Dispensing Cholesterol-Lowering Medications
Full update February 2022
Cholesterol-lowering medications are used to treat high cholesterol in the blood. In both the US and Canada, high cholesterol affects at least one out of three adults. The risk for heart disease in people with high cholesterol is twice as high as those with normal levels. Cholesterol-lowering medications are also used to decrease the risk for heart disease in individuals with certain medical conditions, regardless of their cholesterol levels. Examples of these conditions include diabetes, coronary artery disease, and history of a heart attack. Since some of these conditions are so prevalent, pharmacies dispense many prescriptions for cholesterol-lowering meds every day. Pharmacy technicians can help make sure cholesterol-lowering medications are dispensed correctly and ensure patients get the most benefit from these meds.
You receive an e-Rx for Christina, a 47-year-old patient, for atorvastatin 40 mg tablets, take one tablet by mouth once daily, quantity of 90. What is atorvastatin used to treat? How does it work? Read on to learn the answers to these questions and more.
What are the different types of cholesterol-lowering medications?
There are a few different classes of cholesterol-lowering medications that will be discussed below.
- statins: atorvastatin, fluvastatin, lovastatin, pitavastatin (Livalo [US]), pravastatin, rosuvastatin, simvastatin
- bile acid sequestrants: cholestyramine, colestipol (Colestid), colesevelam (Welchol, [US], Lodalis [Canada])
- nicotinic acids: niacin (Niaspan [extended-release; US], Niacor [immediate release; US])
- fibrates: gemfibrozil, fenofibrate, bezafibrate (Canada)
- cholesterol absorption inhibitors: ezetimibe
- fish oil products (omega-3 fatty acids): omega-3-acid ethyl esters (Lovaza [US]),icosapent ethyl (Vascepa)
In addition, there are some other less frequently used medications that may be tried in patients at the highest risk for heart disease, such as patients with rare forms of very high cholesterol. These medications include alirocumab (Praluent), bempedoic acid (Nexletol [US]), evinacumab-dgnb (Evkeeza [US]), evolocumab (Repatha), inclisiran (Leqvio), and lomitapide (Juxtapid). Most of these medications are injectable and some may be considered “specialty” medications. This means that not as many patients will be prescribed these meds because of the rarity of the condition they treat and their high cost. Also, in some cases their distribution might be limited to certain pharmacies.
It is important to be aware that cholesterol guidelines support statins as first-line therapy to treat high cholesterol. The reason for this is because statins have good evidence for reducing cardiovascular events, including death. The other types of non-statin cholesterol-lowering medications are generally only used as add-on therapy when statin treatment alone is not enough or when statins are not tolerated.
How do cholesterol-lowering medications work?
Most products lower cholesterol by decreasing low-density lipoprotein (LDL) levels (also known as “bad cholesterol”). Some cholesterol-lowering medications may also increase high-density lipoprotein (HDL) levels (also known as “good cholesterol”). For instance, fish oil products do not decrease LDL cholesterol levels by much, but they help decrease triglycerides and can increase good cholesterol (HDL). Triglycerides are a type of lipid (or fat). Like cholesterol, having very high triglycerides levels can increase the risk of heart disease.
Cholesterol-lowering medications work in different ways:
- statins: work best to decrease LDL cholesterol by inhibiting the enzyme that creates it.
- bile acid sequestrants: decrease LDL cholesterol by increasing its removal from the body and decreasing its absorption.
- nicotinic acids: decrease the production of LDL cholesterol, increase HDL cholesterol levels, and decrease triglyceride levels.
- fibrates: decrease triglyceride production and may slightly lower LDL cholesterol, while increasing HDL cholesterol.
- cholesterol absorption inhibitors: decrease LDL cholesterol by blocking its absorption along the intestinal border.
What information should you ask a patient who has an Rx for a cholesterol-lowering med?
