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PDAT5 CV > 15/16 - Lipid Drugs > Flashcards

15/16 - Lipid Drugs Flashcards

1
Q

Primary Prevention

Treatment Decisions

A

Table will be given on EXAM

Patients with:
BODERLINE / INTERMEDIATE RISK
will be based on:
ASCVD RISK ENHANCERS
also given on the exam

  • **Know METABOLIC SYNDROME is one of them**
  • *coronary artery calcium = CAC**
  • CONTROVERSIAL EVIDENCE*
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2
Q

Cardiovascular Risk Factors

NON-MODIFIABLE

A

↑Age

MALE

RACE

Family History of:

  • *Premature CHD** in 1st degree Relative
  • *Males < 55yr** // Females < 65yr
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3
Q

Fibrates

Drugs & Uses

A

Gemfibrozil / Fenofibrate / Fenofibric Acid

1st line for SEVERE HYPERTG’s
TG > 500mg/dL
first rule out secondary causes, can cause PANCREATITIS

TG: ↓ 20-50%
LDL: ↓ 5-20%
May increase in patients with high TG
HDL: ↑ 10-20%

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4
Q

Bile Acid Sequestrants

Drugs / Use?

A

Cholestyramine / Colestipol / Colesevalam
take b4 heaviest meals

can INCREASE TG’s** & **no ASCVD outcomes

Weak recommendation for add on therapy if:

  • *If TG < 300mg/dL**
  • *LDL >190 mg/dL** and < 50% LDL lowering while on statin and ezetimibe
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5
Q

PCSK9 INHIBITORS
Evolocumab (Repatha) / Alirocumab (Praluent)

ADR / CONCERNS

A

NEUROCOGNITIVE EFFECTS
Though seen that:
Risk does NOT outweight benefit of additional CV risk reduction

benefit in severe LDL>190 patients?

PRICE

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6
Q

High Risk Conditions

  • *Very High Risk Clinical ASCVD**
  • *1 Major ASCVD Event + Multiple High Risk Conditions**
A

> 65 y/o - Currently SMOKING

Diabetes / HTN / CKD

  • *Persistant LDL-C elevation**
  • *>** 100 despite max statin + ezetimibe

Heterozygous FC
familial hypercholesterolemia

History of:

  • *CABG** or PCI
  • *Congestive HF**
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7
Q

Clinical ASCVD
What classifies a patient to be
VERY HIGH RISK ASCVD?

A

MULTIPLE Major ASCVD Events

OR

1 Major ASCVD Event** + **Multiple High-Risk Conditions

Age does NOT matter

Major ASCVD Events
Recent ACS (<12mo) - H/O MI - H/O Ischemic Stroke
Symptomatic PAD

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8
Q

MONITORING
STATIN THERAPY

A

4-12 Weeks
after initiation or dose adjustment

  • *3-12 MONTHS after**
  • clinically every 12 months*

Why?
monitor expected response & adherence

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9
Q

Fibrates
Gemfibrozil / Fenofibrate / Fenofibric Acid

Contraindications / ADR / DI

A

CI:
Hepatic / Renal dysfunction
GALLBLADDER DISEASE–>can cause PANCREATITIS

GI Side Effects

DI:
STATINS –> can INCREASE RISK of MYOPATHY
need to monitor closesly

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10
Q

Treatment of Muscle Symptoms
STATINS

Mild-Moderate

A

Evaluate for other conditions that may increase risk:
Renal / Hepatic dysfunction
Rheumatologic Disorders
Vitamin D deficiency
Primary muscle diseaes

DC STATIN
or use LOWER DOSES

Possibly –> HYDROPHILIC STATIN INSTEAD
Rosuvastatin / Pravastatin / Fluvastatin

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11
Q

PCSK9 INHIBITORS
Evolocumab (Repatha) / Alirocumab (Praluent)

Uses / Indications

A

Increased with STATIN COMBINATION

Approximately 60% further LDL reduction

Significant reduction in primary composite endpoint

  • *FOURIER** results driven by reduction in:
  • *stroke, non-fatal MI, and coronary revascularizations**
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12
Q

Cardiovascular Risk Factors

MODIFIABLE

A

SMOKING

  • *HTN**:
  • *> 130/80** or on meds

Obesity / Diabetes / Poor Diet / Physical Inactivity

↑LDL

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13
Q

When do we prefer to take STATINS?

