Preventing and Managing Cardiovascular Disease

Mary Barna Bridgeman, PharmD Rupal Patel Mansukhani, PharmD

Case 1—Fish Oil for Dyslipidemia

C T is a 67-year-old woman who is seeking advice on the use of a fish oil supplement. She reports that she is otherwise healthy, has an active lifestyle that includes a daily exercise routine, and maintains a diet full of fruits and vegetables. She takes a women’s multivitamin each day for good nutrition and a lowdose aspirin daily for heart health. CT is seeking to supplement her diet with fish oil upon the advice of a popular medical talk show host. She believes this supplement has cholesterol and blood pressure lowering effects and, although her blood pressure and lipids are controlled at this time, would like to use a supplement to help keep them that way. What counseling points can you emphasize to CT regarding her use of fish oil?

Answer

OTC fish oil supplements are rich sources of omega-3 fatty acids, particularly docosahexanoic acid (DHA) and eicosapentaenoic acid (EPA), which may have beneficial effects in healthy individuals as well as in those with cardiovascular disease. According to the American Heart Association, omega-3 fatty acids may improve heart health by reducing the risk of arrhythmias, decreasing platelet aggregation, lowering serum triglycerides, and slightly lowering blood pressure, among other effects.¹ Although increasing dietary fish intake to 2 fish meals per week is one way to assure individuals are experiencing the benefits of a diet rich in omega-3 fatty acids, this may not be an option for those individuals who do not eat fish, who have limited access to fish varieties, or who cannot afford to purchase fresh fish. In these individuals, fish oil supplementation may be preferable.¹

The recommended daily intake of omega-3 fatty acid supplementation ranges depending on the indication for use. General nutrition support doses may range from 600 mg to 2 g per day. For the treatment of hypertriglyceridemia, 2 to 4 g per day administered in divided doses may be used. If she will be purchasing a supplement, remind CT to adhere to the directions for use and storage on the label. Not all fish oil products are derived from the same sources, which may include salmon or fish oil, krill oil, or algae derivatives. Some supplements may require refrigeration or may contain antioxidants, such as vitamin E, to prevent spoilage.

Fish oil and vitamin E may increase bleeding risk. Remind CT to restrict her use to 3 g per day or less and to monitor herself for signs of bruising or bleeding, because she is taking low-dose aspirin each day. Instruct CT that the most common side effects of fish oil supplementation are a “fishy” aftertaste and gastrointestinal upset.² Remind her to let her physician know of any OTC vitamins or supplements she is using at her next office visit.

Case 2—Home Cholesterol Monitoring

N F is a 55-year-old man who comes to the pharmacy looking to purchase a home test kit for monitoring his cholesterol. NF has a history of diabetes and hypertension, for which he has been taking lisinopril 40 mg daily, hydrochlorothiazide 25 mg daily, and metformin 1000 mg twice a day for the past 5 years. He is also diagnosed with dyslipidemia, for which he has been taking atorvastatin 40 mg daily for several years. Although he does not experience side effects from these medications, he would like to have better control of his cholesterol. He also says that he would feel more motivated to adhere to diet and exercise recommendations made by his physician if he could monitor his cholesterol as he does his blood glucose. What are your recommendations regarding the use of home test kits for monitoring NF’s cholesterol at home?

Answer

There are a variety of home cholesterol monitoring test kits and collection kits currently on the market that NF may find useful for monitoring the effects of his drug therapy regimen and diet and lifestyle modifications on his cholesterol levels. Because he has diabetes, NF may prefer a monitor that will allow him to check lipid and glucose levels, such as the CardioChek home monitor.³ If NF purchases such a device, remind him that although the monitor is reusable, separate testing strips are required for performing each type of test (ie, total cholesterol, high-density lipoprotein cholesterol, triglycerides, glucose, and ketones).

Reinforce the importance of avoiding the excessive fingertip “milking” that can affect test results, and caution him to avoid supplementing with doses of vitamin C 500 mg or more per day before the test, as this may falsely lower cholesterol results. Remind him that the results of the home monitoring device should not be used as a basis for selfadjusting his cholesterol regimen and to only adjust his treatment plan under physician’s advice.³ PT

Dr. Bridgeman is an internal medicine clinical pharmacist in Trenton, New Jersey, and clinical assistant professor, Ernest Mario School of Pharmacy, Rutgers University. Dr. Mansukhani is a clinical pharmacist in South Plainfield, New Jersey, and clinical assistant professor, Ernest Mario School of Pharmacy, Rutgers University.

References:

• Omega 3 fatty acids. National Institutes of Health National Center for Complementary and Alternative Medicine Web site. http://nccam.nih.gov/health/omega3/introduction.htm. Accessed October 23, 2011.
• Fish oil. Medline Plus Web site. www.nlm.nih.gov/medlineplus/druginfo/natural/993.html. Accessed October 21, 2011.
• Fish oil. In: Merck Manual for Health Care Professionals Online Edition. Merck Manual Web site. www.merckmanuals.com/professional/special_subjects/dietary_supplements/fish_oil.html. Accessed October 2011.
• Fish and omega 3 fatty acids. American Heart Association Web site. www.americanheart.org/presenter.jhtml?identifier=4632. Accessed October 19, 2011.
• What are the American Heart Association recommendations for omega 3 fatty acids? American Heart Association Web site. www.heart.org/HEARTORG/General/Frequently-Asked-Questions-About-Fish_UCM_306451_Article.jsp. Accessed October 20, 2011.
• Omega 3 fatty acids, fish oil, alpha linolenic acid. Medline Plus Web site. www.nlm.nih.gov/medlineplus/druginfo/natural/patient-fishoil.html. Accessed October 20, 2011.
• Covington M. Omega 3 fatty acids. Am Fam Physician 2004:1,70(1):133-140. American Family Physician Web site. www.aafp.org/afp/2004/0701/p133.html. Accessed October 20, 2011.
• Omega[da1] 3 Fatty Acids Drug Information. Medscape Web site. http://reference.medscape.com/drug/lovaza-omega-3-fatty-acids-342455#4. Accessed October 20, 2011.