38. Dyslipidemia (from Rx) Flashcards
Possible side effects of Lovaza include: (Select ALL that apply.)
A. Burping
B. Arthralgias
C. Dyspepsia
D. Taste perversions
E. Flatulence
A, C, D. Lovaza is well-tolerated, but side effects can include dyspepsia, burping, taste perversion, and nausea.
Fish Oils: may be due to reduction of hepatic synthesis of TG. Indicated as adjunct to diet in patients with TG ≥500. Warning: caution with known hypersensitivity to fish/shellfish. SE: eructation (burping), dyspepsia, taste perversions (Lovaza, Epanova), arthralgias (Vascepa), pregnacy (C), can increase LDL. Stop prior to elective surgery (increase bleed risk)
Lovaza: may increase LDL. possible recurrences of Afib
Vascepa: taken following meals
Epanova: may increase LDL
Omtryg: take with meals
What precentage on the 10-year ASCVD risk assessment score is used as the cut point to start statin therapy?
A. ≥ 2.5%
B. ≥ 5%
C. ≥ 7.5%
D. ≥ 10%
E. ≥ 15%
C. An estimated 10-year ASCVD risk score of ≥ 7.5% is an indication to start statin therapy.
4 Groups indicated for Statin Therapy:
- Clinical ASCVD: coronary heart disease (ACS, MI, angina, coronary revascularization), cerebral vascular disease (stroke, TIA), peripheral artery disease (PAD). ≤75 y/o = high intensity. >75 y/o = moderate intensity
- Primary elevations of LDL ≥190mg/dL. high intensity
- Diabetes and 40-75 year old with LDL 70-189mg/dL. 10-year ASCVD risk: ≥7.5% = high intensity, <7.5% = moderate intensity
- 40-75 year old with LDL 70-189mg/dL and estimated 10-year ASCVD risk of ≥7.5% (using Global Risk Assessment Tool). moderate-to-high intensity, if <7.5% can consider risk benefit
What condition is a contraindication to using mipomersen (Kynamro)?
A. Renal disease or moderate to severe renal impairment
B. Hepatic disease or moderate to severe hepatic impairment
C. Pregnancy
D. Concurrent use with strong CYP3A4 inhibitors
E. Arterial hemorrhage
B. Hepatic disease or moderate to severe hepatic impairment is contraindicated in mipomersen
mipomersen (Kynamro): inhibitor of Apo-B-100 synthesis. SQ weekly. Boexed warning: hepatotoxicity (REMS). CI: liver disease, mod-severe liver impairment. Warning: hepatotoxicity. SE: injection site reactions, flu-like symptoms, nausea, headache, increase ALT, antibody formation, fatigue, pregnancy (B)
A patient begins Niaspan and finds she suffers from red, itchy skin. She does not believe she can tolerate the medicine. Which of the following statements are correct that the pharmacist should provide to the patient? (Select ALL that apply.)
A. If your doctor permits it, take 325 mg of aspirin 30 minutes before the Niaspan; this should help reduce the problem.
B. Take Benadryl to reduce the problem since this is due to a histamine response.
C. Avoid alcohol, hot beverages and spicy food near the time of the medicine.
D. This problem should lessen as you take the medicine continuously.
E. Take the Niaspan at bedtime; most of the problem will occur while you sleep.
A, C, D, E. Flushing with niacin is prostaglandin-mediated therefore, an antihistamine such as Benadryl will not help.
