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Antilipemic Drugs & Diuretic Agents
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What is cholestrol??
Cholestrol is a fat-soluble crystalline steroid widely distributed in the body, especially in the bile, blood, brain tissue, liver, kidneys, adrenal glands, and myelin sheaths of nerve fibers
It is found in animal fats, oils, and egg yolk and is used to make steroid hormones, cell membranes, and bile acids

Different types of cholestrol
Very-low-density lipoprotein (VLDL)- produced by the liver and transports endogenous lipids to the cells
High-density lipoprotein (HDL)- "GOOD cholestrol" responsible for "recycling" cholestrol

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Low-density lipoprotein (LDL)- "BAD cholestrol"- binds to the vessels
Healthy cholestrol level ranges
Total cholestrol <200 mg/dL
Triglycerides <150 mg/dL
LDL <130 mg/dL
HDL >60 mg/dL

Are you at risk for high blood cholestrol??
  • Men 45+ Women 55+
  • Women with premature menopause not on estrogen replacement therapy
  • Family Hx: Premature CHD
  • Current cigarette smoker
  • Hypertensive
  • Low HDL ("good cholestrol") levels <35 mg/dL
  • Diabetes mellitus

Treatment
  • All non-drug treatments such as exercise and diet need to be tried for 6 months and fail before drug therapy is considered.

  • Antilipidemic drugs are used as adjunct therapy with diet therapy and the drug choice is based on the lipid profile of the patient.

  • Cholestrol medications are administered at night because the liver and HMG-CoA is working its hardest at night


Drugs
  • "Statin Sisters" (Atorvastatin, Rosuvastatin, Simvastatin)- most potent LDL reducers
- They work by inhibiting HMG-CoA reductase, which is used by the liver to produce cholestrol
- Side effects include upset GI, rash, headache, myopathy, elevation in liver enzymes
  • Bile Acid Sequestrants (Questran)- prevent resorption of bile acids which are necessary for the absorption of cholestrol
- Side effects include constipation, heartburn, belching, bloating
  • Niacin (Nicotinic Acid)- lipid-lowering properties by increasing lipase which breaks down lipids
- High dosage required
- Side effects include flushing, pruritus, and GI distress
  • Fibric Acid Derivatives (Lopid)- same action as Niacin but also suppress release of free fatty acid and decrease triglyceride levels and increase HDL
- Side effects include abdominal discomfort, diarrhea, nausea, blurred vision, etc.
  • Cholestrol Absorption Inhibitor (Zetia)- inhibits absorption of cholestrol, high ADL levels


WARNING: EDUCATE PATIENT TO REPORT MUSCLE PAIN OR DISCOMFORT TO PHYSICIAN RIGHT AWAY BECAUSE MUSCLE PAIN CAN PROGRESS TO RHABDOMYOLYSIS AND CAN CAUSE SEVERE STRAIN ON THE KIDNEYS LEADING TO KIDNEY FAILURE... AND POSSIBLY EVEN DEATH.
Nursing Implications
  • Assess patient's diet, exercise level, weight, height, vs, tobacco and alcohol use, and family hx
  • Assess baseline liver function, if there are problems DO NOT start patients on antilipemic drugs
  • If your patient is taking long-term therapy medications supplemental fat-soluble vitamins (A,D,K) are needed
  • Take with meals to decrease GI upset
  • Educate the importance of diet and exercise
  • No medications an hour before antilipemic drug or 4-6 hours after
  • Often cause constipation so increase fluid and fiber in patient's diet
  • Monitor liver function

Therapeutic effects of antilipemic drugs
  • Decreased cholestrol
  • Decreased triglycerides


Diuretic Agents!
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Drugs that work in the functional unit of the kidney,
the nephron, to accelerate the rate of urine formation
resulting in the removal of sodium and water

Types of Diuretics:

Carbonic anhydrase inhibitors
  • Acetazolamide (Diamox)
- CAI's block the action of carbonic anhydrase resulting in resorption of water decreasing and urine production increasing
-Useful in glaucoma, epilepsy, and edema
-Contraindications with individuals who have hypokalemia, hyponatremia, or renal or hepatic dysfunction

