What medications can cause dyslipidemia?

Medications That Cause Dyslipidemia

Multiple medications can cause dyslipidemia, with immunosuppressive drugs (corticosteroids, cyclosporine, sirolimus, tacrolimus), certain antipsychotics (clozapine, olanzapine, quetiapine), and some cardiovascular medications being the most significant contributors to lipid abnormalities. 1

Common Medication Classes That Cause Dyslipidemia

Immunosuppressive Medications

• Corticosteroids: Increase total cholesterol, LDL, and triglycerides 1
• Calcineurin inhibitors:
  • Cyclosporine: Significantly increases total cholesterol and LDL 1
  • Tacrolimus: Less lipid effects than cyclosporine but still causes dyslipidemia 1
• mTOR inhibitors:
  • Sirolimus: Marked increases in triglycerides and LDL 1

Antipsychotic Medications

• High risk: Clozapine, olanzapine, quetiapine - associated with significant dyslipidemia 1, 2, 3
• Lower risk: Ziprasidone, risperidone, aripiprazole, haloperidol 2, 3, 4
• Mechanism: Direct effects on lipid metabolism independent of weight gain 4

Cardiovascular Medications

• Beta-blockers: Increase triglycerides, decrease HDL 1, 5
• Thiazide diuretics: Increase total cholesterol and triglycerides 1, 5

Hormonal Agents

• Androgens/anabolic steroids: Lower HDL, variable effects on LDL 1, 5
• Oral estrogens: Can increase triglycerides 5
• Oral contraceptives: Can cause dyslipidemia, especially older formulations 1

Retinoids

• 13-cis-retinoic acid (isotretinoin): Increases triglycerides and LDL, reduces HDL 1, 5
• Etretinate: Similar lipid effects 1

Antiretroviral Therapy

• Protease inhibitors: Significant dyslipidemia with increased triglycerides and LDL 1
• Some NNRTIs: Variable effects on lipid profiles 1

Other Medications

• Anticonvulsants: Some can alter lipid metabolism 1
• Interferons: Can cause hypertriglyceridemia 5
• Bile acid sequestrants: Can increase triglycerides 1
• L-asparaginase and cyclophosphamide: Associated with lipid abnormalities 1

Monitoring and Management

Monitoring Recommendations

• Obtain baseline lipid panel before starting high-risk medications 2, 3
• For high-risk medications (e.g., clozapine, olanzapine, cyclosporine, sirolimus):
  • Monitor lipids quarterly 2, 3
• For lower-risk medications:
  • Monitor lipids annually 2, 3
• Fasting lipid profile preferred, but non-fasting is better than no testing 1

Management Approach

1. Identify and address the causative medication when possible 6
2. Consider medication alternatives with better lipid profiles:
   • Switch from cyclosporine to tacrolimus 1
   • Change from high-risk to lower-risk antipsychotics 2, 3
   • Use pravastatin for HIV patients on protease inhibitors (fewer drug interactions) 1
3. Treat underlying conditions that may contribute to dyslipidemia:
   • Hypothyroidism 1
   • Diabetes 1
   • Nephrotic syndrome 1
   • Excessive alcohol consumption 1

Clinical Pearls and Pitfalls

• Pitfall: Treating medication-induced dyslipidemia without addressing the causative medication may lead to inadequate response or drug interactions 6
• Caution: Statins combined with certain medications (cyclosporine, protease inhibitors) increase risk of myopathy and rhabdomyolysis 1
• Important: Some medication-induced lipid changes occur independently of weight gain, particularly with certain antipsychotics 4
• Consider: Patients with psychiatric disorders or on immunosuppression after transplantation are at particularly high risk for medication-induced dyslipidemia and require close monitoring 1

By recognizing medications that cause dyslipidemia and implementing appropriate monitoring and management strategies, clinicians can reduce the risk of cardiovascular complications in patients requiring these therapies.