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NAPLEX 2024 > 27. Dyslipidemia > Flashcards

27. Dyslipidemia Flashcards

1
Q

TG > ____ can cause acute pancreatitis

A

> 500

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2
Q

Friedewald equation (LDL)

A

LDL = TC - HDL - (TG/5)
Do NOT use when TG > 400, can lead to falsely low LDL

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3
Q

Severe cholesterol elevations (including LDL ≥___ and TG ≥____) are very high risk and must be treated

A

LDL ≥ 190
TG ≥ 500

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4
Q

ASCVD risk is calculated using ___

A

Gender, age, race, smoking status
TC, HDL, LDL, statin use
BP, HTN med use
DM hx and aspirin use

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5
Q

Drugs that increase LDL and TG

A

Diuretics
Efavirenz
Immunosuppressants (e.g. cyclosporine, tacrolimus)
Atypical antipsychotics
Protease inhibitors

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6
Q

Drugs that increase LDL only

A

Fibrates
Fish oils (except Vascepa)

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7
Q

Drugs that increase TG only

A

IV lipid emulsions
propofol
clevidipine
bile acid sequestrants (~5%)

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8
Q

Conditions that increase cholesterol

A

Obesity, poor diet, alcohol use disorder, hypothyroidism, smoking, diabetes, renal/liver disease, nephrotic syndrome

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9
Q

ASCVD risk assessment should be repeated every ____ if low risk (<7.5%)

A

4-6 years

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10
Q

ASCVD risk score is not needed for pts with _____, as all pts in these groups should be started on a statin

A

clinical ASCVD, diabetes, or LDL≥190

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11
Q

Natural products for dyslipidemia

A

Red yeast rice (contains naturally occurring statin in varying amounts, can lower LDL)
OTC fish oils (can lower TG but increase LDL)
Garlic is no longer considered effective

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12
Q

Concern with cholesterol-lowering drugs and liver damage

A

Niacin, fibrates, potentially statins and ezetimibe may cause liver damage
Should not be used if AST or ALT is ≥ 3xULN

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13
Q

Statins MOA

A

inhibit HMG-CoA reductase, which prevents conversion of HMG-CoA to mevalonate
This is the rate-limiting step in cholesterol synthesis

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14
Q

Clinical ASCVD (CHD, stroke/TIA, PAD) - What intensity statin should be started in this patient?

A

High-intensity

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15
Q

Baseline LDL ≥190 - What intensity statin should be started in this patient?

A

High-intensity

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16
Q

DM and age 40-75 with LDL between 70-189 and multiple ASCVD risk factors - What intensity statin should be started in this patient?

A

High-intensity

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17
Q

DM and age 40-75 with LDL between 70-189 - What intensity statin should be started in this patient?

A

Moderate-intensity

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18
Q

Age 40-75 with LDL between 70-189 and ASCVD risk ≥20% - What intensity statin should be started in this patient?

A

high-intensity

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19
Q

Age 40-75 with LDL between 70-189 and ASCVD risk ≥ 7.5-19.9% + risk enhancing factors - What intensity statin should be started in this patient?

A

Moderate-intensity

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20
Q

High intensity statin options

A

Atorvastatin 40-80mg
Rosuvastatin 20-40mg

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21
Q

Moderate intensity statin options

A

Atorvastatin 10-20mg
Rosuvastatin 5-10mg
Simvastatin 20-40mg
Pravastatin 40-80mg
Lovastatin 40mg
Fluvastatin 40mg BID/80XL
Pitavastatin 1-3mg

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22
Q

Low-intensity statin options

A

Simvastatin 10mg
Pravastatin 10-20mg
Lovastatin 20mg
Fluvastatin 20-40mg

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23
Q

Statin equivalent doses

A

Pharmacists Rock At Saving Lives and Preventing Fatty deposits
Pitavastatin 2mg
Rosuvastatin 5mg
Atorvastatin 10mg
Simvastatin 20mg
Lovastatin 40mg
Pravastatin 40mg
Fluvastatin 80mg

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24
Q

Muscle damage from statins typically presents as muscle soreness, tiredness, or weakness that is symmetrical and occur within ___ of starting treatment (but can develop at any time)

A

6 weeks

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25
Q

Compare myalgias, myopathy, myositis, vs rhabdomyolysis

A

Myalgias = muscle scoreness and tenderness
Myopathy = muscle weakness ± CPK elevations
Myositis = muscle inflammation
Rhabdomyolysis = muscle symptoms with very high CPK (>10,000) plus muscle protein in the urin (myoglobinuria), which can lead to acute renal failure

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26
Q

How to reduce risk of myalgias in pts taking statins

A

avoid drug interactions, including OTC products
Do not use simvastatin 80mg/day
Do not use gemfibrozil + statin

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27
Q

If myalgias occur, what should you do?

