Medications used to treat high cholesterol and their side effects PowerPoint Presentation

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MEDICATIONS USED TO TREAT HIGH CHOLESTEROLANDTHEIR SIDE EFFECTS Cristi FroymanBSP StudentUniversity of SaskatchewanStueck Pharmacy Ltd.Leader, Saskatchewan

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TOTAL BLOOD CHOLESTEROL: Wax-like substance produced by liver Essential for the body to function Used to make cell membranes, vitamin D and hormones If too high, plaque deposits build up on the artery walls Adapted from the Cypress Health Region’s Nutrition for Heart Health Handout

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Low-density Lipoprotein (LDL) Cholesterol: “Bad” or “Lousy” cholesterol Sticks to artery walls High levels can increase the risk of heart disease To help lower LDL: Eat a healthy diet, low in saturated and trans fats, and high in soluble fiber Maintain a healthy weight Adapted from the Cypress Health Region’s Nutrition for Heart Health Handout

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High-density Lipoprotein (HDL) Cholesterol: “Good” cholesterol or “Healthy” Helps carry LDL-cholesterol away from the artery walls To help increase HDL: Participate in regular physical activity Do not smoke Maintain a healthy weight Adapted from the Cypress Health Region’s Nutrition for Heart Health Handout

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Triglycerides: Not a type of cholesterol Storage form of fat in our bodies High levels can lead to increased risk of heart disease and stroke To help lower TG levels: Limit sugar, alcohol and fat Participate in regular physical activity Maintain a healthy weight Do not smoke Adapted from the Cypress Health Region’s Nutrition for Heart Health Handout

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LIPID TARGETS: Adapted from the Cypress Health Region’s Nutrition for Heart Health Handout

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RESINS: 1, 2 Cholestyramine (Questran®) Colestipol (Colestid®)

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WHAT THEY DO: Attach to bile salts and cholesterol in the stomach and intestine ↓ bad cholesterol ↑ good cholesterol May ↑ TG (blood fats)

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DRUG INTERACTIONS: Resins can also bind to other drugs and fat-soluble vitamins, decreasing their amount in the body Take other medications at least 1 hour before or 4 to 6 hours after

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SIDE EFFECTS: Not absorbed from the GIT Mostly stomach related Titrate dose slowly

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Common Side Effects: Constipation (dose related) (10%) Bloating and gas (resolves) (1-5%) Feelings of fullness (1-5%) Nausea (1-5%) ↑ triglycerides (blood fats) ↑ liver enzymes (reversible) Vitamin deficiency

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Constipation: High doses and in the elderly Always take with liquids Fiber and fluids Doctor may lower the dose or stop medication

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MONITORING: Liver function Triglycerides INR (impaired vitamin K absorption) Electrolytes (increased chloride)

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HMG-CoA REDUCTASE INHIBITORS: (Statins)1, 3 Atorvastatin (LipitorTM) Simvastatin (Zocor®) Rosuvastatin (Crestor®) Fluvastatin (Lescol®) Lovastatin (Mevacor®) Pravastatin (Pravacol®)

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WHAT THEY DO: Block cholesterol synthesis in the liver Best medications to ↓ bad cholesterol ↓ the chance of having a heart attack or stroke by 26% 4 ↓ the chance of dying from a heart attack or stroke Beneficial regardless of age, sex or health Maximum therapeutic benefit seen after 4 weeks of therapy

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SIDE EFFECTS:Mild and transient

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SIDE EFFECTS:Mild and transient

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Liver Side Effects: ↑ in liver enzymes: 1 to 2% incidence Occurs within 3 to 12 months LFT’s at baseline, 3, 6 and 12 months, then yearly People who drink a lot of alcohol and/or have a history of liver disease need to be monitored more carefully

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Liver Side Effects: If liver enzymes rise to 3x ULN and are sustained, the drug should be discontinued Liver slowly returns to normal once drug stopped

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Muscle Side Effects: Not common with statin mono-therapy If muscle symptoms occur, they usually appear within weeks to months after starting statin It takes days to weeks for muscle pain, weakness, and serum CK concentrations to return to normal after stopping the statin

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Myalgia: Muscle pain Tenderness Weakness Serum CK may or may not be high 2 to 11 % incidence 5

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Myositis: Inflammation / swelling of the muscles Serum CK levels > 10 x ULN 0.5 % incidence 5

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Rhabdomyolysis: Skeletal muscle breakdown / death Toxic muscle cell components released into the blood Can lead to kidney problems, high potassium levels and cardiac arrest Very Rare: occurs in approximately 0.2/1 million statin prescriptions 6 < 0.1 % incidence 5 Death occurs in ~ 10 % of cases 7

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Risk Factors for Muscle Side Effects: Higher doses Liver problems Kidney problems Alcohol abuse Advanced age (> 80 yrs old) Women > men Frailty, small body frame Untreated low thyroid levels Multiple medications Grapefruit juice intake

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NICOTINIC ACID: 1, 8 Niacin (Vitamin B3)

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WHAT IT DOES: Slows down the rate and production of bad cholesterol in the liver ↓ TG’s and bad cholesterol Best medication to ↑ good cholesterol