Information such as allergies, date of birth, phone number, and address should be requested and updated at every opportunity. Additional details can be helpful to ensure optimal safety and efficacy for patients taking cholesterol-lowering medications. For example, gather information on other medical conditions, such as diabetes, angina, previous stroke, or previous heart attack. The pharmacist can use this information to check that the patient has been prescribed the right statin dose. Patients with these risk factors might be candidates for higher statin doses. Also ask about pregnancy and breastfeeding status. Statins should generally be avoided in patients who are pregnant or breastfeeding due to the potential risk of harm to the baby. For example, you could ask patients of childbearing age, “We ask patients if they're pregnant because the pharmacist needs to check that medicines taken during pregnancy are safe. Are you pregnant or planning to become pregnant soon?” Don’t be surprised if a statin is continued during pregnancy in very rare exceptions. For instance, a pregnant patient might stay on a statin if they have a hereditary form of high cholesterol or have had a heart attack or stroke since these patients are at very high risk for cardiovascular events.
Ask patients presenting with a new or refill prescription if they take any dietary supplements, over-the-counter (OTC) medications, or if they take any prescription medications that they get at another pharmacy. It’s important to gather this information so that pharmacists can identify drug interactions or duplicate therapy. For example, gemfibrozil, a fibrate, can be an issue if prescribed along with a statin due to the increased risk for muscle damage. Also, to avoid the risk of increased muscle damage, some statins may need to be avoided or the dose adjusted when taken with certain antibiotics (such as clarithromycin and erythromycin), human immunodeficiency virus (HIV) medications (specifically protease inhibitors including atazanavir or ritonavir), or antifungals (like ketoconazole or itraconazole). In addition, fish oil products may increase the risk of bleeding when taken with blood thinners (warfarin, Xarelto, etc).
There are some herbals and foods that can be an issue when taken along with cholesterol-lowering medications. St. John’s wort can decrease the effectiveness of some statins. Grapefruit juice can increase the concentration of some statins in the blood, which can put patients at a greater risk for adverse effects such as muscle damage. Asking a simple question to find out if patients ever drink grapefruit juice can help alert the pharmacist to a potential drug-food interaction.
In addition to asking about drug allergies, for some medications it is helpful to know about food allergies. Fish oil products are a good example of that. Knowing if a patient has a fish or shellfish allergy is important if they are prescribed Lovaza or Vascepa. The pharmacist will want to know this information so they can determine if the med is safe for the patient.
To help prevent nonadherence, take care to listen to complaints from patients and share them with the pharmacist. Some examples of things you might hear patients complain of include muscle pain with statins, flushing with niacin, or stomach distress with bile acid sequestrants. Even though statin users commonly report muscle symptoms, over 70% of these patients can continue to take a statin. Many times, the statin can be changed, or the dose lowered to reduce symptoms. Let your pharmacist know if a patient is having problems tolerating their meds.
What should be considered when entering a cholesterol-lowering med Rx into the computer?
Medication profile review. Before filling any prescription for a patient, it’s important to check their medication profile to see if they have been on the product before. You might find prescriptions for the exact same thing that have been put “on hold” that you could fill first. Always make sure to verify that dosage, directions, and quantity are exactly the same.
When filling a new prescription for a non-statin cholesterol-lowering medication, check the patient’s profile to see if they’ve tried a statin in the past. If it doesn’t appear that they have, let the pharmacist know so that they can ask the patient some follow-up questions to ensure they are on the best and most effective therapy. The pharmacist can then reach out to the prescriber if needed.
Patients getting cholesterol-lowering meds, especially statins, are great candidates for your pharmacy’s automatic refill program or med sync, if you offer it. Adherence to statins is often a target of quality measures, such as those used in the Medicare Star Rating program in the US. In addition, statin use in diabetes is another quality measure that Medicare and some other payers may use. This measure assesses the number of patients with diabetes between the ages of 40 and 75 who are on a statin. That’s because statin use in these patients with diabetes can decrease the risk for heart disease. You can help improve your pharmacy’s performance on this measure by reviewing patient profiles when filling diabetes prescriptions to see if the patient is also taking a statin. If you don’t see an active prescription for a statin, let the pharmacist know so they can look into it further.