A

Hold statin, check CPK, investigate other possible causes
After 2-4 weeks: rechallenge with same statin at same or lower dose

If myalgias return, discontinue statin. Once muscle symptoms resolve, use a low dose of a diff statin; gradually increase dose

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28
Q

Which statins are recommended to take in the evening?

A

Fluvastatin IR
Lovastatin IR take with evening meal
Lovastatin ER take at bedtime
Simvastatin

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29
Q

Contraindications for statins

A

Breastfeeding, liver disease, CYP3A4 inhibitors (with simvastatin and lovastatin), concurrent use of cyclosporine (with pitavastatin)

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30
Q

Warnings with statins

A

Muscle damage: myopathy/rhabdomyolysis with increased CPK ± acute renal failure
Higher risk with higher doses (e.g. simvastatin 80mg), advanced age, concurrent use of niacin, fibrates (e.g. gemfibrozil), or CYP3A4 inhibitors, hypothyroidism, renal impairment
Do not use during pregnancy for most pts (can consider for high risk CV events)
Diabetes: increased A1C/fasting BG; benefit of statin outweighs risk

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31
Q

When should lipid panel be checked after starting/changing dose of statin?

A

4-12 weeks after starting or changing dose and then annually

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32
Q

Which statins can you take any time of day?

A

Atorvastatin (Lipitor)
Rosuvastatin (Crestor)
Pitavastatin (Livalo)
Fluvastatin XL (Lescol XL)
Pravastatin (Pravachol)

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33
Q

Lipid effects of statins

A

Decrease LDL ~20-55%
Increase HDL ~5-15%
Decrease TG ~10-30%

34
Q

In general, ____ and __ have less drug interactions compared to other statins

A

Rosuvastatin and pravastatin

35
Q

Drug interactions with statins

A

CYP3A4 inhibitors
grapefruit
protease inhibitors
azole antifungals
cyclosporine
cobicistat
macrolides (except azithro)
amiodarone = limit max dose simvastatin 20mg/day/max, lovastatin 40mg/day
non-DHP CCBs = Amlodipine - Limit max dose simvastatin 10mg/day, lovastatin 20mg/day

Fibrates (gemfirbozil) and niacin can increase risk of myopathies and rhabdo

36
Q

Add on therapies if statin is not enough

A

Ezetimibe and/or PCSK9 MAbs

If ezetimibe and/or PCKS9 MAbs are not enough: bempedoic acid (cholesterol synthesis inhibitor) and iclisiran (intracellular inhibitor of PCSK9 production)

37
Q

In select populations, ___ and ___ are used to target high TG

A

Fish oils and fibrates

38
Q

LDL threshold to add non-statin therapy for pt with clinical ASCVD and either very high risk or baseline LDL≥190

A

LDL ≥ 55

39
Q

LDL threshold to add non-statin therapy for pt with clinical ASCVD not at very high risk

A

LDL ≥ 70

40
Q

LDL threshold to add non-statin therapy for pt with no clinical ASCVD with DM and/or ASCVD Risk ≥ 20%

A

LDL ≥ 70

41
Q

Ezetimibe MOA

A

inhibits absorption of cholesterol in small intestine

42
Q

Side effects with ezetimibe (Zetia)

A

Myalgias
OtherS: Diarrhea, URTIs, arthralgias, pain in extremities, sinusitis

43
Q

Lipid effects with Ezetimibe (Zetia)

A

Decrease LDL 18-23%
Increase HDL 1-3%
Decrease TG 5-10%

44
Q

PCSK9 monoclonal antibodies (Alirocumab (Praluent), Evolucumab (Repatha)) MOA

A

block ability of PCSK9 to bind to LDL receptor, dramatically decrease LDL and reduce risk of CV revents

45
Q

How are PCSK9 monoclonal antibodies (Alirocumab (Praluent), Evolucumab (Repatha)) administered?

A

SC once every 2 weeks of monthly

46
Q

Lipid effects of PCSK9 monoclonal antibodies (Alirocumab (Praluent), Evolucumab (Repatha))

A

Decrease LDL~60%

47
Q

Bile acid sequestrants (Colesevelam (Welchol), cholestyramine, colestipol) MOA

A

Bind bile acids in the intestine, excreted in feces

48
Q

How should Colesevelam (Welchol) be taken?

A

with meal and liquid (comes as tabor granule packet)
sipping or holding suspension in mouth for prolonged periods may lead to tooth discoloration, erosion of enamel or decay - use good oral hygene

49
Q

Statins are typically not recommended in pregnant patients. What cholesterol lowering medication is an option for pregnant pt?

