Bile acid resins

Combination drug therapy is an effective means to achieve greater reductions in LDL cholesterol (statin + ezetimibe or bile acid resin, bile acid resin + ezetimibe, or three-drug combinations) as well as raising HDL cholesterol and lowering serum triglycerides (statin + niacin or fibrate). 

Increased intake of soluble fiber in the form of oat bran, pectins, certain gums, and psyllium products can result in useful adjunctive reductions in total and LDL cholesterol (5% to 20%), but these dietary alterations or supplements should not be substituted for more active forms of treatment. They have little or no effect on HDL-C or triglyceride concentrations. These products may also be useful in managing constipation associated with the bile acid resins (BARs). 

Bile Acid Resins (Cholestyramine, Colestipol, Colesevelam)... 

BARs, bile acid resins fibrates include gemfibrozil or fenofibrate. 

Concomitant lipid-lowering therapy- When administering a bile acid resin and fluvastatin, administer fluvastatin at bedtime, at least 2 hours following the resin. 

The principal precaution with use of the bile acid resins is the possibility of impaired absorption of other drugs given orally at the same time. Cholestyramine and colestipol can bind many other drugs, such as digitoxin, phenobarbital, chlorothiazide, and warfarin, and delay or prevent their absorption. For this reason, other drugs should always be taken at least 1 hour before or 4 to 6 hours after the resin. The resins can also decease absorption of fat-soluble vitamins. 

Bile acid resins Nicotinic acid (niacin) Fibrates... 

Drugs Alcohol, estrogens, isotretinoin, beta blockers, glucocorticoids, bile-acid resins, thiazides asparaginase, interferons, azole antifungals, mirtazapine, anabolic steroids, sirolimus, bexarotene Malnutrition Malabsorption Myeloproliferative diseases Chronic infectiousdiseases AIDS, tuberculosis Monoclonal gammopathy Chronic liver disease Malnutrition Obesity... 

Niacin TLDL and VLDL Synthesis 4-Triglyceride and cholesterol 4VLDL, 4LDL, fHDL Problems with patient acceptance good in combination with bile acid resins extended-release niacin causes less flushing and is less hepatotoxic than sustained-release niacin... 

ALLHAT-LLT Antihypertensive and Lipid-Lowering Treatment to Prevent Heart Attack Trial ALT Alanine aminotransferase apoJ apolipoprotein J ARR Absolute risk reduction ATP III Adult Treatment Panel III AVERT Atrovastatin Versus Revascularization Treatments BAR Bile acid resin bid Twice daily... 

Bile acid resins increase fecal excretion of bile salts f 15-20% f 10-25% t 3-5% Variable, depending on pretreatment level of triacylglycerols (may increase)... 

Helsinki Heart Study (15) have all demonstrated the benefit of lipid lowering using various hypolipidemic agents for prevention of initial cardiac events. Secondary prevention trials have unequivocally shown that lipid lowering therapy not only reduces acute coronary events and other clinical endpoints, but also results in angiographic improvement. These studies have used different classes of drugs (statins, fibrates, niacin, bile acid resins—alone and in combination) in both hyper- and normo-cholesterolemic patients with established CAD. 

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