A

EVENING
due to nighttime upturn in endogenous cholesterol synthesis

except for:
atorvastatin / rosuvastatin / pitavastatin

due to long half lives

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14
Q

Clinical ASCVD

  • *Treatment for:**
  • *Max Tolerated statin** + LDL > 70 mg/dL
A

add:
EZETIMIBE

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15
Q

Bile Acid Sequestrants
Cholestyramine / Colestipol / Colesevalam

Contraindications / ADR / DI’s

A

Contraindicated:
Fasting TG > 300mg/dL
biliary or bowel obstruction

ADR:
GI issues, not absorbed from GI tract

DI:
binds NEGATIVELY charged drugs –> ↓Absorption
warfarin / thiazide / beta blockers
seperation of doses

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16
Q

Major ASCVD Events

4

A

Recent ACS
within 12 months

  • *History of MI**
  • other than recent ACS event above*

History of ISCHEMIC STROKE

Symptomatic PAD

  • *>1** of these OR 1 of these + High Risk Conditions
  • *Very High Risk Clinical ACSVD**
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17
Q

Clinical ASCVD

  • *Treatment for:**
  • *Very High Risk** with Statin & Ezetimibe
  • *LDL > 70**
A

Max Statin + Ezetimibe

ADD:
PCSK9 INHIBITOR

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18
Q

Which drug has the special indication for:

HeFH
Heterozygous Familial HyperCholesterolemia

A

PCSK9 INHIBITORS
Evolocumab (Repatha) / Alirocumab (Praluent)

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19
Q

Ezetimibe = Zetia

Effects & MoA

A

Cholesterol Absorption Inhibitor
selectively inhibits absorption of dietary & biliary choleseterol
@brush border of intestine

LDL: ↓ 18-22%
HDL: ↑ 0-2%
TG: ↓ 0-5%

Combination with Statin –> ↓Risk of CV events
IMPROVE-IT Trial

20
Q

When would we consider:
MODERATE INTENSITY STATIN >High Intensity?

A
  • *Qualify for HIGH-intensity but have:**
  • *>** 75 y/o

Multiple or serious comorbidities:
Renal or Hepatic Impairment

H/O of:
previous STATIN intolerance or Muscle disorders

ALT Elevations > 3x ULN

Drug interations

21
Q

Omega-3 Fatty Acids​

ADR / CI / DI

A

ADR:
Dyspepsia / FISH TASTE

DI:
ANTIPLATELET ACTIVITY
can increase risk of bleeding with AntiCoag meds

22
Q

Statin

Effects / Uses

A

Most Potent LDL-Lowering Agents

LDL: ↓ 18-55%

HDL: ↑5-15%

TG: ↓ 7-30%

Significantly Reduce:
CHD Death / Non-Fatal MI / Strokes
Revascularization Procedures
Total Mortality

23
Q

RHABDOMYOLYIS

Statin ADR / Monitoring

A

CK > 10x ULN** + **ELEVATED SCr

Muscle breakdown –> myoglobinuria

Reoutine monitoring of CK is NOT NECESSARY
only check if unexplained muscle pain / tenderness / weakness
increased risk in:
>65 y/o
Renal Dysfunction
Check @ Baseline only

24
Q

PCSK9 INHIBITORS
Evolocumab (Repatha) / Alirocumab (Praluent)

MoA

A
  • *Indirectly decreases LDL levels** by
  • *regulating available LDL receptors**

•Binds to PCSK9

•Prevents PCSK9 from binding to LDL-R

↑hepatocellular LDL-R

•Decreases circulating LDL

25
Q

Diabetes** & **Age 40-75

When to ADD EZETIMIBE?

A

High Intensity Statin + Ezetimibe for Diabetes if:

10 year ASCVD risk > 20%

26
Q

Primary Prevention

ASCVD Risk Enhancer:

METABOLIC SYNDROME

A

> 3 Criteria = Metabolic Syndrome

“WTH-HtG”

Waist Circumference
>40in males // >35in Females

↑TG’s
meds or >175

↑Fasting Blood Glucose
meds or >100

HyperTension
meds or >130/85

↓__HDL-C
meds or <40 males // <50 females

27
Q

Nicotinic Acid / Niacin

USES

A

previously used to:
↓ TG and ↑ HDL​
BUT:
no longer used due to INCREASED ISCHEMIC STROKES

was the best drug to ↑ HDL​

ADR:

  • *liver / PUD**
  • *alcohol / FLUSHING**
28
Q

Therapeutic Lifestyle Changes

A

DIET

Physical Activity
Aerobic exercise = 3-4x week @40min per session

SMOKING CESSATION

WEIGHT MANAGEMENT

29
Q

Statin ADRs

A

MYALGIA
Muscle pain / tenderness / weakness
routine CK monitoring is NOT necessary

HA / Fatigue / GI upset

Elevated LFTs
rare, check LFT @ baseline

Cognitive Impairment

↑HbA1cand ↑Fasting Glucose
ASCVD risk benefit OUTWEIGHT the risk

30
Q

Diabetes** & **Age 40-75

Treatment?