Niacin: decreases rate of hepatic synthesis of VLDL and LDL to decrease LDL and TG, and increase HDL. Mainly used to decrease TG. Also known as nicotinic acid or vitamin B3. CI: active liver disease, active PUD, arterial bleeding, arterial hemorrhage. Warning: caution in unstable angina or acute phase of MI, hepatoxicity. SE: flushing (take ASA prior), pruritis, NVD, GI distress, hyperglycemia, hyperuricemia, cough, hepatotoxicity, orthostatic hypotension, hypophosphatemia. Take with food, but avoid hot liquids and spicy food which can worsen flushing.
niacin IR (Niacor): higher incidence of flushing (can take ASA prior)
niacin ER (Niaspan): best SE profile
niacin CR/SR (Slo-Niacin): high incidence of increase LFTs (monitor LFTs)
HL, a 42 year old male, has gained 40 pounds over the last 5 years since he injured his left knee and can no longer play basketball. He has a sedentary lifestyle including a job that requires him to be at a desk all day. HL has tried the Atkins diet, South Beach diet, and many other popular diets but has gained the weight back. HL does not smoke and admits to having 1-3 alcoholic beverages per month. Lifestyle modifications have been inadequate in controlling his weight gain.
Allergies: NKDA
Current Medications:
Vasotec 10 mg daily
Norvasc 10 mg daily
Crestor 20 mg daily
Glucophage 850 mg BID
Claritin 10 mg daily
Tylenol 500 mg Q4-6H PRN
MVI daily
Past Medical History:
Allergic rhinitis
Dyslipidemia
Diabetes mellitus
Hypertension
Vitals:
Height: 5’11” Weight: 225 lbs
BP: 140/80 mmHg HR: 85 BPM RR: 20 BPM
Temp: 98.6ºF Pain: 1/10
4/14/14 Labs:
AST (units/L) = 37 (10 - 40)
ALT (units/L) = 32 (10 - 40)
CH, T (mg/dL) = 247 (125 - 200)
TG (mg/dL) = 242 (< 150)
HDL (mg/dL) = 34 (> 40)
LDL (mg/dL) = 183 ( < 100)
GLU (mg/dL) = 108 (65 - 99)
Na (mEq/L) = 143 (135 - 145)
K (mEq/L) = 4.1 (3.5 - 5)
Cl (mEq/L) = 102 (95 - 103)
HCO3 (mEq/L) = 26 (24 - 30)
BUN (mg/dL) = 15 (7 - 20)
SCr (mg/dL) = 0.8 (0.6 - 1.3)
Mg (mEq/L) = 1.8 (1.3 - 2.1)
PO4 (mg/dL) = 4.1 (2.3 - 4.7)
Ca (mg/dL) = 9.7 (8.5 - 10.5)
TSH (mIU/L) = 2.2 (0.3 - 3.0)
Hgb A1C = 7.9% (4 - 6%)
10/9/14 Labs:
AST (units/L) = 168 (10 - 40)
ALT (units/L) = 145 (10 - 40)
CH, T (mg/dL) = 224 (125 - 200)
TG (mg/dL) = 218 (< 150)
HDL (mg/dL) = 35 (> 40)
LDL (mg/dL) = 145 ( < 100)
GLU (mg/dL) = 108 (65 - 99)
Na (mEq/L) = 142 (135 - 145)
K (mEq/L) = 4.2 (3.5 - 5)
Cl (mEq/L) = 97 (95 - 103)
HCO3 (mEq/L) = 29 (24 - 30)
BUN (mg/dL) = 18 (7 - 20)
SCr (mg/dL) = 0.9 (0.6 - 1.3)
Mg (mEq/L) = 1.9 (1.3 - 2.1)
PO4 (mg/dL) = 4.3 (2.3 - 4.7)
Ca (mg/dL) = 9.5 (8.5 - 10.5)
TSH (mIU/L) = 1.8 (0.3 - 3.0)
Hgb A1C = 7.8% (4 - 6%)
What intervention would be most appropriate on the 10/9/14 visit?
A. Increase statin dose
B. Decrease statin dose
C. Discontinue statin therapy
D. Add a bile acid sequestrant
E. Add niacin
C. AST or ALT levels are elevated and statin therapy should be discontinued when LFTs are greater than 3 times the upper limit of normal.
