page188
Lopid
c
(Pfizer) A
‘300’ capsules
,
white/maroon,
gemfibrozil 300 mg,
net price 112-cap pack = £35.57.
Label:
22
‘600’ tablets
,
f/c,
gemfibrozil 600 mg,
net price 56-
tab pack = £35.57.
Label:
22
Nicotinic acid group
The value of nicotinic acid is limited by its side-effects,
especially vasodilatation.
In doses of 1.5 to 3 g daily it
lowers both cholesterol and triglyceride concentrations
by inhibiting synthesis; it also increases HDL-cholester-
ol.
Nicotinic acid is licensed for use with a statin if the
statin alone cannot
adequately control
dyslipidaemia
(raised
LDL-cholesterol,
triglyceridaemia,
and
low
HDL-cholesterol);
it can be used alone if the patient is
intolerant of statins (for advice on treatment of dyslipi-
daemia,
including use of
combination treatment,
see
p.
161).
A preparation combining laropiprant with nicotinic acid
(
Tredaptive
c
)
is
available;
laropiprant
has
no lipid-
regulating effect, but reduces the symptoms of flushing
associated with nicotinic acid.
Acipimox seems to have fewer side-effects than nico-
tinic acid but may be less effective in its lipid-regulating
capabilities.
ACIPIMOX
Indications
hyperlipidaemias of types IIb and IV in
patients who have not responded adequately to diet
and other appropriate measures
Contra-indications
peptic ulcer
Renal impairment
reduce dose if eGFR 30–60 mL/
minute/1.73 m
2
;
avoid if eGFR less than 30 mL/min-
ute/1.73 m
2
Pregnancy
manufacturer advises avoid
Breast-feeding
manufacturer advises avoid
Side-effects
vasodilatation,
flushing,
itching,
rashes,
urticaria,
erythema;
heartburn,
epigastric pain,
nausea, diarrhoea, headache, malaise, dry eyes; rarely
angioedema,
bronchospasm, anaphylaxis
Dose
. Usually 500–750 mg daily in divided doses
Olbetam
c
(Pharmacia) A
Capsules
,
brown/pink,
acipimox 250 mg,
net price
90-cap pack = £46.33.
Label:
21
NICOTINIC ACID
Indications
adjunct to statin in dyslipidaemia or used
alone if statin not tolerated (see also p.
161)
Cautions
unstable angina, acute myocardial infarction,
diabetes mellitus,
gout,
history of peptic ulceration;
interactions: Appendix 1 (nicotinic acid)
Contra-indications
arterial bleeding;
active peptic
ulcer disease
Hepatic impairment
manufacturer advises monitor
liver function in mild to moderate impairment and
avoid in severe impairment; discontinue if severe
abnormalities in liver function tests
Renal impairment
manufacturer advises use with
caution—no information available
Pregnancy
no information available—manufacturer
advises avoid unless potential benefit outweighs risk
Breast-feeding
present in milk—avoid
Side-effects
diarrhoea,
nausea,
vomiting,
abdominal
pain,
dyspepsia;
flushing;
pruritus, rash;
less com-
monly
tachycardia, palpitation,
shortness of breath,
peripheral oedema, headache,
dizziness,
increase in
uric acid,
hypophosphataemia,
prolonged prothrom-
bin time,
and reduced platelet count;
rarely
hypo-
tension,
syncope,
rhinitis,
insomnia,
reduced glucose
tolerance, myalgia, myopathy, myasthenia;
very rarely
anorexia,
rhabdomyolysis,
visual disturbance,
and
jaundice also reported
Note
Prostaglandin-mediated symptoms (such as flushing)
can be reduced by low initial doses taken with meals or, if
patient taking aspirin,
aspirin dose should be taken 30
minutes before nicotinic acid
Dose
. See under preparation
Modified release
Niaspan
c
(Abbott) A
Tablets
,
m/r,
nicotinic acid 500 mg,
net price 56-tab
pack = £18.98; 750 mg, 56-tab pack = £28.88; 1 g, 56-
tab pack = £38.23; 21-day starter pack of 7 375-mg
tab with 7 500-mg tab and 7 750-mg tab = £15.40.
Label:
21,
25
Dose
375 mg once daily at night (after a low-fat snack) for 1
week,
then 500 mg once daily at night for 1 week,
then 750 mg
once daily at night for 1 week,
then 1 g once daily at night for 4
weeks, increased if necessary in steps of 500 mg at intervals of at
least 4 weeks to max.
2 g daily;
usual maintenance dose 1–2 g
once daily at night
With laropiprant
Tredaptive
c
(MSD) T A
Tablets
, m/r, nicotinic acid 1 g, laropiprant 20 mg, net
price 28-tab pack = £16.73;
56-tab pack = £33.46.
Label:
21,
25
Dose
1 tablet once daily at night,
increased after 4 weeks to 2
tablets once daily at night
Omega-3 fatty acid compounds
The omega-3 fatty acid compounds comprise omega-3-
acid
ethyl
esters
(
Omacor
c
)
and
omega-3-marine
triglycerides
(
Maxepa
c
).
Omega-3
fatty
acid com-
pounds
may be used to reduce triglycerides,
as
an
alternative to a fibrate and in addition to a statin,
in
patients
with combined (mixed)
hyperlipidaemia not
adequately controlled with a statin alone. A triglyceride
concentration exceeding 10 mmol/litre is
associated
with acute pancreatitis and lowering the concentration
reduces this risk.
The fat content of omega-3 fatty acid
compounds (including excipients in the preparations)
should
be
taken
into
consideration
when
treating
hypertriglyceridaemia.
There
is
little
clinical
trial
evidence that the triglyceride lowering effect decreases
the risk of cardiovascular disease.
The
Scottish Medicines Consortium
(p.
4) has advised
(November
2002)
that
omega-3-acid
ethyl
esters
(
Omacor
c
)
is not
recommended for
use within NHS
Scotland for the treatment of hypertriglyceridaemia.
OMEGA-3-ACID ETHYL ESTERS
Indications
adjunct to diet and statin in type IIb or III
hypertriglyceridaemia; adjunct to diet in type IV
hypertriglyceridaemia; adjunct in secondary preven-
tion in those who have had a myocardial infarction in
the preceding 3 months
168
2.12 Lipid-regulating drugs
BNF 61
2
Cardiovascular system