pregnancy
412 UNIT VI ● Drugs That Affect the Cardiovascular System

Category X) and lactation. The HMG-CoA reductase

N U R S I N G P R O C E S S
inhibitors are used cautiously in patients with a history
of alcoholism, acute infection, hypotension, trauma, ● The Patient Receiving an Antihyperlipidemic Drug
endocrine disorders, visual disturbances, and myopathy.
The HMG-CoA reductase inhibitors have an additive ASSESSMENT
effect when used with the bile acid sequestrants, which
may provide an added benefit in treating hypercholes- Preadministration Assessment
terolemia that does not respond to a single-drug regi- In many individuals, hyperlipidemia has no symptoms
men. There is an increased risk of myopathy (disorders and the disorder is not discovered until laboratory tests
of the striated muscle) when the HMG-CoA reductase reveal elevated cholesterol and triglyceride levels, ele-
inhibitors are administered with erythromycin, niacin, vated LDL levels, and decreased HDL levels. Often,
or cyclosporine. When the HMG-CoA reductase these drugs are initially prescribed on an outpatient
inhibitors are administered with oral anticoagulants, basis, but initial administration may occur in the hospi-
there is an increased anticoagulant effect. talized patient. Serum cholesterol levels (ie, a lipid pro-
file) and liver functions tests are obtained before the
drugs are administered.
Fibric Acid Derivatives The nurse takes a dietary history, focusing on the
The fibric acid derivatives are contraindicated in types of foods normally included in the diet. Vital signs
patients with hypersensitivity to the drugs and those and weight are recorded. The skin and eyelids are
with significant hepatic or renal dysfunction or primary inspected for evidence of xanthomas (flat or elevated
biliary cirrhosis because these drugs may increase the yellowish deposits) that may be seen in the more severe
already elevated cholesterol. The drugs are used cau- forms of hyperlipidemia.
tiously during pregnancy (Pregnancy Category C) and
lactation and in patients with peptic ulcer disease or Ongoing Assessment
diabetes. Although it rarely occurs, when the fibric acid The patient will usually take these drugs on an outpa-
derivatives, particularly gemfibrozil, are administered tient basis and come to the clinic or the primary health
with the HMG-CoA reductase inhibitors, there is an care provider’s office for periodic monitoring. Frequent
increased risk for rhabdomyolysis (see Nursing Alert). monitoring of blood cholesterol and triglyceride levels is
When clofibrate, fenofibrate, or gemfibrozil is adminis- done as a part of the ongoing assessment.
tered with the anticoagulants, there is an increased risk
for bleeding.

Miscellaneous Antihyperlipidemic
❊Nursing Alert
Sometimes a paradoxical elevation of blood lipid levels
Drug: Niacin occurs. Should this happen, the primary health care provider
is notified because the primary health care provider may pre-
Niacin is contraindicated in patients with known hyper- scribe a different antihyperlipidemic drug.
sensitivity to niacin, active peptic ulcer, hepatic dysfunc-
tion, and arterial bleeding. The drug is used cautiously in
patients with renal dysfunction, high alcohol consump- During the ongoing assessment, the nurse checks
tion, unstable angina, gout, and pregnancy (Category C). vital signs and assesses bowel functioning because an
adverse reaction to these drugs is constipation.
Constipation may become serious if not treated.
❁Herbal Alert: Garlic
Garlic has been used for many years throughout the world.
When administering the HMG-CoA reductase
inhibitors and the fibric acid derivatives, the nurse mon-
The benefits of garlic on cardiovascular health are the best itors the patient’s liver function by obtaining serum
known and most extensively researched benefits of the herb. transaminase levels before the drug regimen is started, at
Its benefits include lowering serum cholesterol and triglyceride
6 and 12 weeks, then periodically thereafter because of
levels, improving the ratio of HDL to LDL cholesterol, lowering
blood pressure, and helping to prevent the development of the possibility of liver dysfunction with the drugs. If
atherosclerosis. The recommended dosages of garlic are 600 aspartate aminotransferase (AST) levels increase to three
to 900 mg/day of the garlic powder tablets, 10 mg of garlic oil times normal, the primary care provider in notified
“perles,” or one moderate-sized fresh clove of garlic a day. immediately because the HMG-CoA reductase inhibitor
Adverse reactions include mild stomach upset or irritation that
therapy may be discontinued.
can usually be alleviated by taking the supplements with food.
Although no serious reactions have occurred in pregnant Because the maximum effects of these drugs are usu-
women taking garlic, its use is not recommended. Garlic is ally seen within 4 weeks, periodic lipid profiles are per-
excreted in breast milk and may cause colic in some infants. formed to determine the therapeutic effect of the drug
regimen. The primary health care provider may increase
 CHAPTER 43 ● Antihyperlipidemic Drugs 413

