September is Cholesterol Education Month – Learn About Cholesterol: The Good, the Bad, and the Ugly

9-16-16_chelsea_francesby: Chelsea E. Leonard, PharmD, Clinical Pharmacist, and Frances V. Cohenour, PharmD, Clinical Pharmacist and Co-Owner, Chad’s Payless  Pharmacy, Florence, AL

According to Quaker Oats, “Cheerios can help lower cholesterol and reduce the risk of heart disease!” If there has been a commercial about something or it has been on the news, chances are your community pharmacist has already been asked about it.  Because we field questions about anything and everything dealing with health, we can be a tremendous resource for advice and guidance.  The term “cholesterol” is mentioned all the time, and most people probably know that high cholesterol is bad (especially since everyone wants to help us lower it), but what exactly does it mean to have high cholesterol?

Cholesterol is a fatty substance found in the cells and the blood.  It literally looks like blobs of grease floating in your blood. Bodies need cholesterol to make some hormones and Vitamin D, but we make all the cholesterol we need. Certain foods that we eat introduce extra cholesterol in our blood stream, and this is where the problems happen. People with high cholesterol have twice the risk of developing heart disease than people with normal cholesterol. Cholesterol levels should be checked at least every five years, although most providers choose to check it annually. When cholesterol is reported, a few different numbers are important:

  • HDL, or “good” cholesterol, absorbs bad cholesterol and takes it back to the liver to be flushed out of the body. If HDL is higher, it can reduce the risk of heart problems and strokes. We want this cholesterol to be high!
  • LDL, or “bad” cholesterol, makes up the majority of cholesterol in the body. These are the blobs of grease. When your LDL is too high, the arteries can become clogged and potentially cause heart problems and strokes. Most medications work on this type of cholesterol.
  • Triglycerides, the “ugly” cholesterol, are a type of fat found in the blood. When high triglycerides are combined with high LDL or low HDL the risk of a heart attack or stroke is increased. Triglycerides are affected by foods we eat. If I ate a giant greasy breakfast and had my cholesterol checked right after, my triglycerides would probably be sky high (and my doctor would probably freak out)! Cholesterol should always be checked when you haven’t eaten anything in the past eight hours to ensure that the results are the most accurate.

Community pharmacists are accessible, knowledgeable and trusted and can help patients and other healthcare providers manage cholesterol. Although we do not usually have access to laboratory values, we are still able to provide education and recommendations. Some pharmacists even have the capability to test your cholesterol in the pharmacy and provide the results in about five minutes! Knowing the results, we can counsel patients on what their numbers mean and what they need to do to improve them. This is a great resource for patients who may not be able to make it to their doctor’s office or want to know how they’re doing in between doctor visits.

PillsInHandThe gold star medications for cholesterol management are known as statins. Common statins include simvaSTATIN (Zocor), atorvaSTATIN (Lipitor), and rosuvaSTATIN (Crestor). These medications are most beneficial for patients with high cholesterol and heart disease. They are the strongest drugs available for reducing LDL cholesterol. Most statin medications are given once daily, and simvastatin, lovastatin, and fluvastatin should be given at bedtime. Muscle symptoms (myopathy), including cramps and weakness, are the most common side effects that are reported from statin medications. Women have a higher risk for developing statin-induced myopathy. Patients with symptoms of myopathy should be monitored and potentially changed to a lower dose of their current medication or a different statin. If the patient still reports symptoms, a nonstatin medication may be necessary. Community pharmacists can make recommendations to patients and prescribers if there is a concern regarding side effects and medications.

Nonstatin medications include bile acid sequestrants (ex. cholestyramine), fibric acid derivatives (ex. fenofibrate), niacin, and cholesterol-absorption inhibitors (ex. Zetia).  Nonstatin medications are only recommended when a patient is unable to tolerate a statin; however, a nonstatin medication may need to be added based on the patient’s cholesterol panel. If a patient has high triglycerides, they might need to be on a statin and a fibric acid derivative. If a statin has not lowered LDL enough, Zetia might need to be added to their regimen. All cholesterol regimens should be tailored to the patient’s needs.

Like any other medication, cholesterol medications are not going to be effective if the patient is not taking them properly. Pharmacists have the ability to monitor a patient’s adherence to the medication and can discuss this with them if they notice a problem. From my personal experience as a community pharmacist, adherence issues are usually due to the medication’s cost. Community pharmacists can intervene to find a cheaper alternative for the patient. Another reason for adherence issues is forgetfulness. Patients often get caught up in the chaos of their day and simply forget to take their medicine. I even forget to take my own medication sometimes! If this happens, I usually recommend that they set a reminder on their phone (if they are tech savvy) or encourage them to keep their medications where they will see them each day, such as on the nightstand or by their toothbrush. The only way to receive the maximum benefit from medications is to take them!

101471962The cholesterol guidelines recommend that lifestyle changes are implemented for at least three months before starting a medication regimen. Pharmacists are also trained to teach patients about lifestyle modifications that can lower cholesterol. Dietary changes and physical activity are two key factor that help lower cholesterol. Thirty minutes of exercise five days per week is the recommendation for most people, and a diet low in fat and high in fiber can help with cholesterol levels. If red wine is more your speed, one glass per day might also be beneficial. Although easier said than done (believe me, I know!), these modifications are crucial for cholesterol management and heart health.

In addition to prescription medications and lifestyle modifications, there are some over-the-counter medications that can also be beneficial for patients with high cholesterol. As with all over-the-counter medications, a pharmacist or prescriber should be consulted before starting something new.

  • Coenzyme Q10 (CoQ10) supplementation has shown some benefit in reducing muscle symptoms from statins. This supplement is relatively inexpensive and low-risk for patients. CoQ10 should not be taken if the patient is taking a blood thinner like warfarin.
  • Omega-3 fish oil can decrease triglycerides and increase HDL. If patients taking fish oil complain of a fishy aftertaste, freezing the capsules before taking them could help. Fish oil should not be taken if the patient is taking a blood thinner like warfarin.
  • Niacin helps to increase HDL. Many patients experience flushing, where the skin becomes red, warm, and sometimes itchy, after taking niacin. Taking an extended-release formulation of niacin and eating beforehand can lessen this effect. Some patients have also seen a decrease in flushing if they take an aspirin 30 minutes before taking the niacin.

Community pharmacists are great resources for cholesterol management and medication management. We are filled with little nuggets of wisdom to help patients and providers achieve goals. I encourage you to contact a pharmacist if you ever have any questions about cholesterol or any other medical problem.

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