A number of patients take lipid lowering medications to lower cholesterol, triglycerides*, or both. Prior to starting these medications, one should have maximized medical nutrition therapy and lifestyle modification. Lipid lowering medications can be divided into those that primarily lower LDL-cholesterol (aka bad cholesterol) and those that primarily lower triglycerides. The most. common class of drugs used to decrease LDL-cholesterol is the HMG CoA reductase inhibitors. These drugs are also known as “statins” because drugs in this class end with the suffix-statin, such as pravastatin, simvastatin, atorvastatin, and rosuvastatin. These drugs inhibit the most crucial’step in cholesterol formation. Adverse effects include muscle inflammation and elevation of liver enzymes. Therefore, a patient should regularly monitor his creatine phosphokinase (CPK), SGPT (ALT) and SGOT (AST).

The fibrates (e.g. fenofibrate) primarily decrease triglycerides or VLDL-cholesterol and increase HDLcholesterol (aka good cholesterol). They stimulate a receptor called PPAR-alpha which increases the elimination of triglyceride-rich particles. Adverse effects are similar to the HMG CoA reductase inhibitors, namely muscle inflammation and elevation of liver enzymes. Taking these two classes of drugs together, especially for those with elevation of both LDL cholesterol and triglycerides, will further aggravate these adverse effects. This was demonstrated when the HMG CoA reductase inhibitor cerivastatin was combined with the fibrate gemfibrozil. The combination led to severe muscle inflammation that caused kidney failure. Cerivastatin was eventually withdrawn from the market.

If the above two classes of drugs used singly or in combination do not produce the target lipid levels, or if adverse effects are intolerable, other alternatives are available. Ezetimibe decreases cholesterol absorption from the intestines. It does not affect triglyceride levels. It is very useful in cofVibination with a statin (HMG CoA reductase inhibitor) because it will allow the use of a lower dose and lower the chances of muscle inflammation and liver derangement. Niacin, aka nicotinic acid, is one of the B complex vitamins. Use of high doses of niacin can decrease triglycerides and increase HDL-C. There are three important side effects. It can cause facial flushing and liver toxicity. It also causes an increase in blood sugar and thus potentially aggravating diabetes mellitus.There is an extended-release niacin preparation (Niaspan) which reduces the chances of these side effects.

Omega-3 fatty acids, aka n-3 polyunsaturated fatty acids, are commonly found in fish oils and can decrease triglycerides but have a tendency to increase LDLC. Generally, cooking or heating polyunsaturated oil makes them saturated. Bile-binding resins, once important drugs to decrease LDL-C,are no longer widely used. Occasionally, we still see some patients taking cholestyramine or colestipol sourced from other countries.The decline in usage is due to their role in decreasing absorption of other drugs. One must take other drugs one hour before or four hours after taking bile-binding resins to minimize interference. These drugs can increase triglycerides and should be avoided in patients with combined hyperlipidemia (wherein LDL-C and triglycerides are both elevated).

I have briefly discussed the individual classes of drugs, and the risks and benefits of some combinations. Because each patient is unique, one cannot generalize and predict with absolute certainty the effects of these drugs. Patients are advised to consult their physicians for more detailed and individualized explanation.

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