4 Groups indicated for Statin Therapy:
- Clinical ASCVD: coronary heart disease (ACS, MI, angina, coronary revascularization), cerebral vascular disease (stroke, TIA), peripheral artery disease (PAD). ≤75 y/o = high intensity. >75 y/o = moderate intensity
- Primary elevations of LDL ≥190mg/dL. high intensity
- Diabetes and 40-75 year old with LDL 70-189mg/dL. 10-year ASCVD risk: ≥7.5% = high intensity, <7.5% = moderate intensity
- 40-75 year old with LDL 70-189mg/dL and estimated 10-year ASCVD risk of ≥7.5% (using Global Risk Assessment Tool). moderate-to-high intensity, if <7.5% can consider risk benefit
Select the correct mechanisms of action of the statins. (Select ALL that apply.)
A. Statins inhibit the enzyme HMG-CoA reductase.
B. Statins block the rate-limiting step in cholesterol synthesis.
C. Statins reduce cholesterol absorption at the brush-border.
D. Statins are peroxisome proliferator alpha activators.
E. Statins bind to and inhibit microsomal triglyceride transfer protein (MTP) in the endoplasmic reticulum.
A, B. The statins block cholesterol synthesis by inhibiting the enzyme HMG-CoA reductase, which catalyzes the rate-limiting step in cholesterol synthesis.
Statins: inhibits HMG-CoA reductase preventing the conversion of HMG-CoA to mevalonate (the rate-limiting step in cholesterol synthesis) resulting in LDL reduction (20-55%), TG reduction (10-30%), increasing HDL (5-15%). CI: active liver disease, pregnancy (X), breastfeeding, concurrent 3A4 inhibitors (with simvastatin & lovastatin) cyclosporine use (pitavastatin only). Warning: skeletal muscle effects (myopathy, rhabdomyolysis), diabetes, liver enzyme elevations. SE: myalgias, arthralgias, myopathy, diarrhea, increase CPK, rhabdomyolysis, cognitive impairment (memory loss, confusion), increase blood glucose, increase A1C, increase LFTs, risk of cataracts. Reduce dose when CrCl <30 (except with Lipitor). Dosed the evening: simvastatin, lovastatin, fluvastatin (“Sam Loathes the Flu”)
atorvastatin (Lipitor): equiv dose = 10. Does not need dose reduction when CrCl <30.
simvastatin (Zocor), Vytorin (simvastatin/ezetimibe): equiv dose = 20. 3A4 substrate (avoid inhibitors)
rosuvastatin (Crestor): equiv dose = 5
pravastatin (Pravachol): equiv dose = 40
lovastatin (Mevacor, Altoprev): equiv dose = 40. with food. 3A4 substrate (avoid inhibitors)
fluvastatin (Lescol): equiv dose = 80. with food, may increase INR in patients taking warfarin
pitavastatin (Livalo): equiv dose = 2. Reduce dose when CrCl <60. minimal CYP metabolism. CI with cyclosporine. monitor PT/INR after dose initiation of dose change of warfarin
HL, a 42 year old male, has gained 40 pounds over the last 5 years since he injured his left knee and can no longer play basketball. He has a sedentary lifestyle including a job that requires him to be at a desk all day. HL has tried the Atkins diet, South Beach diet, and many other popular diets but has gained the weight back. HL does not smoke and admits to having 1-3 alcoholic beverages per month. Lifestyle modifications have been inadequate in controlling his weight gain.
