Lipid-lowering agents and considerations in the post-HSCT population
| Predominant dyslipidemia/drug class . | Agent/daily dose range* . | Expected effect . | Major side effects . | Important interactions . |
|---|---|---|---|---|
| Elevated LDL-C predominant | ||||
| HMG-CoA reductase inhibitors | Pravastatin, lovastatin,† or atorvastatin†/10-80 mg; fluvastatin/20-80 mg; simvastatin†/5-80 mg; rosuvastatin/5-40 mg | ↓ LDL-C 30%-45%; ↓ triglycerides 7%-30%; ↑ HDL-C up to 10% (variable by agent) | Myopathy; elevated liver tests | Increased myopathy risk with renal dysfunction and cyclosporine; fibrates; CYP3A4 inhibitors |
| Cholesterol absorption inhibitor | Ezetimibe/10 mg | ↓ LDL-C 17% | Gastrointestinal upset, elevated liver tests, myalgias (rare) | No major drug interactions |
| Bile acid sequestrants | Colesevelam‡/2400-3750 mg | ↓ LDL-C 15%-30%; can raise triglycerides | Constipation, dyspepsia | Monitor drug levels in IST |
| Hypertriglyceridemia predominant | ||||
| Omega-3 fatty acids | Omega-3-acid ethyl esters/2-4 g daily divided bid | ↓ triglycerides 35%-45%, ↑ HDL-C 3%, ↑ LDL-C 5% | Gastrointestinal upset, diarrhea | No major drug interactions |
| Fibric acid derivatives | Fenofibrate, fenofibric acid/45-200 mg daily; gemfibrozil/600-1200 mg daily divided bid | ↓ triglycerides 20%-50%, ↑ HDL-C 10%-20% | Myopathy, elevated liver tests, gallstones, rash; renal dysfunction (fenofibrate) | Use with caution in combination with statins and cyclosporine. |
| Mixed hyperlipidemia | ||||
| Niacin | Niacin/500-2000 mg | ↓ LDL-C 20%-30%, ↓ triglycerides 35%-55%, ↑ HDL-C 20%-35% | Dyspepsia, flushing, elevated liver tests, ↑ glucose, ↑ uric acid | No major drug interactions |
| Predominant dyslipidemia/drug class . | Agent/daily dose range* . | Expected effect . | Major side effects . | Important interactions . |
|---|---|---|---|---|
| Elevated LDL-C predominant | ||||
| HMG-CoA reductase inhibitors | Pravastatin, lovastatin,† or atorvastatin†/10-80 mg; fluvastatin/20-80 mg; simvastatin†/5-80 mg; rosuvastatin/5-40 mg | ↓ LDL-C 30%-45%; ↓ triglycerides 7%-30%; ↑ HDL-C up to 10% (variable by agent) | Myopathy; elevated liver tests | Increased myopathy risk with renal dysfunction and cyclosporine; fibrates; CYP3A4 inhibitors |
| Cholesterol absorption inhibitor | Ezetimibe/10 mg | ↓ LDL-C 17% | Gastrointestinal upset, elevated liver tests, myalgias (rare) | No major drug interactions |
| Bile acid sequestrants | Colesevelam‡/2400-3750 mg | ↓ LDL-C 15%-30%; can raise triglycerides | Constipation, dyspepsia | Monitor drug levels in IST |
| Hypertriglyceridemia predominant | ||||
| Omega-3 fatty acids | Omega-3-acid ethyl esters/2-4 g daily divided bid | ↓ triglycerides 35%-45%, ↑ HDL-C 3%, ↑ LDL-C 5% | Gastrointestinal upset, diarrhea | No major drug interactions |
| Fibric acid derivatives | Fenofibrate, fenofibric acid/45-200 mg daily; gemfibrozil/600-1200 mg daily divided bid | ↓ triglycerides 20%-50%, ↑ HDL-C 10%-20% | Myopathy, elevated liver tests, gallstones, rash; renal dysfunction (fenofibrate) | Use with caution in combination with statins and cyclosporine. |
| Mixed hyperlipidemia | ||||
| Niacin | Niacin/500-2000 mg | ↓ LDL-C 20%-30%, ↓ triglycerides 35%-55%, ↑ HDL-C 20%-35% | Dyspepsia, flushing, elevated liver tests, ↑ glucose, ↑ uric acid | No major drug interactions |
We recommend submaximal statin dosing in patients on IST agents that may alter metabolism of the statin agents. In general, patients gain only 6% additional LDL-C lowering with each doubling of statin dose.
Metabolized by CYP3A4.
Older bile acid sequestrants (cholestyramine and colestipol) should be avoided in patients on IST or those with complex medication regimens because of the potential inhibition of drug absorption.