2. 29-2
CHOLESTEROL
Critical substrate for the body:
Fundamental building block of steroid hormones
Essential for building cell membranes, the myelin sheath,
and the brain
Core component of bile salts, which helps in digest dietary
fats
3. 29-3
LIPOPROTEINS
There are several different lipoproteins:
Low-density lipoprotein (LDL)
Very-low-density lipoprotein (VLDL)
High-density lipoprotein (HDL)
4. CONTD’…
1.Chylomicrons (TGs): → fat globule formed in GIT from
dietary TG.
2. VLDL (TGs and cholesterol) → endogenously
synthesized in liver.
Degraded by LPL into free fatty acids (FFA) for storage in adipose tissue
and for oxidation in tissues such as cardiac and skeletal muscle.
Chylomicrons are found in the blood and lymphatic fluid where they
serve to transport fat from its port of entry in the intestine to the liver
and to adipose (fat) tissue.
After a fatty meal, the blood is so full of chylomicrons that it looks
5. CONTD’…
3. IDL (TGs, cholesterol); and LDL
(cholesterol) → derived from VLDL hydrolysis by
lipoprotein lipase. Normally, about 70% of LDL is
removed from plasma by hepatocytes.
4. HDL (protective) →exert several anti
atherogenic effects. They participate in retrieval of
cholesterol from the artery wall and inhibit the
oxidation of atherogenic lipoproteins & removes
9. MANAGEMENT OF
HYPERLIPIDEMIA
1.Diet: Avoid saturated fatty acids (animal fats)
and give unsaturated fatty acids (plant fats).
Regular consumption of fish oil which contains
omega 3 fatty acids and vitamins E and C
(antioxidants).
2.Exercise: ↑ HDL levels and insulin sensitivity.
3.Drug therapy: the primary goal of therapy is
to decrease levels of LDL .
10. 29-10
MONITORING THE DISEASE
The goals of treatment are:
Lowering LDL cholesterol
Reducing total serum cholesterol and triglycerides
Increasing HDL cholesterol
15. INHIBITOR OF VLDL SECRETION
AND LIPOLYSIS
Niacin (Nicotinic acid)
Miscellaneous: Gugulipid and fish oil
derivatives
16. 29-16
HMG-COA REDUCTASE
INHIBITORS
Also referred to as statins
MOA—inhibit enzyme that causes cholesterol
synthesis
IND—adjunct to dietary treatment to decrease total
serum and LDL cholesterol:
Reduce LDL level up to 30%
Raise HDL level up to 20%
17. 1-17
HMG-COA REDUCTASE INHIBITORS
An early, very important
step in this process is the
conversion of acetyl-CoA
molecules into HMG-CoA,
which is then converted to
mevalonic acid by HMG-
CoA reductase.
Mevalonic acid is a rate-
limiting pivotal step in
steroid and cholesterol
biosynthesis.
The liver makes two-
thirds of the daily
18. HMG-COA REDUCTASE INHIBITOR
All of the statins reduce LDL up to 30 percent.
When a greater reduction of LDL is required, simvastatin
(Zocor), atorvastatin (Lipitor), and rosuvastatin (Crestor)
reduce more than 45 percent; in fact, rosuvastatin and
atorvastatin have been demonstrated to reduce up to 60
percent.
All of the statins raise the HDL level up to 20
percent.
Again, simvastatin (Zocor), atorvastatin (Lipitor), and
19. HMG-COA REDUCTASE INHIBITORS
Adverse effects:
Headache, dizziness, alteration of taste,
insomnia, abdominal cramping and
photosensitivity
May cause myalgias, leg ache, and
muscle weakness
Contraindicated during pregancy
20. CHOLESTEROL ABSORPTION
INHIBITORS
Ezetimibe:
Inhibits intestinal cholesterol absorption → ↓
concentration of intrahepatic cholesterol→
compensatory ↑ in LDL receptors →↑ uptake of
circulating LDL →↓ serum LDL cholesterol levels
(17%).
Used in hypercholesterolemia together with statins
& diet regulation.
Adverse effects: diarrhea and abdominal pain,
coughing, back pain, and arthralgia
21. BILE ACID SEQUESTRANTS
Cholestyramine, colestipol and
colesevelam.
MOA: anion exchange resins; bind bile
acids in the intestine forming complex
→so, bile acids loss in the stools →↑
conversion of cholesterol into bile acids in
the liver in results, dec’ed concentration
of intrahepatic cholesterol → compensatory
22. NICOTINIC ACID
MOA: It strongly inhibits lipolysis in adipose tissues which is the
primary producer of circulating free fatty acids
The liver normally utilizes these circulating fatty acids as a major
precursor for triacylglycerol synthesis.
Thus Dec’ in liver triacylglycerol synthesis required for VLDL
production dec’ VLDL which dec’ plasma LDL conc.
Thus both plasma triacylglycerol and cholesterol are lowered.
Increases HDL cholesterol levels
Boosting secretion of tissue plasminogen activator and lowering the
level of plasma fibrinogen red’ thrombosis
IND—hyperlipidemia
Adverse effects—cutaneous flushing, nausea, vomiting, and diarrhea
23. THERAPEUTIC USES
&PHARMACOKINETICS:
Treatment of type IIA and IIB hyperlipidemias (along with statins
when response to statins is inadequate or alternative when they are
contraindicated).