Allergies: NKDA
Current Medications:
Vasotec 10 mg daily
Norvasc 10 mg daily
Glucophage 850 mg BID
Claritin 10 mg daily
Tylenol 500 mg Q4-6H PRN
MVI daily
Past Medical History:
Allergic rhinitis
Dyslipidemia
Diabetes mellitus
Hypertension
Vitals:
Height: 5’11” Weight: 225 lbs
BP: 140/80 mmHg HR: 85 BPM RR: 20 BPM
Temp: 98.6ºF Pain: 1/10
4/14/14 Labs:
AST (units/L) = 37 (10 - 40)
ALT (units/L) = 32 (10 - 40)
CH, T (mg/dL) = 247 (125 - 200)
TG (mg/dL) = 242 (< 150)
HDL (mg/dL) = 34 (> 40)
LDL (mg/dL) = 183 ( < 100)
GLU (mg/dL) = 108 (65 - 99)
Na (mEq/L) = 143 (135 - 145)
K (mEq/L) = 4.1 (3.5 - 5)
Cl (mEq/L) = 102 (95 - 103)
HCO3 (mEq/L) = 26 (24 - 30)
BUN (mg/dL) = 15 (7 - 20)
SCr (mg/dL) = 0.8 (0.6 - 1.3)
Mg (mEq/L) = 1.8 (1.3 - 2.1)
PO4 (mg/dL) = 4.1 (2.3 - 4.7)
Ca (mg/dL) = 9.7 (8.5 - 10.5)
TSH (mIU/L) = 2.2 (0.3 - 3.0)
Hgb A1C = 7.9% (4 - 6%)
10/9/14 Labs:
AST (units/L) = 168 (10 - 40)
ALT (units/L) = 145 (10 - 40)
CH, T (mg/dL) = 224 (125 - 200)
TG (mg/dL) = 218 (< 150)
HDL (mg/dL) = 35 (> 40)
LDL (mg/dL) = 145 ( < 100)
GLU (mg/dL) = 108 (65 - 99)
Na (mEq/L) = 142 (135 - 145)
K (mEq/L) = 4.2 (3.5 - 5)
Cl (mEq/L) = 97 (95 - 103)
HCO3 (mEq/L) = 29 (24 - 30)
BUN (mg/dL) = 18 (7 - 20)
SCr (mg/dL) = 0.9 (0.6 - 1.3)
Mg (mEq/L) = 1.9 (1.3 - 2.1)
PO4 (mg/dL) = 4.3 (2.3 - 4.7)
Ca (mg/dL) = 9.5 (8.5 - 10.5)
TSH (mIU/L) = 1.8 (0.3 - 3.0)
Hgb A1C = 7.7% (4 - 6%)
HL’s estimated 10-year ASCVD risk is calculated at 6.9%. According to the ACC/AHA Treatment of Blood Cholesterol Guideline, what would be the most appropriate statin regimen to initiate on the 4/14/14 visit?
A. Simvastatin 10 mg daily
B. Simvastatin 40 mg daily
C. Atorvastatin 40 mg daily
D. Pravastatin 20 mg daily
E. Pravastatin 40 mg daily
E. HL has diabetes, is between 40-75 years, has an LDL between 70-189 mg/dL, and an estimated 10-year ASCVD risk < 7.5%. Therefore he will require a moderate intensity statin. Although simvastatin 40 mg is considered moderate intensity, HL is also on amlodipine and should not exceed simvastatin 20 mg due to CYP3A4 interaction. Therefore, pravastatin 40 mg is the most appropriate statin. All other choices are not moderate intensity.
4 Groups indicated for Statin Therapy:
- Clinical ASCVD: coronary heart disease (ACS, MI, angina, coronary revascularization), cerebral vascular disease (stroke, TIA), peripheral artery disease (PAD). ≤75 y/o = high intensity. >75 y/o = moderate intensity
- Primary elevations of LDL ≥190mg/dL. high intensity
- Diabetes and 40-75 year old with LDL 70-189mg/dL. 10-year ASCVD risk: ≥7.5% = high intensity, <7.5% = moderate intensity
- 40-75 year old with LDL 70-189mg/dL and estimated 10-year ASCVD risk of ≥7.5% (using Global Risk Assessment Tool). moderate-to-high intensity, if <7.5% can consider risk benefit
Statin Therapy Intensity
High (lowers LDL ≥50%): atorvastatin 40-80, rosuvastatin 20-40
Moderate (lowers LDL 30-49%): atorvastatin 10-20, rosuvastatin 5-10, simvastatin 20-40, pravastatin 40-80, lovastatin 40, fluvastatin 80, pitavastatin 2-4
Low (lower LDL <30%): simvastatin 10, pravastatin 10-20, lovastatin 20, fluvastatin 20-40, pitavastatin 1
DL is a 61 y/o male being seen for routine follow up including his risk for ASCVD.
