Step 7: Drug Tx

The table below lists drug classes along with the recommended daily doses, effects
on lipid levels, side effects, and contraindications for use in cholesterol treatment.

Statins are the most widely recommended class of drugs used for treatment of elevated
cholesterol. These have been shown to decrease the risk of heart disease and stroke in addition to lowering cholesterol levels. They work by inhibiting the natural production of cholesterol in the body. Some individuals may require a combination therapy approach
of other drug classes listed in the chart below.

Refer to the table in Step 5 to determine the necessity of drug therapy based
on the patients current LDL measurement and goal with any existing risk factors.

• Drug therapy may be considered in conjunction with TLC for CHD
  and CHD risk equivalents.
• Drug therapy may also be considered if after 3 months TLC has been
  unsuccessful and risk factors are present.
  

Drug Class	Agents and Daily Doses	Lipid/Lipoprotein Effects	Side Effects	Contraindications
HMG CoA reductase inhibitors (statins)	Lovastatin (20-80 mg), Pravastatin (20-40 mg), Simvastatin (20-80 mg), Fluvastatin (20-80 mg), Atorvastatin (10-80 mg), Cerivastatin (0.4-0.8 mg)	LDL-C 18-55% HDL-C 5-15% TG 7-30%	Myopathy Increased liver enzymes	Absolute: Active or chronic liver disease Relative: Concomitant use of certain drugs*
Bile acid Sequestrants	Cholestyramine (4-16 g) Colestipol (5-20 g) Colesevelam (2.6-3.8 g)	LDL-C 15-30% HDL-C 3-5% TG No change or increase	Gastrointestinal distress Constipation Decreased absorption of other drugs	Absolute: dysbeta-lipoproteinemia TG >400 mg/dL Relative: TG >200 mg/dL
Nicotinic acid	Immediate release (crystalline) nicotinic acid (1.5-3 gm), extended release nicotinic acid (Niaspan ®) (1-2 g), sustained release nicotinic acid (1-2 g)	LDL-C 5-25% HDL-C 15-35% TG 20-50%	Flushing Hyperglycemia Hyperuricemia (or gout) Upper GI distress Hepatotoxicity	Absolute: Chronic liver disease Severe gout Relative: Diabetes Hyperuricemia Peptic ulcer disease
Fibric acids	Gemfibrozil (600 mg BID) Fenofibrate (200 mg) Clofibrate (1000 mg BID)	LDL-C 5-20% (may be increased in patients with high TG) HDL-C 10-20% TG 20-50%	Dyspepsia Gallstones Myopathy	Absolute: Severe renal disease Severe hepatic disease

*Cyclosporine, macrolide antibiotics, various anti-fungal agents, and cytochrome P-450 inhibitors (fibrates and niacin
should be used with appropriate caution).