A

Colesevelam (Welchol)

50
Q

Colesevelam (Welchol) is also approved for ____

A

glycemic control in T2DM (decrease A1C by ~0.5%)

51
Q

Lipid effects of Colesevelam (Welchol)

A

Lower LDL and increase HDL
but may increase TG ~5%

52
Q

Colesevelam has fewer DDs compared to cholestyramine or colestipol. For cholestyramine or colestipol, take all other drugs at least ___ before or ___ after the bile acid sequestrants

A

1-4 hrs before
4-6 hrs after

53
Q

Bile acid sequestrants can decrease absorption of which vitamins/supplements? Multivitamin may be needed but separate from bile acid sequestrant.

A

Vitamin A, D, E, K
Folate
Iron

54
Q

The following meds should be taken 4 hrs prior to colesevelam ___

A

levothyroxine
Others: cyclosporine, glimepiride, glipizide, glyburide, olmesartan, phenytoin, and oral contraceptives containing ethinyl estradiol and norethindrone

55
Q

Fibrates (Fenofibrate, gemfibrozil) MOA

A

PPAR alpha activators which upregulate expression of apoC-II and apoA-I. ApoC-II increases lipoprotein lipase acitivity&raquo_space; catabolism of VLDL particles&raquo_space; decrease TG significantly but can lead to increased LDL in the setting of very hihg TG

56
Q

Which formulations of fenofibrate should be taken with emals?

A

Fenoglide, lipofen

57
Q

Contraindications of fibrates

A

Sever eliver disease, including primary biliary cirrhosis, gallbladder disease
Others: severe renal disease CrCl ≤30, breastfeeding, concurrent use with repaglinide or simvastatin (gemfibrozil only)

58
Q

Warnings for fibrates

A

Myopathy, increased risk when coadministered with statin - particularly in the elderly, DM, renal failure, hypothyroidism), cholelithiasis, reversible increase SCr (2mg/dL)

59
Q

Side effects of fibrates

A

Dyspepsia (gemfibrrozil)
Increased LFTs

60
Q

Which fibrates should not be given with ezetimibe or statins?

A

Gemfibrozil

61
Q

Fibrates can increase the effects of ___ and ___

A

sulfonylrueas and warfarin

62
Q

Niacin MOA

A

decrease the rate of hepatic synthesis of VLDL (decrease TG) and LDL
(Does not take up HDL particle&raquo_space; HDL increases)

63
Q

Niacin is also known as ___

A

nicotinic acid or vit B3

64
Q

Administration notes for niacin

A

Titrate slowly
IR: with food
ER: at bedtime after low-fat snack
CR/SR: with food

65
Q

Warnings for niacin

A

Rhabdomyolysis with niacin doses ≥1g/day combined with statins
Hepatotoxicity
Increased BG, uric acid, decreased phosphate

66
Q

Side effects for niacin

A

Flushing, pruritus (itching), vomiting, diarrhea, increased BG, hyperuricemia (gout)
Others: nausea, cough, orthostatic hypotension, hypophosphatemia, decreased platelets

67
Q

IR niacin has poor tolerability d/t ___

A

flushing/itching

68
Q

CR/SR niacin has less (but still significant) flushing but more ___

A

hepatotoxicity

69
Q

ER niacin is preferred d/t less ____ but it is most expensive

A

flushing and hepatotoxicity

70
Q

How to reduce flushing with niacin?

A

Take aspirin 325mg (or ibuprofen 200mg) 30-60min before the dose; take with food but avoid spicy food, alcohol and hot beverages (Which can worsen flushing)

71
Q

T/F: Formulations of niacin are interchangeable

A

False

72
Q

Lipid effects of Niacin

A

Increased HDL

73
Q

Take niacin ___ after bile acid sequestrants

A

4-6hrs

74
Q

Fish oils are indicated as an adjunct to diet when TG ≥ ___

A

500

75
Q

Which fish oil product is recommended for ASCVD risk reduction

A

Icosapent ethyl (Vascepa)

76
Q

When using fish oils, use caution in pts with known hypersensivity to ____

A

fish and/or shellfish

77
Q

What are fish oil products used to lower TG?

A

Omega-3 cid ethyl esters (Lovaza)
Icosapent ethyl (Vascepa)

78
Q

Side effects of fish oils

A

Eructation (burping), dyspepsia, taste perversion (Lovaza), arthralgias (Vascepa)

79
Q

Lipid effects of fish oils

A

Lowers TG up to 45%
Can increase LDL (up to 44% with Lovaza, no increase seen with Vascepa)

80
Q

Concern with fish oil use and surgery/warfarin use

A

Fish oils can prolong bleeding time
Monitor INR if pts are taking warfarin

81
Q

MOA of iclisiran (Leqvio)

A

Inhibits intracellular production of PCSK9
Can be considered as alt add-on treatment to maximally tolerated statin in pts with poor adherence or an inability to tolerate PCSK9 MAb

NAPLEX 2024 (74 decks)

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