Current Medications:
Inderal LA 80 mg daily
Hydrochlorothiazide 25 mg daily
Prinivil 10 mg daily
Mylanta 20 mL Q6H
Plavix 75 mg daily
Aspirin 81 mg
Nitroglycerin 0.3 mg PRN
MVI daily
Past Medical History:
Hypertension
Dyslipidemia
GERD
s/p MI
Vitals:
Height: 5’11” Weight: 202 lbs
BP: 140/80 mmHg HR: 85 BPM RR: 20 BPM
Temp: 98.6ºF Pain: 1/10
Labs:
AST (units/L) = 32 (10 - 40)
ALT (units/L) = 20 (10 - 40)
CH, T (mg/dL) = 221 (125 - 200)
TG (mg/dL) = 238 (< 150)
HDL (mg/dL) = 32 (> 40)
LDL (mg/dL) =
GLU (mg/dL) = 108 (65 - 99)
Na (mEq/L) = 143 (135 - 145)
K (mEq/L) = 4.1 (3.5 - 5)
Cl (mEq/L) = 102 (95 - 103)
HCO3 (mEq/L) = 26 (24 - 30)
BUN (mg/dL) = 15 (7 - 20)
SCr (mg/dL) = 0.8 (0.6 - 1.3)
Mg (mEq/L) = 1.8 (1.3 - 2.1)
PO4 (mg/dL) = 4.1 (2.3 - 4.7)
Ca (mg/dL) = 9.7 (8.5 - 10.5)
TSH (mIU/L) = 1.8 (0.3 - 3.0)
Free T4 (mg/dL) = 0.7 (0.9 - 2.3)
According to the ACC/AHA Treatment of Blood Cholesterol Guideline, what would be the most appropriate statin regimen for DL?
A. Pravastatin 40 mg daily
B. Rosuvastatin 20 mg daily
C. Lovastatin 40 mg daily
D. Atorvastatin 20 mg daily
E. Pitavastatin 4 mg daily
B. DL has ASCVD evidenced by his history of myocardial infarction and is ≤ 75 years of age. According to the ACC/AHA treatment guidelines, DL should receive high intensity therapy.
4 Groups indicated for Statin Therapy:
- Clinical ASCVD: coronary heart disease (ACS, MI, angina, coronary revascularization), cerebral vascular disease (stroke, TIA), peripheral artery disease (PAD). ≤75 y/o = high intensity. >75 y/o = moderate intensity
- Primary elevations of LDL ≥190mg/dL. high intensity
- Diabetes and 40-75 year old with LDL 70-189mg/dL. 10-year ASCVD risk: ≥7.5% = high intensity, <7.5% = moderate intensity
- 40-75 year old with LDL 70-189mg/dL and estimated 10-year ASCVD risk of ≥7.5% (using Global Risk Assessment Tool). moderate-to-high intensity, if <7.5% can consider risk benefit
Statin Therapy Intensity
High (lowers LDL ≥50%): atorvastatin 40-80, rosuvastatin 20-40
Moderate (lowers LDL 30-49%): atorvastatin 10-20, rosuvastatin 5-10, simvastatin 20-40, pravastatin 40-80, lovastatin 40, fluvastatin 80, pitavastatin 2-4
Low (lower LDL <30%): simvastatin 10, pravastatin 10-20, lovastatin 20, fluvastatin 20-40, pitavastatin 1
A pharmacist instructs a patient to contact the doctor right away if he is passing brown or dark-colored urine, feeling more tired than usual or if his skin and/or whites of the eyes become yellow. Which of the following drugs is the most likely to need this counseling?
A. Questran
B. Zetia
C. Advicor
D. Lovaza
E. Metamucil
C. Advicor contains a statin (lovastatin) and niacin extended-release. There is a heightened risk of muscle toxicity. Instruct patients to report at once any unexplained muscle pain, tenderness, or weakness. Zetia rarely causes liver dysfunction on its own; the risk is increased when it is used in combination with a statin.