If this is the patient’s first prescription for this medication, review the patient profile for any other active cholesterol-lowering medications. The pharmacist will want to make sure that the patient should still be taking the meds together. Keep in mind that some cholesterol-lowering meds used for the highest risk patients, such as bempedoic acid or inclisiran, should still be taken with a statin because that’s how they were studied in clinical trials. You can keep an eye out for this by checking to make sure the patient also has an active statin Rx on file.
A unique situation you should let the pharmacist know about is any NEW prescription for simvastatin 80 mg. This dose of simvastatin may be okay as a refill for a patient who has been taking it without any issues for a while. But simvastatin 80 mg should not be started in patients who haven’t already been taking it. This dose was found to increase muscle damage compared to patients taking lower doses of simvastatin or other statins. Since the risk is higher during the first year of treatment, this dose is no longer recommended. It is unlikely that you will see this situation, but it is still important to be aware of.
You review Christina’s medication profile and see that she gets prescriptions for metformin and insulin to treat diabetes. You don’t see a statin currently in her medication profile, so you assume this is a new medication for Christina.
Avoiding look-alike/sound-alike errors. Statins can be confused for each other since they all end in “-statin.” In addition, nystatin, an antifungal, can also be confused for being one of the statins since it has the same ending.
When handwritten, atorvastatin can look like atomoxetine, and vice versa. Atomoxetine comes in several different doses, some of which overlap with doses that atorvastatin comes in: 10 mg, 40 mg, and 80 mg. Atomoxetine is used to treat attention-deficit hyperactivity disorder (ADHD). If you are unsure if a prescription is written for atomoxetine or atorvastatin, and the patient is waiting in the pharmacy, asking why they were prescribed the medicine can help.
Look out for name mix-ups with some of the newer therapies that you may not be as familiar with. For instance, bempedoic acid may be confused with aminocaproic acid or valproic acid, Leqviocan be misread as Livalo, and Nexletol can be misheard as labetalol. Nexletol could also be confused with Nexlizet, the version of bempedoic acid that is formulated with ezetimibe.
You begin typing Christina’s prescription for atorvastatin. You type “ato” and then hit enter to begin the search. You are working quickly and accidentally select atomoxetine 40 mg. You notice this right away and make the correction to atorvastatin 40 mg. You remind yourself in the future to type out at least the first five letters of the drug name to prevent medication errors.
Generic substitution. Many cholesterol-lowering medications have a generic alternative. However, there are a few that do not and could be very expensive for the patient. If you notice a copay that is extremely high in comparison to what the patient typically pays, you should talk to the pharmacist. Even if the drug does not have a generic alternative, there could be other options the patient can try in the same or a different class.
Days’ supply. In general, it is important to pay attention to accurate days’ supply. If entered inaccurately, this could make it more difficult for the patient to get their next refill. It could also make it look like the patient is nonadherent to their medication.
Most of the dosing for cholesterol-lowering meds is fairly straightforward. Statins and the cholesterol absorption inhibitor ezetimibe are typically dosed as one tablet once daily. The exception to this can be lovastatin and immediate-release fluvastatin which may be dosed twice daily. Additionally, fibrates and nicotinic acid preparations can have once- or twice-daily dosing. Bile acid sequestrants are usually prescribed to be taken twice daily and can come as tablets or an oral powder for suspension. For these drugs, you will want to make sure you understand the instructions on the prescription and refer to the product labeling itself. When ordering the powder for suspension, prescribers may indicate the number of packets or the number of grams to be taken twice daily. In either case, be familiar with how many grams are in each packet. Also be aware that pill burden can be very high for the bile acid sequestrant oral tablets (colesevelam and colestipol). Patients may be taking up to seven tablets a day of colesevelam and up to 16 tablets a day of colestipol. Since this is not as straightforward as a “Take 1 tablet once a day” dose, make sure to take your time when calculating days’ supply or quantities for these meds.
