Dyslipidemia

All Cholesterol Medications
 For all cholesterol medicines: your healthcare provider should recommend
lifestyle changes including heart healthy eating habits and exercise.
Statins
 Contact your healthcare provider right away if you have muscle weakness,
tenderness, aching, cramps, stiffness or pain that happens without a good reason,
especially if you also have a fever or feel more tired than usual. These may be
symptoms of muscle damage.
Contact your healthcare provider right away if you are passing brown or dark-
colored urine, have pale stools, feel more tired than usual or if your skin and/or
whites of your eyes become yellow. These may be symptoms of liver damage.
 Take Simvastatin and Fluvastatin IR in the evening, Lovastatin IR with the
evening meal, and Lovastatin at bedtime.
 All other statins can be taken at any time of day.

Grapefruit and grapefruit juice can interact with this medication.
This could lead to higher amounts of the drug in your body.
Do not consume grapefruit products without discussing with your healthcare provider
(for Lovastatin, Simvastatin or Atorvastatin).
Do not use if pregnant or nursing or if you think you may be pregnant.
This drug can harm your unborn baby.
If you become pregnant, stop statin therapy and call your healthcare provider right away.

Ezetimibe
 Contact your healthcare provider right away if you are passing brown or dark-
colored urine, have pale stools, feel more tired than usual or if your skin and/or
whites of your eyes become yellow. These may be symptoms of liver damage.
 Contact your healthcare provider right away if you have muscle weakness,
tenderness, aching, cramps, stiffness or pain that happens without a good reason,
especially if you also have a fever or feel more tired than usual. These may be
symptoms of muscle damage.
 Take this medication once daily, with or without food.

Proprotein Convertase Subtilisin Kexin Type 9 Inhibitors (PCSK9 Inhibitors):
Alirocumab and Evolocumab

Proprotein Convertase Subtilisin Kexin Type 9 Inhibitors
(PCSK9 Inhibitors)
*Alirocumab and Evolocumab are human monoclonal antibodies that bind to PCSK9.
 The most common side effects include runny nose, sore throat, symptoms of the common
cold or flu, back pain, and redness, pain or bruising at the injection site.
 This medication can cause an allergic reaction. Seek emergency medical care right away
if you develop symptoms of rash, redness, severe itching, a swollen face or trouble
breathing.
 Prior to administration, allow prefilled pen/syringe to warm to room temperature (30 to 45
minutes) and inspect visually for particulate matter and discoloration.
 Do not freeze, expose to extreme heat or shake.
 Rotate the injection sites.
 Do not inject into areas that are injured, tender, bruised, red, firm or hot.
 Avoid scars, visible veins or stretch marks.

 If you miss a dose, inject the missed dose as soon as you remember,
within seven days of your missed dose.
 Then, take the next dose two weeks from the missed dose.
 If the missed dose is not given within seven days, skip the dose and
wait until the next scheduled dose.

Alirocumab
 Administer by subcutaneous injection into the thigh, abdomen or upper
arm using a single-dose prefilled pen/syringe.
 It can take up to 20 seconds to inject all contents of the pen.
 Store in the refrigerator in the outer carton in order to protect from light.
 This drug should be used as soon as possible after it has warmed up (it
should not be out of the refrigerator for > 24 hours).

PRALUENT is available in 2 different dosing strengths (75 mg and 150 mg) and different dosing options.

PRALUENT is taken every 2 weeks or 4 weeks (monthly)

Evolocumab
 Given as an injection under the skin (subcutaneously), every two weeks
or one time each month.
 Available as a single-use prefilled autoinjector, a single use on-body
infusor or as a single-use prefilled syringe.
 Store in the refrigerator. Can be kept at room temperature (up to 77°F) in
the original carton; it must be used within 30 days if removed from
refrigerator.

 If your healthcare provider prescribes the monthly dose, you will give yourself three
separate injections in a row, using a different syringe or autoinjector for each
injection.
 Give all of these injections within 30 minutes and alternate the injection site.
 If your healthcare provider prescribes the Pushtronex system, you can give the
once monthly injection as one injection.
 This is available as an on-body infusor with a cartridge that will infuse the dose over
nine minutes.
 Do not inject together with other medications at the same injection site.

How to Take Repatha®
Repatha® is available in three injection options.
Prefilled syringe
1.
2. 3.

Bile Acid Sequestrants/Bile Acid Binding Resins
(Cholestyramine, Colesevelam, Colestipol )

Bile Acid Sequestrants/Bile Acid Binding Resins
(Cholestyramine, Colesevelam, Colestipol )
 Take this medication at mealtimes with plenty of water or other liquid. Never take dry.
This medication can cause constipation, your pharmacist can recommend a laxative
(senna) or stool softener (docusate).
 Drink plenty of water and eat food with fiber such as fruits, vegetables and grains.
Separate the dose of this medication from multivitamins, due to absorption of
vitamins A, D, E and K (mostly K), folate and iron.
 You may need to take a multivitamin (especially women and children) while taking
this medication.
 The following medications should be taken four hours prior to colesevelam:
cyclosporine, glimepiride, glipizide, glyburide, levothyroxine, olmesartan,
phenytoin, and oral contraceptives containing : (ethinyl estradiol and
norethindrone) .