Questran (cholestyramine)
Zetia (ezetimibe)
Which of the following products are statin-niacin combinations? (Select ALL that apply.)
A. Advicor
B. Simcor
C. Juvisync
D. Liptruzet
E. Vytorin
A, B. Lovastatin/niacin is Advicor and simvastatin/niacin is Simcor. With these combinations, there is a higher risk of muscle toxicity; patients must be self-monitoring for symptoms.
A patient’s triglycerides were recorded at 510 mg/dL. Which of the following agents will help to lower triglycerides? (SelectALL that apply.)
A. Lovaza
B. Trilipix
C. Niacin
D. Vascepa
E. WelChol
A, B, C, D. The bile-acid binding resins can raise triglycerides modestly (about 5%) and cannot be used if the triglycerides are elevated.
Niacin: decreases rate of hepatic synthesis of VLDL and LDL to decrease LDL (5-25%) and TG (20-50%), and increase HDL (15-35%). Mainly used to decrease TG. Also known as nicotinic acid or vitamin B3. CI: active liver disease, active PUD, arterial bleeding, arterial hemorrhage. Warning: caution in unstable angina or acute phase of MI, hepatoxicity. SE: flushing (take ASA prior), pruritis, NVD, GI distress, hyperglycemia, hyperuricemia, cough, hepatotoxicity, orthostatic hypotension, hypophosphatemia. Take with food, but avoid hot liquids and spicy food which can worsen flushing.
niacin IR (Niacor): higher incidence of flushing (can take ASA prior)
niacin ER (Niaspan): best SE profile
niacin CR/SR (Slo-Niacin): high incidence of increase LFTs (monitor LFTs)
Fibrates: peroxisome proliferator receptor alpha (PPARa) activators, which upregulates the expression of apolipoprotein CII and apolipoprotein A-I to reduce TG (20-50%) and LDL (5-20%), and increase HDL (15%). Mainly used to decrease TG. CI: severe liver disease, severe renal disease (CrCl <30), gallbladder disease, nursing mothers. Warning: myopathy, increase risk with statin (elderly, diabetes, renal failure, hypothyroidism). SE: increase LFts, abdominal pain, increase CPK, dyspepsia, URTIs
fenofibrate, fenofibric acid (TriCor, Trilipix):
gemfibrozil (Lopid): taken 30 minutes before breakfast and dinner. CI with repaglinide
Fish Oils: may be due to reduction of hepatic synthesis of TG. Reduce TG (45%) and increase HDL (9%). Indicated as adjunct to diet in patients with TG ≥500. Warning: caution with known hypersensitivity to fish/shellfish. SE: eructation (burping), dyspepsia, taste perversions (Lovaza, Epanova), arthralgias (Vascepa), pregnacy (C), can increase LDL. Stop prior to elective surgery (increase bleed risk)
Lovaza: may increase LDL. possible recurrences of Afib
Vascepa: taken following meals
Epanova: may increase LDL
Omtryg: take with meals
DL is a 61 y/o male being seen for routine follow up including his risk for ASCVD.
