Other Drugs, e.g. hormones, aspirin, beta blockers
Bile Acid Resins
Bile acid resins bind with cholesterol-containing bile acids in the intestines and are then eliminated in the stool. The major effect of bile acid resins is to lower LDL-cholesterol by about 10 to 20 percent. Small doses of resins can produce useful reductions in LDL-cholesterol. Bile acid resins are sometimes prescribed with a statin for patients with heart disease to increase cholesterol reduction. When these two drugs are combined, their effects are added together to lower LDL-cholesterol by over 40 percent. Cholestyramine and colestipol are the two main bile acid resins currently available. These two drugs are available as powders or tablets. They are not absorbed from the gastrointestinal tract and 30 years of experience with the resins indicate that their long-term use is safe.
Bile acid resin powders must be mixed with water or fruit juice and taken once or twice (rarely three times) daily with meals. Tablets must be taken with large amounts of fluids to avoid gastrointestinal symptoms. Resin therapy may produce a variety of symptoms including constipation, bloating, nausea, and gas.
The bile acid resins are not prescribed as the sole medicine to lower your cholesterol if you have high triglycerides or a history of severe constipation.
Although resins are not absorbed, they may interfere with the absorption of other medicines if taken at the same time. Other medications therefore should be taken at least 1 hour before or 4 to 6 hours after the resin. Talk to your doctor about the best time to take this medicine, especially if you take other medications.
Fibrates
The cholesterol-lowering drugs called fibrates are primarily effective in lowering triglycerides and, to a lesser extent, in increasing HDL-cholesterol levels. Gemfibrozil, the fibrate most widely used in the United States, can be very effective for patients with high triglyceride levels. However, it is not very effective for lowering LDL- cholesterol. As a result, it is used less often than other drugs in patients with heart disease for whom LDL-cholesterol lowering is the main goal of treatment. Gemfibrozil therapy by itself is not recommended by the Food and Drug Administration for patients with heart disease. Fibrates are usually given in two daily doses 30 minutes before the morning and evening meals. The reductions in triglycerides generally are in the range of 20 to 50 percent with increases in HDL-cholesterol of 10 to 15 percent.
Fibrates are generally well tolerated by most patients. Gastrointestinal complaints are the most common side effect and fibrates appear to increase the likelihood of developing cholesterol gallstones. Fibrates can increase the effect of medications that thin the blood, and this should be monitored closely by your physician.
Nicotinic Acid (Niacin)
Nicotinic acid or niacin, the water-soluble B vitamin, improves all lipoproteins when given in doses well above the vitamin requirement. Nicotinic acid lowers total cholesterol, LDL-cholesterol, and triglyceride levels, while raising HDL-cholesterol levels. There are two types of nicotinic acid: immediate release and timed release. Most experts recommend starting with the immediate-release form; discuss with your doctor which type is best for you. Nicotinic acid is inexpensive and widely accessible to patients without a prescription but must not be used for cholesterol lowering without the monitoring of a physician because of the potential side effects. (Nicotinamide, another form of the vitamin niacin, does not lower cholesterol levels and should not be used in the place of nicotinic acid.)
All patients taking nicotinic acid to lower serum cholesterol should be closely monitored by their doctor to avoid complications from this medication. Self-medication with nicotinic acid should definitely be avoided because of the possibility of missing a serious side effect if not under a doctor's care.
Patients on nicotinic acid are usually started on low daily doses and gradually increased to an average daily dose of 1.5 to 3 grams per day.
Nicotinic acid reduces LDL-cholesterol levels by 10 to 20 percent, reduces triglycerides by 20 to 50 percent, and raises HDL-cholesterol by 15 to 35 percent.
A common and troublesome side effect of nicotinic acid is flushing or hot flashes, which are the result of the widening of blood vessels. Most patients develop a tolerance to flushing, and in some patients, it can be decreased by taking the drug during or after meals or by the use of aspirin or other similar medications prescribed by your doctor. The effect of high blood pressure medicines may also be increased while you are on niacin. If you are taking high blood pressure medication, it is important to set up a blood pressure monitoring system while you are getting used to your new niacin regimen. A variety of gastrointestinal symptoms including nausea, indigestion, gas, vomiting, diarrhea, and the activation of peptic ulcers have been seen with the use of nicotinic acid. Three other major adverse effects include liver problems, gout, and high blood sugar. Risk of the latter three increases as the dose of nicotinic acid is increased. Your doctor will probably not prescribe this medicine for you if you have diabetes, because of the effect on your blood sugar.
