What are the contraindications for colestiramine (bile acid sequestrant) administration?

Contraindications for Cholestyramine Administration

Cholestyramine is absolutely contraindicated in patients with complete biliary obstruction where bile is not secreted into the intestine and in individuals with hypersensitivity to any of its components. 1

Primary Contraindications

• Complete biliary obstruction 1
• Hypersensitivity to cholestyramine or its components 1
• Triglycerides >500 mg/dL 2, 3
• History of hypertriglyceridemia-induced pancreatitis 2, 3
• Bowel obstruction 2, 3
• Extensive ileal resection (>100 cm) or severe ileal involvement 3

Precautions and Relative Contraindications

Gastrointestinal Concerns

• Use with caution in patients with:
  • Gastroparesis 2
  • GI motility disorders 2
  • History of major GI tract surgery with risk for bowel obstruction 2

Medication Interactions

• May decrease absorption of other medications 2
• Critical medications should be administered at least 4 hours before cholestyramine 2
• Specific medications requiring separation:
  • Cyclosporin
  • Oral contraceptives containing ethinyl estradiol and norethindrone
  • Olmesartan
  • Phenytoin
  • Sulfonylureas
  • Thyroid replacement therapy
  • Warfarin 2

Nutritional Considerations

• May cause vitamin K or fat-soluble vitamin deficiencies 2
• Oral vitamins should be given at least 4 hours before cholestyramine 2
• Some products contain phenylalanine, which is harmful to patients with phenylketonuria 2

Monitoring Recommendations

1. Triglyceride levels: Monitor closely as cholestyramine may increase triglycerides 2, 3
2. Signs of pancreatitis: Discontinue if symptoms develop 2
3. INR: Monitor frequently during initiation in patients on warfarin 2
4. Vitamin levels: Consider monitoring fat-soluble vitamins in long-term use 2, 3

Clinical Considerations

When prescribing cholestyramine, start at a low dose (2-4 g/day) and gradually titrate based on response and tolerability 3. This approach helps minimize common gastrointestinal side effects such as constipation, dyspepsia, and nausea 2.

For patients who cannot tolerate cholestyramine due to palatability or side effects, consider colesevelam as an alternative, which has better tolerability and fewer drug interactions, though at higher cost 2, 3.

Remember that while cholestyramine is generally considered safe during pregnancy and lactation 2, individual risk-benefit assessment should be performed in these populations.