The injectable drugs, such as evolocumab, alirocumab, or inclisiran, are dosed less frequently so take care to determine days’ supply if you are responsible for billing these drugs. You’ll want to know how often the patient will be using the medication and how many doses are available in the prescribed quantity. For instance, alirocumab is administered subcutaneously every two weeks and comes as a single-dose pre-filled pen. Therefore, a quantity of two pens should last the patient 28 days since they will use one pen every two weeks (2 pens x 2 weeks/1 pen x 7 days/1 week = 28 days).
What should be considered when selecting a cholesterol-lowering medication from the shelf?
Statins come in a few different doses, so when selecting these medications from the shelf pay close attention to the specific dose. Also watch for drugs that come in several different dosage forms, such as fenofibrate which is available in tablets, capsules, and micronized capsules. Usually, manufacturers will use different colors on the labeling to represent the different doses or dosage forms. However, the bottles may otherwise look similar, so be sure to match up the national drug code (NDC) number (or drug identification number [DIN] in Canada) on the prescription label to the bottle you are selecting.
Be aware that even if you select the right bottle, this doesn’t always mean the product you are expecting is in the bottle. Make it a habit to look closely when counting or pouring pills into an automation device to make sure they all look the same, especially when the bottle is already open. Pills can get accidentally comingled if returned to stock items are emptied back into the wrong stock bottle.
When pulling atorvastatin 40 mg from the shelf, you notice a few different strengths in bottles that look very similar. You double-check the NDC of the bottle you select against that on the prescription label.
What auxiliary labels should be added to prescriptions for cholesterol-lowering medications?
Auxiliary labels can help draw a patient’s attention to information that is most relevant. Usually, these labels include information related to administration techniques, things to avoid, or specific side effects to look out for. The purpose of these labels is to help increase efficacy and decrease the risk of adverse effects.
Some statins will include a warning about avoiding grapefruit juice, and all statins will include warnings about avoiding if pregnant, planning to become pregnant, or while breastfeeding. It is important to include these labels when you see them. Grapefruit juice consumption can increase the risk for muscle damage and other adverse effects. Taking a statin while pregnant or breastfeeding may cause harm to the child and should generally be avoided unless the patient is at very high cardiovascular risk.
Look out for drugs that come in sustained- or extended-release formulations, such as Niaspan or fluvastatin ER (US). You will want to include a label alerting the patient not to crush or chew these tablets. Additionally, letting patients know that they should take a medication with food or with plenty of water is important to help improve efficacy and decrease side effects. For instance, niacin should be taken with food and bile acid sequestrants should be taken with plenty of water, so any labels that include this information should be affixed to the Rx bottle if possible. Attach labels to bile acid sequestrants that inform patients to avoid other meds one hour before and four hours after. This helps reduce the chance that bile acid sequestrants will impact the absorption of other drugs.
Auxiliary labels warning about avoiding grapefruit juice and avoiding use while pregnant or breastfeeding print out with the label of Christina’s atorvastatin prescription. You attach both.
Can cholesterol-lowering medications be obtained without a prescription?
There are several fish oil and niacin products currently available over the counter. Quality and content of these products varies since they are considered dietary supplements, not drugs. If a patient is interested in choosing an OTC version of these, instruct them to choose a product with the “USP Verified Mark” (or Natural Product Number [NPN] in Canada) on the label. These have been tested for good quality. Also, when helping patients find niacin products to choose from, be aware of the potential for confusion. Niacin is a kind of B3 vitamin, also called nicotinic acid. Niacinamide is another kind of vitamin B3, but it has no effect on cholesterol. Instruct patients interested in a niacin product for cholesterol to look for products that say niacin, not niacinamide. If a patient has been taking the prescription versions of fish oil or niacin and is interested in trying the nonprescription products, the pharmacist should get involved. They can work with the patient and the prescriber to determine if an OTC product would be a suitable alternative.
You might have heard, or will hear in the future, discussion about statins being made available without a prescription. Drug manufacturers have tried unsuccessfully in the past to submit applications to Food and Drug Administration (FDA) for their product to be available without a prescription. While statins are available over the counter in the United Kingdom and other countries, in the US and Canada, they are currently available by prescription only.