Current Medications:
Inderal LA 80 mg daily
Hydrochlorothiazide 25 mg daily
Prinivil 10 mg daily
Mylanta 20 mL Q6H
Plavix 75 mg daily
Aspirin 81 mg
Nitroglycerin 0.3 mg PRN
MVI daily
Past Medical History:
Hypertension
Dyslipidemia
GERD
s/p MI
Vitals:
Height: 5’11” Weight: 202 lbs
BP: 140/80 mmHg HR: 85 BPM RR: 20 BPM
Temp: 98.6ºF Pain: 1/10
Labs:
AST (units/L) = 32 (10 - 40)
ALT (units/L) = 20 (10 - 40)
CH, T (mg/dL) = 221 (125 - 200)
TG (mg/dL) = 238 (< 150)
HDL (mg/dL) = 32 (> 40)
LDL (mg/dL) =
GLU (mg/dL) = 108 (65 - 99)
Na (mEq/L) = 143 (135 - 145)
K (mEq/L) = 4.1 (3.5 - 5)
Cl (mEq/L) = 102 (95 - 103)
HCO3 (mEq/L) = 26 (24 - 30)
BUN (mg/dL) = 15 (7 - 20)
SCr (mg/dL) = 0.8 (0.6 - 1.3)
Mg (mEq/L) = 1.8 (1.3 - 2.1)
PO4 (mg/dL) = 4.1 (2.3 - 4.7)
Ca (mg/dL) = 9.7 (8.5 - 10.5)
TSH (mIU/L) = 1.8 (0.3 - 3.0)
Free T4 (mg/dL) = 0.7 (0.9 - 2.3)
DL was prescribed Crestor 40 mg, but his insurance will not cover a brand name statin, and no generic of Crestor is available. Which generic statin would be an appropriate alternative?
A. Atorvastatin 20 mg
B. Pravastatin 40 mg
C. Atorvastatin 40 mg
D. Atorvastatin 80 mg
E. Pravastatin 80 mg
D. Rosuvastatin 5 mg is equivalent to atorvastatin 10 mg. Therefore, an appropriate equivalent dose would be atorvastatin 80 mg. The other statins are not equivalent to rosuvastatin 40 mg.
atorvastatin (Lipitor): equiv dose = 10. Does not need dose reduction when CrCl <30.
simvastatin (Zocor), Vytorin (simvastatin/ezetimibe): equiv dose = 20. 3A4 substrate (avoid inhibitors)
rosuvastatin (Crestor): equiv dose = 5
pravastatin (Pravachol): equiv dose = 40
lovastatin (Mevacor, Altoprev): equiv dose = 40. with food. 3A4 substrate (avoid inhibitors)
fluvastatin (Lescol): equiv dose = 80. with food, may increase INR in patients taking warfarin
pitavastatin (Livalo): equiv dose = 2. Reduce dose when CrCl <60. minimal CYP metabolism. CI with cyclosporine. monitor PT/INR after dose initiation of dose change of warfarin
Maurice is a 58 year-old male with dyslipidemia and prostate enlargement. He was started on and is currently taking pravastatin 40 mg daily and tamsulosin 0.4 mg daily. Today he reports with muscle aches. The physician discontinued the pravastatin and evaluated Maurice for other conditions that can increase muscle damage and found none. According to the ACC/AHA Blood Cholesterol Guidelines, what would be an appropriate next step for treating Maurice’s dyslipidemia?
A. If muscle aches resolve, restart pravastatin at 20 mg daily.
B. If muscle aches do not resolve, restart pravastatin at 20 mg daily.
C. If muscle aches resolve, start rosuvastatin at 20 mg daily.
D. If muscle aches do not resolve, start rosuvastatin at 20 mg daily.
E. If muscle aches resolve, do not use statin therapy again.
A. If muscle symptoms resolve, it is recommended to restart the same statin at the same or lower dose.
Which formulation of niacin has the highest risk for liver damage?
A. Niaspan
B. Slo-Niacin
C. Niacor
D. Inositol hexanicotinate
E. Inositol hexaniacinate
B. Slo-Niacin has the highest risk of hepatotoxicity.
Niacin: decreases rate of hepatic synthesis of VLDL and LDL to decrease LDL (5-25%) and TG (20-50%), and increase HDL (15-35%). Mainly used to decrease TG. Also known as nicotinic acid or vitamin B3. CI: active liver disease, active PUD, arterial bleeding, arterial hemorrhage. Warning: caution in unstable angina or acute phase of MI, hepatoxicity. SE: flushing (take ASA prior), pruritis, NVD, GI distress, hyperglycemia, hyperuricemia, cough, hepatotoxicity, orthostatic hypotension, hypophosphatemia. Take with food, but avoid hot liquids and spicy food which can worsen flushing.
niacin IR (Niacor): higher incidence of flushing (can take ASA prior)
niacin ER (Niaspan): best SE profile
niacin CR/SR (Slo-Niacin): high incidence of increase LFTs (monitor LFTs)
A patient gave the pharmacist a prescription for Crestor 10 mg PO daily. Which of the following is an appropriate generic substitution for Crestor?
