Strong record of efficacy and safety o Most useful for pts with moderately elevated LDL and low CHD risk profile (pts who are not able to reduce their LDLs with lifestyle modifications o Can be used together with fibrates o ADRs: GI (constipation, bloating, abd pain, unpleasant taste and texture), HA, reduced folate levels with long-term use o Initial dose: one packet mixed with juice, never swallowed in dry form o Drug interactions: interfere with absorption of other medications o Monitoring: lipid levels in 4-6wks then every 3-4 months until controlled, LDL levels most important o Pt Education: take with meals mixed with 4-6 oz of fluid; constipation (may need stool softener)
o Bulks up stool Niacin : has lost its luster Not really recommended anymore o Lower LDL, TC, TG and elevate HDL o Clinical efficacy: lower ischemic heart disease-related mortality; lower risk of recurrent, non-fatal MI o OTC doses not sufficient to lower LDL. Usually prescribed as adjunctive therapy with a bile acid sequestrant or statin for pts with very high TG and very low LDL levels o ASA given 30 min before niacin dose may prevent or reduce flushing o ADRs: flushing pruritus, HA, fatigue; gastritis, abd pain, aggravation of PUD; hepatotoxicity; impaired glucose control; increase uric acid concentrations (gout) o Drug interactions: alcohol (increases risk of hepatotoxicity); statins and fibrates (increase risk of hepatotoxicity and/or myalgias o Monitoring: lipid q 4-6wks then 3-4 months. *LFTs, uric acid levels and blood glucose before starting* o Research demonstrated high CV and stroke effects- must consider the risk/benefit of use Ezetimibe (Zetia) : most effective in combination with a statin o Reduce TC, LDL and TG and elevate HDL o Dosing: 10mg/day o Pregnancy Category C; not for children < 10yrs o ADRs: diarrhea, tiredness, joint pain o Can also be taken with a fibrate Vitamins/ Antioxidants/ Herbs/ natural products Vitamin E, C, folic acid, garlic, fish oils, fiber, coenzyme Q10, flax seed **active liver disease is a contraindication for all except the bile acid sequestrants!
Diuretics Thiazide diuretics HCTZ, chlorthalidone, indapamide, metolozone o High dose therapy (HCTZ >50) has increased risk of hypokalemia, increase in uric acid levels, and serious CV outcomes o Use in combination vs. pushing high doses Loop Diuretics Furosemide, bumetanide, torsemide o Potential for cross-sensitivity with sulfa Potassium-Sparing Triamterene, spironolactone, eplerenone (Inspra) o Often used in combination with thiazide to help reverse low potassium effect o Eplerenone (Inspra): next generation aldosterone agent; K+ sparing, selective aldosterone blocker Major CYP3A4 substrate: decreased effects with NSAIDs. Drug effects increase with grapefruit juice, azoles, CCBs. Increases effects of ACEI, ARB, BB, K+ replacement ADRs: hypotension, decreased GFR, hypo/hyperkalemia, electrolyte abnormalities, metabolic acidosis, hyponatremia Monitoring: BP, HR, edema, weight gain, dyspnea, cough, urine output. Prior to initiating therapy- BUN, creatinine, electrolytes, uric acid, and glucose levels. Ongoing
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- Winter '19
- Vitamin B12, ACEI