Colesevelam
Bile acid sequestrant — 2nd generation · “The dual-indication resin”
The Clinical Case
Female, 58 yo. Type 2 diabetes on metformin, HbA1c 7.8%. LDL 3.0 mmol/L, TG 1.8 mmol/L. Cannot tolerate statins (confirmed myopathy), refuses injectables. Endocrinologist prescribes a non-absorbed oral polymer that lowers LDL by ~18% AND carries FDA approval for improving HbA1c in T2DM — the only lipid-lowering agent with this dual indication. She is warned about the timing of her other medications.
The Answer
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Clinical Pearl
Mechanism: Non-absorbed polymer binds bile acids in the gut → interrupts enterohepatic circulation → hepatic LDL receptor upregulation
All Hints
Mechanism: Non-absorbed polymer binds bile acids in the gut → interrupts enterohepatic circulation → hepatic LDL receptor upregulation
Diabetes: Only lipid drug with FDA approval for T2DM glycaemic control (HbA1c↓ ~0.5%) — possible "mechanism": ↑GLP-1 secretion
Safety: Not absorbed → no systemic toxicity; safe in pregnancy; paediatric FH approval (≥10 yo); no liver monitoring needed
Drug interaction: Binds oral drugs in the gut — warfarin, levothyroxine, statins, fat-soluble vitamins; take others 1 h before or 4 h after
Adverse effects: GI side effects (constipation, bloating); raises TG — contraindicated if TG >3.4 mmol/L; large tablet burden
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