severe, a stool softener or laxative may be required.

Nursing Diagnoses Checklist
Some patients require decreased dosage or discontinua-
✓ Constipation related to adverse drug reactions tion of the drug therapy.
✓ Risk for Imbalanced Nutrition: Less than Body
Requirements related to adverse drug reactions

❄ Gerontologic Alert
Older adults are particularly prone to constipation when tak-
the dosage, add another antihyperlipidemic drug, or dis- ing the bile acid sequestrants. The nurse should monitor older
continue the drug therapy, depending on the patient’s adults closely for hard dry stools, difficulty passing stools, and
any complaints of constipation. An accurate record of bowel
response to therapy.
movements must be kept.

NURSING DIAGNOSES
Drug-specific nursing diagnoses are highlighted in the
HMG-COA REDUCTASE INHIBITORS AND FIBRIC ACID
Nursing Diagnoses Checklist. Other nursing diagnoses
DERIVATIVES. The antihyperlipidemic drugs, particu-
applicable to these drugs are discussed in depth in
larly the HMG-CoA reductase inhibitors, have been
Chapter 4.
associated with skeletal muscle effects leading to rhab-
domyolysis. Rhabdomyolysis is a very rare condition
PLANNING in which muscle damage results in the release of muscle
cell contents into the bloodstream. Rhabdomyolysis
The expected outcomes for the patient may include a
may precipitate renal dysfunction or acute renal failure.
therapeutic response to therapy (lowered blood lipid lev-
The nurse is alert for unexplained muscle pain, muscle
els), management of common adverse drug reactions,
tenderness, or weakness, especially if they are accompa-
and an understanding of the dietary measures necessary
nied by malaise or fever. These symptoms should be
to reduce lipid and lipoprotein levels.
reported to the primary health care provider because the
drug may be discontinued.
IMPLEMENTATION
NIACIN. Patients taking nicotinic acid may experience
Promoting an Optimal Response to Therapy
moderate to severe generalized flushing of the skin, a
Because hyperlipidemia is often treated on an outpa-
sensation of warmth, and severe itching or tingling.
tient basis, the nurse explains the drug regimen and pos-
Although these reactions are most often seen at higher
sible adverse reactions. If printed dietary guidelines are
dose levels, some patients may experience them even
given to the patient, the nurse emphasizes the impor-
when small doses of nicotinic acid are administered.
tance of following these recommendations. Drug ther-
The sudden appearance of these reactions may frighten
apy usually is discontinued if the antihyperlipidemic
the patient.
drug is not effective after 3 months of treatment.
Bile acid sequestrants may interfere with the diges-
tion of fats and prevent the absorption of the fat-soluble
vitamins (vitamins A, D, E, and K) and folic acid. When
the bile acid sequestrants are used for long-term ther-
❊Nursing Alert
The nurse should advise the patient taking nicotinic acid to
apy, vitamins A and D may be given in a water-soluble put the call light on if discomfort is experienced. Contact the
form or administered parenterally. If bleeding tendencies primary health care provider before the next dose is due
occur as the result of vitamin K deficiency, parenteral should this adverse reaction occur. If the patient is in severe
discomfort, the nurse should contact the primary health care
vitamin K is administered for immediate treatment, and
provider immediately. The nurse advises outpatients to con-
oral vitamin K is given for prevention of a deficiency in tact their primary health care provider if these reactions are
the future. severe or cause extreme discomfort.

