What is the recommended dosing for Welchol (colesevelam)

Welchol (Colesevelam) Dosing

The recommended dose of Welchol is 3.75 grams daily, administered either as 6 tablets (625 mg each) once daily or 3 tablets twice daily with meals, or as one 3.75-gram oral suspension packet once daily (or one 1.875-gram packet twice daily) mixed with 8 ounces of liquid and taken with a meal. 1, 2

Standard Dosing Regimens

Tablet Formulation

• 6 tablets (625 mg each) once daily with a meal and liquid 1, 2
• Alternative: 3 tablets twice daily with meals and liquid 1, 2

Oral Suspension

• One 3.75-gram packet once daily mixed with 8 ounces of water, fruit juice, or diet soft drink, taken with a meal 1, 2
• Alternative: One 1.875-gram packet twice daily with the same preparation instructions 1, 2
• Note: 3.75 grams of suspension is equivalent to 6 tablets; 1.875 grams equals 3 tablets 1

Critical Administration Requirements

Must Take With Food

• Colesevelam must be taken with meals to ensure optimal interaction with bile acids released during digestion 3, 2
• Taking with food maximizes the drug's ability to sequester bile acids and achieve lipid-lowering effects 3
• Scheduling with breakfast and/or dinner is recommended for consistency 3

Drug Interaction Timing

• All other medications must be taken at least 1 hour before or 4 hours after colesevelam to avoid impaired absorption 1, 2
• This is particularly critical for medications with narrow therapeutic windows including: 1, 2
  • Thyroid hormone replacement therapy
  • Warfarin (monitor INR frequently during initiation) 1
  • Phenytoin
  • Oral contraceptives containing ethinyl estradiol and norethindrone
  • Cyclosporine
  • Olmesartan
  • Sulfonylureas (glimepiride, glipizide, glyburide)

Population-Specific Dosing

Adults with Primary Hyperlipidemia

• 3.75 grams daily as monotherapy or in combination with statins 1, 2
• Achieves approximately 15% LDL-C reduction as monotherapy 1
• Provides additional 10-16% LDL-C reduction when combined with low- to moderate-intensity statins 1

Pediatric Patients (Ages 10-17 Years)

• Same dosing as adults: 3.75 grams daily for boys and post-menarchal girls with heterozygous familial hypercholesterolemia 1, 2, 4
• Can be used as monotherapy or with statins after adequate trial of diet therapy 1, 2
• Well tolerated for up to 26 weeks in pediatric trials 4

Adults with Type 2 Diabetes

• 3.75 grams daily as adjunct to diet and exercise for glycemic control 1, 2
• Same dosing regimen applies whether used for lipid lowering or glycemic control 2

Dose Titration Considerations

Gradual Titration for Bile Acid Diarrhea

• When using colesevelam for bile acid diarrhea (off-label), gradual dose titration is recommended to minimize side effects 1
• Start with 2 tablets (1.25 grams) three times daily and adjust based on response 1
• This approach differs from the standard fixed-dose regimen for hyperlipidemia 1

Standard Hyperlipidemia Treatment

• No dose titration is recommended for cholesterol-lowering indications 1, 2
• Start directly at the full therapeutic dose of 3.75 grams daily 2

Important Contraindications

Do not use colesevelam in patients with: 1, 2

• Triglyceride levels >500 mg/dL
• History of hypertriglyceridemia-induced pancreatitis
• Bowel obstruction
• History of bowel obstruction

Common Pitfalls to Avoid

Medication Timing Errors

• Failure to separate other medications by 4 hours is the most common error leading to reduced efficacy of concomitant drugs 1, 2
• Practical approach: Take other medications first thing in the morning (1+ hours before colesevelam) or at bedtime (4+ hours after) 3

Inadequate Liquid Intake

• Taking tablets without adequate liquid may increase risk of gastrointestinal obstruction 2
• Always take with a full glass of liquid and a meal 3, 2

Monitoring Failures

• Monitor triglycerides as colesevelam may increase TG levels and cause pancreatitis 1, 2
• Monitor INR frequently in patients on warfarin during colesevelam initiation 1
• Monitor TSH in patients on thyroid replacement therapy 1

Expected Efficacy

Monotherapy

• 15% median reduction in LDL-C at the standard 3.75-gram daily dose 1
• Up to 20% reduction reported in some studies 5

Combination Therapy with Statins

• Additional 10-16% LDL-C reduction beyond statin alone 1
• Combination with simvastatin 10 mg or atorvastatin 10 mg demonstrates additive effects 1

Tolerability Profile

• Most common adverse effects: constipation, dyspepsia, and nausea 1
• Significantly better tolerability than older bile acid sequestrants (cholestyramine, colestipol) 5, 6, 7
• Compliance rates of 93% reported in clinical trials 7
• Taking with adequate liquid may help mitigate gastrointestinal symptoms 3