Useful for Pruritus in biliary obstruction (↑ bile acids).
Treatment of diarrhea resulting from bile acid mal-absorption or
secondary to Crohn's disease or the postcholecystectomy syndrome.
Pharmacokinetics:
Orally given but neither absorbed nor metabolically altered by
intestine, totally excreted in feces.
24. ADVERSE EFFECTS:
CONSTIPATION IS MAJOR
↓ absorption of fat soluble vitamins (A, D, K, E)
, ↓ Vit K → hypoprothrombinemia.
↓ absorption of many drugs as digitoxin,
warfarin, aspirin, phenobarbitone.
25. FIBRIC ACID DERIVATIVES
(FIBRATES)
Fenofibrate and gemfibrozil
MOA: Agonists at PPAR (peroxisome
proliferator-activated receptor) → expression of
genes responsible for increased activity of
plasma lipoprotein lipase enzyme → hydrolysis
of VLDL and chylomicrons→ ↓ serum TGs
Increase clearance of LDL by liver & ↑ HDL.
IND—Hypertriglyceridemia (the most effective in reduction
TGs, combined hyperlipidemia (type III) if statins are
contraindicated.
Adverse effects—nausea, vomiting, diarrhea, and
26. GUGULIPID
Consists of Z and E gugulsterone
Inhibit cholesterol biosynthesis and also
enhance rate of cholesterol excretion
Dose 25 mg 3 times a day
Reduced total CH, LDL-C with an elevation of
HDL-C
It is well tolerated, no side effect, except
loose stool
27. FISH OIL DERIVATIVE
Omega-3-fatty acids
Eicosa-pentanoic and docosa-
hexanoic acid
Prophylaxis use in high risk patient
of CAD
Usually formulated with vit.E
30. PREFERRED THERAPY
All hypolipidemic drugs are indicated as adjunctive
therapy to reduce elevated cholesterol levels.
HMG-CoA reductase inhibitors are the most
prescribed.
Cholestyramine can also be used in the treatment
of partial biliary obstruction.
31. CONTRAINDICATIONS
Systemic hypolipidemic drugs should not be used in
patients with liver dysfunction.
Bile acid sequestrants should not be used in patients with
biliary obstruction.
Statins should not be used in pregnant women.
Learning Outcomes
29.1 Explain the importance of triglycerides and cholesterol and their role in atherosclerosis.
Learning Outcomes
29.1 Explain the importance of triglycerides and cholesterol and their role in atherosclerosis.
Learning Outcomes
29.1 Explain the importance of triglycerides and cholesterol and their role in atherosclerosis.
Learning Outcomes
29.1 Explain the importance of triglycerides and cholesterol and their role in atherosclerosis.
Learning Outcomes
29.3 Explain the mechanism of action of five different hypolipidemic drugs.
29.4 Explain why the HMG-CoA inhibitors are more effective than other hypolipidemic drugs.
Learning Outcomes
29.3 Explain the mechanism of action of five different hypolipidemic drugs.
29.4 Explain why the HMG-CoA inhibitors are more effective than other hypolipidemic drugs.
Learning Outcomes
29.2 Discuss the treatment of hyperlipidemia.
29.3 Explain the mechanism of action of five different hypolipidemic drugs.
29.6 Explain the essential terminology associated with atherosclerosis and hypolipidemic drugs.
Learning Outcomes
29.2 Discuss the treatment of hyperlipidemia.
29.3 Explain the mechanism of action of five different hypolipidemic drugs.
Learning Outcomes
29.2 Discuss the treatment of hyperlipidemia.
29.3 Explain the mechanism of action of five different hypolipidemic drugs.
Learning Outcomes
29.2 Discuss the treatment of hyperlipidemia.
29.3 Explain the mechanism of action of five different hypolipidemic drugs.
Learning Outcomes
29.2 Discuss the treatment of hyperlipidemia.
29.3 Explain the mechanism of action of five different hypolipidemic drugs.
Learning Outcomes
29.2 Discuss the treatment of hyperlipidemia.
29.3 Explain the mechanism of action of five different hypolipidemic drugs.
Learning Outcomes
29.6 Explain the essential terminology associated with atherosclerosis and hypolipidemic drugs.
The bile acid sequestrants stay in the lumen of the intestine and trap other subtances during transit through the intestine. Cholestyramine binds with fat-soluble vitamins (A, D, and K), folic acid, and many drugs, thus reducing their GI absorption. Supplementation at time intervals when the bile acids are no longer in the absorption area may be necessary to avoid vitamin deficiencies.
Taking some medication in the presence of grapefruit juice can significantly decrease drug metabolism at the intestinal wall and increase its bioavailability. Increasing a drug’s bioavailability will increase risk of developing adverse effects. Grapefruit juice interacts only with drugs that are administered orally.
Atorvastatin, lovastatin, and simvastatin are definitely affected by grapefruit. Although the studies concerning grapefruit interactions with pravastatin, fluvastatin, or rosuvastatin were not as significant, it probably would be prudent not to consume grapefruit a few hours before or after taking these medications. Orange juice does not have any effect on absorption of these drugs.
Drugs that are potent inhibitors of CYP3A4 and also cause an increase in statin blood levels include cyclosporine, itraconazole, ketoconazole, erythromycin, clarithromycin, and HIV protease inhibitors. For patients who require antifungal therapy, the statins should be stopped until the fungal treatment is discontinued.