Monitoring and Managing Adverse Reactions

BILE ACID SEQUESTRANTS. Patients taking the antihy- Educating the Patient and Family
perlipidemic drugs, particularly the bile acid seques- The nurse stresses the importance of following the diet
trants, may experience constipation. The drugs can pro- recommended by the primary health care provider
duce or severely worsen preexisting constipation. The because drug therapy alone will not significantly lower
nurse instructs the patient to increase fluid intake, eat cholesterol and triglyceride levels. The nurse provides a
foods high in dietary fiber, and exercise daily to help copy of the recommended diet and reviews the contents
prevent constipation. If the problem persists or becomes of the diet with the patient and family. If necessary, the
414 UNIT VI ● Drugs That Affect the Cardiovascular System

Patient and Family • Colestipol granules: The prescribed dose must be

Teaching Checklist mixed in liquids, soup, cereals, carbonated bever-
ages, or pulpy fruits. The granules will not dissolve.
Using Diet and Drugs to Control Therefore, when mixing with a liquid, slowly stir
High Blood Cholesterol Levels the preparation until ready to drink. Take the entire
The nurse: drug, rinse the glass with a small amount of water,
and drink.
✓ Reviews the reasons for the drug and prescribed • Colesevelam: Mix the granules in liquids, soups,
drug therapy, including drug name, form and
cereals, or pulpy fruits. Do not take dry. Mix the
method of preparation, correct dose, and frequency
prescribed amount in a glassful of liquid.
of administration.
Carbonated beverages should be stirred slowly in a
✓ Emphasizes that drug therapy alone will not signifi-
large glass. The tablets are taken twice daily without
cantly lower blood cholesterol levels.
regard to meals.
✓ Stresses importance of taking drug exactly as • Constipation, flatulence, nausea, and heartburn may
prescribed.
occur and may disappear with continued therapy. The
✓ Reinforces the importance of adhering to prescribed primary health care provider is notified if these effects
diet. become bothersome or if unusual bleeding occurs.
✓ Provides a written copy of dietary plan and reviews
contents. HMG-CoA INHIBITORS
✓ Contacts dietitian for assistance with diet teaching. • Lovastatin is taken once daily, preferably with the
✓ Answers questions and offers suggestions for ways evening meal. Fluvastatin, pravastatin, and simva-
to reduce dietary fat intake. statin are taken, without regard to meals, once daily
✓ Instructs in possible adverse reactions and signs and in the evening or at bedtime.
symptoms to report to primary health care provider. • If fluvastatin or pravastatin is prescribed with a bile
✓ Reviews measures to minimize gastrointestinal upset. acid sequestrant, take fluvastatin 2 hours after the
✓ Explains possible need for vitamin A and D therapy bile acid sequestrant and pravastatin at least 4 hours
and high-fiber foods if patient is receiving bile acid afterward.
sequestrant. • Contact the primary health care provider as soon as
✓ Reassures that results of therapy will be monitored possible if nausea; vomiting; muscle pain, tender-
by periodic laboratory and diagnostic tests and fol- ness, or weakness; fever; upper respiratory infec-
low-up with primary health care provider. tion; rash; itching; or extreme fatigue occurs.
FIBRIC ACID DERIVATIVES