A

at LEAST

MODERATE INTENSITY STATIN
↓ LDL 30% to < 50%

Atorvastatin 10 (20) mg

Rosuvastatin (5) 10 mg

Simvastatin 20, 40 mg

Pravastatin 40 (80) mg

Lovastatin 40 mg

Fluvastatin XL 80 mg

Fluvastatin 40 mg BID

Pitavastatin 2 – 4 mg

31
Q

CONTRAINDICATIONS

Statins

Specific Drugs?

A
  • *PREGNANCY**
  • *Lactation**

ACTIVE LIVER DISEASE

  • *SIMVASTATIN**
  • *10 mg** –> Verapamil / Diltiazem

20mg –> Amiodarone / Amlodipine / Ranolazine

↑Chance of Myalgas

32
Q

Omega-3 Fatty Acids

USES / MoA

A
  • *Add on Therapy for**
  • *TG CONTROL**
  • if intolerant to FIBRATES*
  • no LDL / HDL effects,*
  • *TG: ↓ 14-40%​**

MoA:
↓hepatic VLDL production
↓# of FFA available for TG synthesis

33
Q

Diabetes** & **Age 40-75

When to give HIGH INTENSITY STATIN?

Atorvastatin 40 / 80
Rosuvastatin 20 / 40

A

Multiple ASCVD Risk Factors
OR
RISK MODIFIERS
Long duration of DM (> 10 yrs for DM2; > 20 yrs for DM1)
Albuminuria > 30 mcg
eGFR < 60
Retinopathy / Neuropathy
ABI < 0.9

34
Q

Treatment of Muscle Symptoms
STATINS

SEVERE

A

Severe muscle symptoms or Fatigue
that are UNEXPLAINED

DC STATIN
Evaluate CK / SCr / Urinalysis for myoglobinuria

Rhabdo = all 3

  • *Myopathy = CK >10x ULN + Myalgia**
  • DOSE dependent*
35
Q
  • *Severe HYPERcholesterolemia**
  • *LDL >** 190

When to add EZETIMIBE?

A

< 50% Reduction with Statin

36
Q

Statin’s

MoA

A

Competitive inhibitor of:
HMG CoA Reductase
rate-limiting step of cholesterol syntehsis

↓Hepatocellular Cholesterol –> ↑LDL Receptors
VV
↑LDL Clearance

Non-Lipid Effects:
Restore Endothelial Function
↓Inflammation / ↓Ischemic Episodes
Stabilize Vunrable Plaques

37
Q

Clinical ASCVD

  • *Treatment for:**
  • *Very High Risk** OR < 75 y/o

MULTIPLE Major ASCVD Events
OR
1 Major ASCVD Event + Multiple High-Risk Conditions

A

HIGH INTENSITY STATIN
Atorvastatin 40 / 80
Rosuvastatin 20 / 40

Goal:
↓LDL > 50%

38
Q

When can we NOT use LDL levels?

A

TG > 400
we can NOT use calculated LDL levels

LDL > 190 = Very High

TG > 500 = Very High

39
Q

Myopathy

Statin ADR / Monitoring

A

MYALGIA** + **CK > 10x ULN

Dose Dependent

Reoutine monitoring of CK is NOT NECESSARY
only check if unexplained muscle pain / tenderness / weakness
increased risk in:
>65 y/o
Renal Dysfunction
Check @ Baseline only

40
Q

Low Intensity Statins

A

↓ LDL < 30%

Pravastatin 10 / 20

Lovastatin 20

  • *Simvastatin 10mg**
  • 20 is moderate*

Flustatin 20 / 40

Pitavastatin 1mg

Only 10mg or 20mg Doses except for:
Atorvastatin / Rosuvastatin / Simvastatin 20mg
All are either moderate or high intensity

41
Q

What is
CLINICAL ASCVD?

A

AtheroSclerotic CardioVascular Disease
someone who has or has had:

ACS** / **TIA** / **Stroke** / **PAD

History of:

  • *MI** = Myocardial infarction
  • *UA** = Stable or unstable angina

ALL FROM ATHEROSCLEROTIC ORIGIN

42
Q

HIGH-Intensity Statins

A

↓ LDL > 50%

Atorvastatin 40 / 80

Rosuvastatin 20 / 40

43
Q
  • *Severe HYPERcholesterolemia**
  • *LDL >** 190

When to add PCSK9 Inhibitor?

A

On Statin + Ezetimibe
&
LDL > 130

44
Q

Ezetimibe = Zetia

CI / ADR / DI

A

Contraindicated in:

  • *Active Liver Disease** or unexplained ↑LFT
  • *Pregnancy & Lactation**

ADR:
Diarrhea / Ab Pain

DI:
FIBRATES –> ↑Liver Enzymes / ↑cholecstectomy

CHOLESTYRAMINE = ↓Ezetimibe AUC

45
Q

What is considered
PREMATURE ASCVD?

ASCVD Risk Factor if First Degree Relative has…

A

Males < 55yr

Females < 65yr

PDAT5 CV (30 decks)

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