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838 PA R T V / Health Promotion and Disease Prevention
Intestinal Absorption Inhibitors The nurse is in an excellent position to promote adherence.
A new class of medication (intestinal absorption blockers) has The focus of the intervention should include the concept of dys-
recently been released by the Food and Drug Administration lipidemia as a “silent disease,” one that is present for life but one
(FDA). This medication (ezetimibe) acts by preventing the ab- for which treatment has been proven effective.
sorption of cholesterol at the intestinal brush border. The action
of ezetimibe is similar to that of the plant stanols and sterols.
This medication appears to be relatively “nonsystemic” in that it R EFERENCES
works exclusively in the intestine to block the uptake of choles- 1. American Heart Association Statistics Committee. (2008). Heart disease
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terol. Through this action, serum cholesterol is lowered, uptake and stroke statistics 2008 update. Circulation, 117, e25–e146.
by the liver of LDL is enhanced, and LDL levels decrease. This 2. National Cholesterol Education Program (NCEP). (2001). Expert Panel
medication has been shown to lower LDL cholesterol alone or in on Detection, Evaluation, and Treatment of High Blood Cholesterol in
Adults (Adult Treatment Panel III) (NIH Publication No. 01-3670).
combination with other cholesterol-lowering medica- Bethesda, MD: U.S. Department of Health and Human Services.
tions. 138,139 3. Grundy, S. M., Cleeman, J. I., Bairey Merz, C. N., et al., for the Coor-
dinating Committee of the NCEP. (2004). Implications of recent clini-
cal trials for the NCEP Adult Treatment Panel III Guidelines. Circula-
Fibric Acid Derivatives tion, 110, 227–239.
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Fibric acid derivatives have been used as hypolipidemic agents. 4. Armstrong, M. L., Warner, E. D., & Connor, W. E. (1970). Regression
They act primarily to increase LPL activity, which enhances ca- of coronary atheromatosis in rhesus monkeys. Circulation Research, 27,
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tabolism of VLDL and thereby reduces triglyceride levels. 137 Be- 59–67.
cause of their limited LDL effect, these drugs are not considered 5. Anderson, K. M., Castelli, W. P., & Levy, D. (1987). Cholesterol and
mortality: 30 years of follow-up from the Framingham Study. JAMA,
first-line therapy for LDL lowering. They are effective in treating 257, 2176–2180.
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hypertriglyceridemia and low HDL cholesterol states. 6. Yusuf, S., Hawken, S., Ôunpuu, S., et al. (2004). Effect of potentially
modifiable risk factors associated with myocardial infarction in 52 coun-
tries (the INTERHEART study): Case-control study. Lancet, 364,
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General Adherence Strategies 937–952.
7. Downs, J. R., Clearfield, M., Weis, S., et al. (1998). Primary prevention
It is estimated that 50% of patients discontinue drug therapy af- of acute coronary events with lovastatin in men and women with average
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cholesterol levels. JAMA, 279, 1615–1622.
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ter 1 year and only one third adhere to dietary interventions be- 8. Scandinavian Simvastatin Survival Study Group. (1995). Randomised
yond 1 year. 140,141 Factors related to nonadherence include lack of trial of cholesterol lowering in 4444 patients with coronary heart disease:
knowledge, misconceptions, beliefs and attitudes about the ther- The Scandinavian Simvastatin Survival Study (4S). Lancet, 344,
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apy, complexity of the regime, side effects, and the strength of the 1383–1389.
relationship between the patient and the health care provider. 141 9.Sacks, F. M., Pfeffer, M. A., Moye, L. A., et al. (1996). The effect of
Patient education should include information about the specific pravastatin on coronary events after myocardial infarction in patients
with average cholesterol levels. New England Journal of Medicine, 335,
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drug regime, how the drug works, when and how to use the drug, 1001–1009.
and how to minimize potential side effects. Barriers to medication 10. Shepherd, J., Cobbe, S. M., Ford, I., et al. (1995). Prevention of coro-
adherence include faulty health perceptions. Beliefs and attitudes nary heart disease with pravastatin in men with hypercholesterolemia.
New England Journal of Medicine, 333, 1301–1307.
may interfere with adherence. Social and environmental barriers 11. Long-Term Intervention with Pravastatin in Ischaemic Disease (LIPID)
may include such problems as difficulty taking medication in so- Study Group. (1998). Prevention of cardiovascular events and death with
cial settings or restaurants and lack of equipment for mixing med- pravastatin in patients with coronary heart disease and a broad range of
ication. It is appropriate to explore common beliefs, attitudes, and initial cholesterol levels. New England Journal of Medicine, 339,
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difficulties with the patient and develop strategies together to ad- 1349–1357.
dress these issues. Anticipation of potential side effects should also 12. Heart Protection Study Collaborative Group. (2002). Heart Protection
Study of cholesterol lowering with simvastatin in 20,536 high-risk indi-
be explored. Studies indicate that adverse side effects and thera- viduals: A randomised placebo-controlled trial. Lancet, 360, 7–22.
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peutic ineffectiveness were the major reasons cited for discontinu- 13. Cannon, C. P., Braunwald, E., McCabe, C. H., et al. (2004). Intensive
ing lipid-lowering drugs. 141 versus moderate lipid lowering with statins after acute coronary syn-
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dromes. New England Journal of Medicine, 350, 1495–1504.
Cues to action are important determinants of adherence to 14. Shepherd, J., Blauw, G. J., Murphy, M. B., et al. (2002). Pravastatin in
medication regimes. Ideal cues are ones that are a part of the pa- elderly individuals at risk of vascular disease (PROSPER): A randomised
tient’s habitual routine. Because such cues are habitual, the pa- controlled trial. PROspective Study of Pravastatin in the Elderly at Risk.
tient may need assistance in recognizing possible cues. Monitor- Lancet, 360, 1623–1630.
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ing and recording medication as it is taken can be useful in 15. Sever, P. S., Dahlof, B., Poulter, N. R., et al. (2003). Prevention of coro-
identifying potential cues. Feedback is a powerful reinforcer of nary and stroke events with atorvastatin in hypertensive patients who
have average or lower-than-average cholesterol concentrations, in the An-
behavior. Procedures for rapid lipid analysis should be used when glo-Scandinavian Cardiac Outcomes Trial–Lipid Lowering Arm (AS-
possible. Communicating changes in blood lipid response and re- COT-LLA): A multicentre randomised controlled trial. Lancet, 361,
sponding to side effect issues are essential components of lipid 1149–1158.
management and can often be accomplished by telephone. 16. Gould, A. L., Rossouw, J. E., Santanello, N. C., et al. (1995). Choles-
terol reduction yields clinical benefit: A new look at old data. Circulation,
Consideration should be given to routine telephone contacts to 91, 2274–2282.
promote adherence and increase the effectiveness of lipid man- 17. Law, M. R. (1999). Lowering heart disease risk with cholesterol reduc-
agement. Nursing case-managed intervention studies have tion: Evidence from observational studies and clinical trials. European
demonstrated that adherence to lifestyle changes and lipid-low- Heart Journal Supplement, 1(Suppl. S), S3–S8.
ering drug therapies can be achieved, perhaps caused in part by 18. Deedwania, P., Stone, P. H., Bairey Merz, C. N., et al. (2007). Effects of
intensive versus moderate lipid-lowering therapy on myocardial ischemia
the strength of the relationship between the nurse and the in older patients with coronary heart disease. Results of the Study As-
patient. 126,142 sessing Goals in the Elderly (SAGE). Circulation, 115, 700–707.
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