• Clofibrate: If gastrointestinal upset occurs, take the

nurse refers the patient or family member to a teaching drug with food. Notify the primary health care
dietitian, a dietary teaching session, or a lecture provided provider if chest pain, shortness of breath, palpita-
by a hospital or community agency (see Patient and tions, nausea, vomiting, fever, chills, or sore throat
Family Teaching Checklist: Using Diet and Drugs to occurs.
Control High Blood Cholesterol Levels). The nurse devel- • Gemfibrozil: Dizziness or blurred vision may occur.
ops a teaching plan to include the following information: Observe caution when driving or performing haz-
ardous tasks. Notify the primary health care
BILE ACID SEQUESTRANTS provider if epigastric pain, diarrhea, nausea, or vom-
iting occurs.
• Take the drug before meals unless the primary
health care provider directs otherwise.
MISCELLANEOUS PREPARATION
• Cholestyramine powder: The prescribed dose must
be mixed in 4 to 6 fluid ounces of water or noncar- • Nicotinic acid: Take this drug with meals. This drug
bonated beverage and shaken vigorously. The pow- may cause mild to severe facial flushing, feeling of
der can also be mixed with highly fluid soups or warmth, severe itching, or headache. These symp-
pulpy fruits (applesauce, crushed pineapple). The toms usually subside with continued therapy, but
powder should not be ingested in the dry form. contact the primary health care provider as soon as
Other drugs are taken 1 hour before or 4 to 6 hours possible if symptoms are severe. The primary health
after cholestyramine. Cholestyramine is available care provider may prescribe aspirin (325 mg) to be
combined with the artificial sweetener, aspartame taken about 30 minutes before nicotinic acid to
(Questran Light), for patients with diabetes or those decrease the flushing reaction. If dizziness occurs,
who are concerned with weight gain. avoid sudden changes in posture.
 CHAPTER 43 ● Antihyperlipidemic Drugs 415

EVALUATION C. at least 1 hour before or 2 hours after meals

D. twice daily without regard to meals
• The therapeutic effect is achieved and serum lipid
levels are decreased. 3. When assessing a patient taking cholestyramine
• Adverse reactions are identified, reported to the pri- (Questran) for vitamin K deficiency, the nurse
mary health care provider, and managed successfully would .
through successful nursing interventions. A. check the patient for bruising
• The patient and family demonstrate an understand- B. keep a record of the patient’s intake and output
ing of the treatment regimen. C. monitor the patient for myalgia
D. keep a dietary record of foods eaten

4. A patient taking niacin reports flushing after each

● Critical Thinking Exercises dose of the niacin. Which of the following drugs
would the nurse expect to be prescribed to help alle-
1. A patient in the medical clinic is taking cholestyramine viate the flushing?
(Questran) for hyperlipidemia. The primary health
A. Demerol
care provider has prescribed TLC for the patient. The
B. Aspirin
patient is on a low-fat diet and walks daily for exercise.
C. Vitamin K
His major complaint at this visit is constipation, which
D. Benadryl
is very bothersome to him. Discuss how you would
approach this situation with the patient. What infor- 5. Which of the following points would the nurse
mation would you give the patient concerning his con- include when teaching a patient about drug and diet
stipation? therapy for hyperlipidemia?
2. Discuss the important points to include in a teaching A. Fluids are taken in limited amounts when eating
plan for a patient who is prescribed atorvastatin a low-fat diet.
(Lipitor). B. The medication should be taken at least 1 hour
3. Describe the important aspects of the ongoing assess- before meals.
ment when administering fluvastatin to a patient. C. Medication alone will not lower cholesterol.
D. Meat is not allowed on a low-fat diet.

● Review Questions
● Medication Dosage Problems
1. Which of the following adverse reactions is most
1. A patient is prescribed 10 mg simvastatin (Zocor) PO
common in a patient taking a bile acid sequestrant?
daily for high cholesterol. The drug is available in 5-mg
A. Anorexia tablets. The nurse administers .
B. Vomiting
C. Constipation 2. The primary care provider prescribes fenofibrate
D. Headache (Tricor) for the treatment of hypertriglyceridemia. The
patient is now taking 200 mg/d PO. Is this an appropri-
2. Lovastatin (Mevacor) is best taken . ate dosage? If not, what action would you take? If the
A. once daily, preferably with the evening meal dose is appropriate, how many capsules would you
B. three times daily with meals administer if the drug is available in 54-mg capsules?