 Colesevelam levels of metformin ER.
With warfarin, monitor INR frequently during initiation and after dose
change.
Bile acid sequestrants can absorption of fat soluble vitamins (A, D, E, K),
folate and iron.
 Separate administration times with multivitamin.
Colesevelam can be considered as an option in a pregnant patient

FIBRATES
Fibrates are peroxisome proliferate receptor alpha (PPARα) activators,
which upregulate the expression of apolipoprotein C2 (apoC-Il) and
apolipoprotein A1 (apoA-l).
Members : Fenofibrate/ Fenofibric Acid and Gemfibrozil

 Fenofibrate/ Fenofibric Acid: Take once daily, with or without food.
 Gemfibrozil : 600 mg take twice daily, 30 minutes before breakfast
and dinner.

 Do not crush or chew.
 Contact your healthcare provider if you experience muscle aches.
 Contact your healthcare provider right away if you experience abdominal pain,
nausea or vomiting.
 These may be signs of inflammation of the gallbladder or pancreas.
Contact your healthcare provider right away if you are passing brown or dark-
colored urine, feel more tired than usual or if your skin and/or whites of your eyes
become yellow.
 These may be signs of liver damage.

 Antara, Fibricor, Triglide and Trilipix: take once daily, with
or without food.
 Fenoglide, TriCor and Lipofen: Take once daily, with food.
Antara (micronized capsule): 30-90 mg daily
Fenofibrate (micronized): 43-130 mg daily
Fenoglide: 40-120 mg daily with meals
Fibricor: 35-105 mg daily
Lipofen: 50-150 mg daily with meals
TriCor. 48-145 mg daily
Triglide: 160 mg daily
Trilipix: 45-135 mg daily
Gemfibrozil (Lopid) 600 mg BID, 30 minutes before breakfast and dinner

Niacin (also known as nicotinic acid or vitamin B3 )
Niacin decreases the rate of hepatic synthesis of VLDL (decreases TG) and LDL;
can also increase the rate of chylomicron TG removal from plasma.
 Extended-Release Niacin (Niaspan): take at bedtime after a low-fat snack.
 Other niacins: take with food.
 Do not crush or chew long-acting formulations.
 Contact your healthcare provider right away if you are passing brown or dark-colored
urine, feel more tired than usual or if your skin and/or whites of your eyes become
yellow.
 These may be symptoms of liver damage.

 Flushing (warmth, redness, itching and/or tingling of the skin) is a common side effect
that may subside after several weeks of consistent use.
 Taking 325 mg of aspirin (or 200 mg of ibuprofen) 30 - 60 minutes before the dose (for
a few weeks) can help flushing. With Niaspan, flushing will occur mostly at night; use
caution if awakened due to dizziness.
 Avoid drinking alcohol or hot beverages or eating spicy foods around the time
of taking this medicine to help reduce flushing.
 If you have diabetes, check your blood sugar when starting this medication
because there may be a mild increase.
 Take niacin 4-6 hours after bile acid sequestrants.

Fish Oils
The mechanism is not completely understood; may reduce hepatic synthesis of TG.
These are indicated as an adjunct to diet when TG > 500 mg/dL.
Fish oil is also known as omega-3 fatty acids.
Lipid Effects: TG up to 45%, HDL ~9%
 Omega-3 Acid Ethyl Esters (Lovaza ): can be taken once daily, or split BID.
with or without food
 Omega-3-carboxylic acids (Epanova): is taken once daily with or without food
 Icosapent ethyl (Vascepa): Take with food .
 Take whole; do not break, crush, dissolve or chew.
 This medication does not usually cause side effects, but can cause
indigestion (stomach upset), abnormal sense of taste (Lovaza)
or joint pain (Vascepa).
 Omega-3-fatty acids can prolong bleeding time, use with caution with other
medications that cant bleeding risk (e.g., antiplatelets, anticoagulants) .
 Monitor INR if patients are taking warfarin at dose initiation or dose change.

Lomitapide and Mipomersen
 are specialty drugs that work by decreasing apoB, which is the main component
of LDL and VLDL (the precursor to LDL).
 Lomitapide binds to and inhibits microsomal triglyceride transfer protein (MTP),
which prevents the assembly of apoB containing lipoproteins.
 Mipomersen is an oligonucleotide inhibitor of apoB synthesis.
 Both medications are approved for use in patients with homozygous familial
hypercholesterolemia (HoFH).
Monitoring:
 LFTs (including total bilirubin), alkaline phosphatase, lipids.
 Lomitapide: pregnancy test in females of reproductive potential at baseline
Side Effects:
 N/V/D, dyspepsia, abdominal pain, constipation, flatulence, increase in
LFTs, chest pain, back pain, fatigue, weight loss, influenza, nasopharyngitis
 Mipomersen: Injection site reactions, flu-like symptoms, antibody formation

 Lomitapide (Juxtapid): 5-60 mg daily Capsule
 Hepatic impairment or ESRD: dosage adjustment required.
Take whole, with water,but without food, at least two hours after the evening
meal
 Due to the risk of hepatotoxicity, this agent is only available through a Juxtapid
Risk Evaluation and Mitigation Strategy (REMS) program.
Mipomersen (Kynamro): 200 mg SC once weekly Prefilled syringe
Maximal LDL reduction seen after -6 months
 Due to the risk of hepatotoxicity, this agent is only available through a Kynamro
REMS program.