Loop Diuretics
  • Furosemide (Lasix)
-Inhibits sodium and chloride resorption resulting in the dilation of blood vessels and reduced peripheral vascular resistance
-Used for individuals with edema from HF or renal disease, hypertension, and hypercalcemia
- Potassium depletion is an important drug effect to know patient will probably be on K+ supplements
-Very useful when rapid diuresis is needed, however it may cause orthostatic hypotension (Educate patient on this risk and advise them to sit down if dizzy and to stand up slowly)

Osmotic Diuretics**
  • Mannitol (Osmitrol)
-Pulls water into the blood vessels and nephron from the surrounding tissues
-Used in the early stages of acute renal failure when there is decreased urine production
-Also used to excrete toxic substances, reduction of intracranial pressure and cerebaral edema
Should always be administered intravenously through a FILTER !

Potassium Sparing Diuretics
  • Spironolactone (Aldactone)
-Prevents potassium from being pumped into the tubule resulting in the excretion of potassium and increasing the excretion of sodium and water
-Used for hyperaldosteronism, hypertension and reversing the potassium loss from Loop and Thiazide drugs
Important side effect to be aware of is hyperkalemia*
Thiazide and Thiazide-like Diuretics**
Most commonly used diuretics!
  • hydrochlorothiazide (Esidrix, HydroDIURIL)
-Inhibit tubular resoprtion of sodium and chloride ions resulting in water, sodium and chloride excretion which dilates the arterioles by direct relaxation
-Used in hypertension, edema, diabetes insipidus and used with other agents to treat HF
IMPORTANT DRUG REACTION TO BE AWARE OF IS DIGOXIN+THIAZIDE= DIGOXIN TOXICITY

Nursing Implications
-Teach patients to eat more potassium-rich foods when taking any but the potassium-sparing agents
-Foods High in Potassium Include:
  • Bananas
  • Oranges
  • Dates
  • Raisins
  • Plums
  • Fresh Vegetables
  • Potatoes
  • Meat
  • Fish
-Potassium supplements are usually not recommended when potassium level exceed 3 mEq/L
-Assess baseline fluid volume status, input and output, serum electrolytes, weight, and vital signs---> especially postural BPs
-Take in the morning to avoid interference with sleep patterns

MONITOR FOR DIGOXIN TOXICITY WHEN TAKING A DIURETIC

-Teach patients to change positions slowly and rise slowly after sitting/lying to prevent dizziness or fainting --> Orthostatic hypotension
-The physician should be notified if the patient gains 2 or more pounds in a day or 5 more pounds in a week
-The physician should be notified if fluid loss from nausea/vomiting/or diarrhea occur

S/S HYPOKALEMIA, MUSCLE WEAKNESS, CONSTIPATION, IRREGULAR PULSE RATE, OVERALL FEELING OF LETHARGY

-Avoid licorice--> it can lead to an additive hypokalemia in patients taking thiazides

Adverse Effects = Metabolic alkalosis, drowsiness, lethargy, hypokalemia, tachycardia, hypotension, leg cramps, restlessness, decreased mental alerrtness
Therapeutic Effects = Reduction in edema, fluid volume overload, reduction of hypertension

Test Your Knowledge:

1) Carbonic Anhydrase Inhibitors are useful in the treatment of ___.


2) What type of Diuretic is useful when rapid dieresis is needed?


3) How should Mannitol (Osmitrol), an osmotic diuretic me administered?



4) Name 3 side effects of potassium-sparing diuretics.


5) What is an important drug regimen to be aware of?














Answers:
1) Glaucoma, Edema, Epilepsy, High-altitude Sickness
2) Loop Diuretic
3) Intravenously through a filter
4) Gynecomastia, Urinary frequency, Amenorrhea, Irregular menses, Postmenopausal bleeding, Hyperkalemia
5) Digoxin + thiazides = increased digoxin toxicity

References:
Petges, N. (2011). Antilipemic & Diuretic Agents, Pharmacological Concepts, Aurora, IL
Lilly, L., Harrington, S., & Snyder, J. (2011). Pharmacology and the nursing process. (6th ed.). St. Louis: Mosby