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SIDE EFFECTS: Hot flushes Itchy / dry skin Skin discoloration (reversible) Reactivation of peptic ulcer

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SIDE EFFECTS: Stomach problems ↑ sugar, uric acid and liver enzymes (SR product) in the blood Blood sugar and liver function should be monitored at 3, 6 and 12 months, then yearly

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Flushing: Starts in the face but it may spread to the arms, chest, legs and feet Also feel hot, itchy and may have stomach upset Starts within 20 minutes and lasts up to 60 minutes

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Flushing: Tolerance develops after 2 weeks Do not miss a dose! Avoid hot drinks, hot showers, spicy food or alcohol for 1–2 hours after a dose

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Flushing: Regular aspirin (325 mg) daily in the first few weeks of treatment or when increasing the dose may be helpful (if no CI’s!) Taking niacin with food may help to decrease stomach upset and flushing

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FIBRATES:1, 9 Gemfibrozil (Lopid®) Fenofibrate (Lipidil™ EZ) Bezafibrate (Bezalip® SR)

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WHAT THEY DO: Inhibit fat breakdown in the tissues so less fat is taken up by the liver from the blood; therefore less TG’s are made ↓ TG (blood fat) ↑ good cholesterol

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SIDE EFFECTS: Nausea Stomach pain / gas Muscle pain (reversible) Gall stones ↑ liver enzymes (reversible) Mild Hgb, Hct, and WBC decrease (stabilize with long term use)

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SIDE EFFECTS: CBC’s, LFT’s and renal function at 3, 6 and 12 months, then yearly Fibrates are usually not given with statins because the combination increases the risk of developing muscle problems

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CHOLESTEROL ABSORPTION INHIBITORS: 1, 10 Ezetimibe (Ezetrol®)

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WHAT IT DOES: Blocks the absorption of cholesterol from the intestine Less cholesterol is taken to the liver, forcing the body to take it from the blood

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Advantages… Better tolerated than resins Less drug interactions than statins Does not affect the absorption of fat-soluble vitamins

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SIDE EFFECTS: Back pain (4.1% vs. 3.9% placebo) Joint pain (3.8% vs. 3.4%) Muscle pain (5.0% vs. 4.6%) Diarrhea (3.7% vs. 3.0%) Stomach pain (3.0% vs. 2.8%) Fatigue (2.2% vs. 1.8%) Dizziness (2.7% vs. 1.2%) Headache (8.0% vs. 5.4%)

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Muscle Side Effects: In clinical trials, the number of people who developed muscle disease or rhabdomyolysis was similar with the control group Most people who developed muscle pain had also had it before while taking a statin

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Rare Side Effects: Increased liver enzymes (0.5% vs placebo 0.3%) It has not been proven that Ezetrol causes hepatitis or pancreatitis

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Comparison of Effects of Cholesterol Lowering Drugs: 1

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Comparison of Effects of Cholesterol Lowering Drugs: 1 *Atorvastatin and rosuvastatin have the greatest TG-lowering effect *Bezafibrate and fenofibrate ↓ bad cholesterol > gemfibrozil

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REFERENCES: 1) e-Therapeutics. Cardiovascular Disorders: Dyslipidemias [Online]. [cited 2007 Jan 18]; Available from: URL: https://www.e-therapeutics.ca 2) Compendium of Pharmaceuticals and Specialties. Cholestyramine CPhA Monograph [online version (e-CPS)]. CPhA, 2007. [cited 2007 Jan 18]; Available from: URL: https://www.e-therapeutics.ca 3) Compendium of Pharmaceuticals and Specialties. HMG-CoA Reductase Inhibitors CPhA Monograph [online version (e-CPS)]. CPhA, 2007. [cited 2007 Jan 18]; Available from: URL: https://www.e-therapeutics.ca 4) Silva, M.A., Swanson, A.C., Gandhi, P.J., et al. Statin-related adverse events: a meta-analysis. Clinical Therapeutics. 28(1):26-35, 2006 Jan. 5) Miller, M.L., Rosenson, R.L. Muscle injury associated with lipid lowering drugs [online]. 2007 UpToDate®. [cited 2007 Jan 19]; Available from: URL: http://www.utdol.com/utd/store/index.do

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REFERENCES: 6) Koller, H., Neuhaus, O., Schroeter, M. et al. Myopathies under therapy with lipid-lowering agents. Nervenarzt. 76(2):212-7, 2005 Feb. 7) Law, M., Rudnicka, A.R. Statin safety: a systematic review. Am J Cardiol. 97(8A):52C-60C, 2006 Apr 17. 8) Compendium of Pharmaceuticals and Specialties. Niacin/Niacinamide CPhA Monograph [online version (e-CPS)]. CPhA, 2007. [cited 2007 Jan 18]; Available from: URL: https://www.e-therapeutics.ca 9) Compendium of Pharmaceuticals and Specialties. Lopid Product Monograph [online version (e-CPS)]. CPhA, 2007. [cited 2007 Jan 18]; Available from: URL: https://www.e-therapeutics.ca 10) Compendium of Pharmaceuticals and Specialties. Ezetrol Product Monograph [online version (e-CPS)]. CPhA, 2007. [cited 2007 Jan 18]; Available from: URL: https://www.e-therapeutics.ca