Statins
There are currently six statin drugs on the market in the United States: lovastatin, simvastatin, pravastatin, fluvastatin, atorvastatin, and cerivastatin. The major effect of the statins is to lower LDL-cholesterol levels, and they lower LDL-cholesterol more than other types of drugs. Statins inhibit an enzyme, HMG- CoA reductase, that controls the rate of cholesterol production in the body. These drugs lower cholesterol by slowing down the production of cholesterol and by increasing the liver's ability to remove the LDL-cholesterol already in the blood. Statins were used to lower cholesterol levels in both the 4S and CARE studies. The large reductions in total and LDL-cholesterol produced by these drugs resulted in large reductions in heart attacks and heart disease deaths. Thanks to their track record in these studies and their ability to lower LDL-cholesterol, statins have become the drugs most often prescribed when a person with heart disease needs a cholesterol- lowering medicine.
Studies using statins have reported 20 to 60 percent lower LDL-cholesterol levels in patients on these drugs. Statins also produce a modest increase in HDL- cholesterol and reduce elevated triglyceride levels.
The statins are usually given in a single dose at the evening meal or at bedtime. It is important that these medications be given in the evening to take advantage of the fact that the body makes more cholesterol at night than during the day.
You should begin to see results from the statins after several weeks, with a maximum effect in 4 to 6 weeks. After about 6 to 8 weeks, your doctor can do the first check of your LDL-cholesterol while on the medication. A second measurement of your LDL-cholesterol level will have to be averaged with the first for your doctor to decide whether your dose of medicine should be changed to help you meet your goal.
The statins are well tolerated by most patients, and serious side effects are rare. A few patients will experience an upset stomach, gas, constipation, and abdominal pain or cramps. These symptoms usually are mild to moderate in severity and generally go away as your body adjusts. Rarely a patient will develop abnormalities in blood tests of the liver. Also rare is the side effect of muscle problems. The symptoms are muscle soreness, pain, and weakness. If this happens, or you have brown urine, contact your doctor right away to get blood tests for possible muscle problems.
Other Drugs
The risk of heart disease is increased in postmenopausal women, whether the menopause is natural, surgical, or premature. This increasing risk may be related to the loss of estrogens after menopause. Hormone replacement therapy (HRT) is treatment with estrogen, either alone or with another hormone called progestin. HRT may be prescribed when women experience symptoms from menopause.
HRT can be given in many different forms and amounts. Your doctor will help you select the best form for you.
A recent study called the Postmenopausal Estrogen/Progestin Interventions (PEPI) Trial looked at whether estrogen acts on some of the factors that define a woman's risk of heart disease. Results from the PEPI study showed that:
Estrogen-only therapy raises the level of HDL- cholesterol.
Combined estrogen-progestin therapies also increased HDL levels, although less than estrogen alone.
All of the hormone regimens decreased the level of LDL- cholesterol about equally well.
None of the hormone regimens caused a significant weight gain.
All of the hormone regimens caused a rise in triglyceride levels.
In postmenopausal women with heart disease, HRT can play a role in improving LDL- and HDL-cholesterol levels. In addition to cholesterol lowering and control of the other risk factors, there are other treatments to help lower your risk from heart disease. Aspirin, a drug that has been used for centuries to relieve pain and reduce fever, has been shown to reduce the risk of future heart attacks in patients who have already had one. Aspirin seems to work by reducing the stickiness of the platelets (the cells that cause blood clotting) so that blood clots do not form as readily. After bypass surgery, patients treated with aspirin have fewer early closures of the newly grafted blood vessels in their hearts.
Beta-blockers, another type of drug, have been shown to reduce death rates in patients who have heart disease. Beta-blockers slow the heart and make it beat with less contracting force--so blood pressure drops and the heart works less hard.
Many patients with heart disease have high blood pressure. Other drugs in addition to beta-blockers may be needed to reach a normal blood pressure.
The amount of risk reduction shown by aspirin and beta- blockers is similar to that of cholesterol lowering, making all three important in the treatment of heart disease.
Above courtesy of C.D.C.
