Miscellaneous lipid-lowering medications

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Miscellaneous lipid-lowering medications

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A 45-year-old man comes to the office for the evaluation of his abnormal lipid panel and is currently asymptomatic. Past medical history is significant for type II diabetes mellitus, and an episode of pancreatitis 6 months ago. Current medications include metformin and atorvastatin. Family history is significant for myocardial infarction in father and chronic renal failure in mother. He smokes a pack of cigarettes daily, drinks 2 glasses of beer on weekends and does not use illicit drugs. Vitals are within normal limits. His BMI is 33.5 kg/m2. Physical examination is noncontributory. Fasting laboratory workup at today’s visit is shown below. The patient is recommended to maintain a low-fat diet to reduce weight, and fenofibrate is added to his medication regime. Which of the following best describes the effect of fenofibrate therapy on serum LDL, HDL and TGs?  

Laboratory value
Results
Glucose
120 mg/dL
Low-density lipoprotein (LDL)  
160 mg/dL
High-density lipoprotein (HDL)
30 mg/dL
Triglycerides
700 mg/dL
Hemoglobin A1c
6.6 %

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Lipid-lowering medications work to decrease levels of cholesterol and triglycerides in the body.

Several medications fall outside the more commonly used classes like statins and fibrates, so in this video, we're going to discuss the bile acid resins, niacin or vitamin B3, ezetimibe, and the PCSK9 inhibitors.

Although it’s got a bad reputation, cholesterol is actually a critical component of our cells and is used to build the cell membrane.

It also has other uses like the synthesis of: steroid hormones, vitamin D, and bile.

Normally, we get our cholesterol from the food we eat, but it can also be synthesized by the liver.

So when we eat a box of chili fries, the fats and cholesterol are absorbed in the small intestine.

However, they’re not water soluble, so they can’t travel freely in the blood.

To fix this, our body makes shipping boxes called lipoproteins.

These containers consist of a shell made of phospholipids and protein tags that act as instructions for their destination.

So after absorption, the small intestinal cells package the fats and cholesterol into the largest but least dense lipoproteins, called chylomicrons.

These are released into the lymphatic system and then enter the bloodstream via the subclavian vein. Then they travel through the blood to reach adipose tissue and the liver.

Now, the liver can also synthesize intrinsic cholesterol through the mevalonate pathway, which happens in the smooth endoplasmic reticulum of liver cells.

Sources

  1. "Katzung & Trevor's Pharmacology Examination and Board Review,12th Edition" McGraw-Hill Education / Medical (2018)
  2. "Rang and Dale's Pharmacology" Elsevier (2019)
  3. "Goodman and Gilman's The Pharmacological Basis of Therapeutics, 13th Edition" McGraw-Hill Education / Medical (2017)
  4. "Cholestyramine" Can Med Assoc J (1971)
  5. "Cholestyramine treatment of healthy humans rapidly induces transient hypertriglyceridemia when treatment is initiated" American Journal of Physiology-Endocrinology and Metabolism (2017)
  6. "Bile Acid Malabsorption in Chronic Diarrhea: Pathophysiology and Treatment" Canadian Journal of Gastroenterology (2013)
  7. "Statins for children with familial hypercholesterolemia" Cochrane Database of Systematic Reviews (2017)
  8. "Ezetimibe for the prevention of cardiovascular disease and all-cause mortality events" Cochrane Database of Systematic Reviews (2018)
  9. "Evolocumab and Clinical Outcomes in Patients with Cardiovascular Disease" New England Journal of Medicine (2017)
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