Initial attempts to maintain an appropriate serum lipid profile should always include dietary and behavioral modifications. These steps remain the mainstay for the management of all patients with hyperlipidemia. However, many patients will require lipid-lowering medications to achieve and maintain lipid levels.
The bile acid sequestrants bind bile acids in the intestinal tract and interfere with reabsorption. This results in decreased return of bile acids to the liver, increased endogenous synthesis of bile acids and enhanced degradation of cholesterol. This in turn results in decreased hepatic cholesterol, increased hepatic LDL receptor synthesis and expression, and enhanced clearance of LDL cholesterol from the blood. The net result is commonly a 15 to 20 percent reduction in serum cholesterol. Cholestyramine and colestipol are both well tolerated in divided doses. Constipation and indigestion are relatively common side effects that may limit patient compliance. These resins may also interfere with the uptake of numerous medications and this should be considered prior to initiation of therapy in patients taking cardiac and other medications.
Niacin (nicotinic acid) inhibits the hepatic secretion of very low-density lipoprotein (VLDL) cholesterol and lowers serum VLDL and LDL cholesterol, and may raise HDL cholesterol. The most common side effects include flushing and itching.
Fibric acid derivatives have a variety of effects on lipid metabolism that result in significant improvements in the lipid profile. These include reductions in VLDL cholesterol and triglycerides, and an increase in HDL cholesterol. Intolerable side effects occur rarely. Patients may experience nonspecific gastrointestinal symptoms and weight gain. Myopathy is a rare but serious complication that typically accompanies the use of multiple lipid- lowering medications. Gemfibrozil is commonly prescribed at a dose of 600mg taken twice a day.