Christina’s filled prescription sits in your will call bin for about a week before she comes in to pick up her metformin and insulin prescriptions. You let her know that she also has a prescription for atorvastatin ready. She tells you she doesn’t think she needs it since she doesn’t have high cholesterol. You know that statins are also used to decrease the risk for heart disease in individuals with diabetes, regardless of their cholesterol levels. You let Christina know that you’ll get the pharmacist to discuss the importance of this new medication with her.
─Continue to the “Cheat Sheet” for Dispensing Cholesterol-Lowering Meds─
Cite this document as follows: Technician Tutorial,Dispensing Cholesterol-Lowering Meds. Pharmacist’s Letter/Pharmacy Technician’s Letter. February 2022. [380280]
“Cheat Sheet” for Dispensing Cholesterol-Lowering Meds
What are cholesterol-lowering medications used for?
- To treat high cholesterol and decrease LDL levels (also known as “bad cholesterol”).
- To decrease the risk of heart disease in people with certain medication conditions (diabetes, etc).
What are the different types of cholesterol-lowering medications?
- statins: atorvastatin, fluvastatin, lovastatin, pitavastatin (Livalo [US]), pravastatin, rosuvastatin, simvastatin
- bile acid sequestrants: cholestyramine, colestipol (Colestid), colesevelam (Welchol, [US], Lodalis [Canada])
- nicotinic acids: niacin (Niaspan [extended-release; US], Niacor [immediate release; US])
- fibrates: gemfibrozil, fenofibrate, bezafibrate (Canada)
- cholesterol absorption inhibitors: ezetimibe
- fish oil products (omega-3 fatty acids): omega-3-acid ethyl esters (Lovaza [US]), icosapent ethyl (Vascepa)
- other products for the highest-risk patients (who typically don’t get enough LDL lowering with a statin alone): alirocumab (Praluent), bempedoic acid (Nexletol [US]),evinacumab-dgnb (Evkeeza [US]), evolocumab (Repatha), inclisiran (Leqvio), lomitapide (Juxtapid)
Which cholesterol-lowering medications are preferred?
Statins are first-line therapy because they have the best evidence for reducing cardiovascular events, including death. The other types of non-statin cholesterol-lowering medications are generally only used as add-on therapy when statin treatment alone is not enough or when statins are not tolerated.
How can I prevent mix-ups and help patients get the most from their cholesterol-lowering meds?
- Gather and document information on other medical conditions, pregnancy, and breastfeeding status.
- Confirm drug allergies and food allergies.
- Fish or shellfish allergies may be an issue with the Rx forms of fish oil, Lovaza or Vascepa.
- Ask about and document Rxs filled at other pharmacies, herbals, supplements, and OTC meds.
- Try to find out if a patient who is filling an Rx for a non-statin cholesterol-lowering med has tried a statin in the past, and if they haven’t, refer them to the pharmacist.
- Be on the lookout for adherence issues and refer these patients to the pharmacist.
- Statin adherence is often a target for quality measures.
- Watch for look-alike/sound-alike mix-ups; especially with newer meds you aren’t as familiar with.
- Double-check you’ve entered correct days’ supplies, especially for bile acid sequestrants and injectable meds.
- Pay close attention when pulling product off the shelf.
- Compare NDC/DIN numbers on the product with the NDC/DIN on the Rx label.
- Apply appropriate auxiliary labels, for example:
- “Avoid grapefruit” and “Avoid if pregnant or breastfeeding” for statin Rxs.
- “Do not crush or chew” for sustained- or extended-release formulations (Niaspan, fluvastatin ER, etc).
- Direct patients seeking OTC fish oil or niacin to products with the “USP Verified Mark” (NPN in Canada) on the label.
- If the patient has been prescribed the Rx versions of fish oil or niacin and is interested in trying the OTC products instead, get the pharmacist involved.
[February 2022; 380280]