A. Atorvastatin
B. Lovastatin
C. Pravastatin
D. Simvastatin
E. Rosuvastatin
E. The generic name of Crestor is rosuvastatin.
atorvastatin (Lipitor)
lovastatin (Mevacor, Altoprev)
pravastatin (Pravachol)
simvastatin (Zocor)
A patient gave the pharmacist a prescription for Lipitor 40 mg PO daily. Which of the following is an appropriate generic substitution for Lipitor?
A. Atorvastatin
B. Lovastatin
C. Pravastatin
D. Simvastatin
E. Rosuvastatin
A. The generic name of Lipitor is atorvastatin.
lovastatin (Mevacor, Altoprev)
pravastatin (Pravachol)
simvastatin (Zocor)
rosuvastatin (Crestor)
Which of the following patient types would benefit from moderate-intensity statin therapy according to the ACC/AHA Blood Cholesterol Guidelines? (Select ALL that apply.)
A. Those unable to tolerate high-intensity statin therapy
B. A 35 year old with a LDL of 140 mg/dL and no other comorbidities
C. A 80 year old patient who is S/P MI
D. A 45 year old patient with diabetes and a LDL of 140 mg/dL and no other comorbidities; 10-year ASCVD risk score is 6.5%
E. A 32 year old with a LDL of 195 mg/dL and no other comorbidities
A, C, D. These represent the patient types that benefit from moderate-intensity statin treatment according to the ACC/AHA Blood Cholesterol Guidelines.
4 Groups indicated for Statin Therapy:
- Clinical ASCVD: coronary heart disease (ACS, MI, angina, coronary revascularization), cerebral vascular disease (stroke, TIA), peripheral artery disease (PAD). ≤75 y/o = high intensity. >75 y/o = moderate intensity
- Primary elevations of LDL ≥190mg/dL. high intensity
- Diabetes and 40-75 year old with LDL 70-189mg/dL. 10-year ASCVD risk: ≥7.5% = high intensity, <7.5% = moderate intensity
- 40-75 year old with LDL 70-189mg/dL and estimated 10-year ASCVD risk of ≥7.5% (using Global Risk Assessment Tool). moderate-to-high intensity, if <7.5% can consider risk benefit
Maria has been given a prescription for simvastatin 20 mg PO QHS. Which of the following statements are correct? (SelectALL that apply.)
A. Mary can take this medication in the morning if it works better for her schedule.
B. Simvastatin can cause pancreatitis; triglycerides should be monitored.
C. The brand name of simvastatin is Zocor.
D. The dose of simvastatin can be titrated to a max dose of 40 mg/day.
E. She needs to take her simvastatin with food.
C, D. Simvastatin is taken at bedtime, with or without food. Simvastatin has a short half life and must be in the body during sleep when most cholesterol synthesis occurs. The max dose for new starts is 40 mg/day.
Statins: inhibits HMG-CoA reductase preventing the conversion of HMG-CoA to mevalonate (the rate-limiting step in cholesterol synthesis) resulting in LDL reduction (20-55%), TG reduction (10-30%), increasing HDL (5-15%). CI: active liver disease, pregnancy (X), breastfeeding, concurrent 3A4 inhibitors (with simvastatin & lovastatin) cyclosporine use (pitavastatin only). Warning: skeletal muscle effects (myopathy, rhabdomyolysis), diabetes, liver enzyme elevations. SE: myalgias, arthralgias, myopathy, diarrhea, increase CPK, rhabdomyolysis, cognitive impairment (memory loss, confusion), increase blood glucose, increase A1C, increase LFTs, risk of cataracts. Reduce dose when CrCl <30 (except with Lipitor). Dosed in the evening: simvastatin, lovastatin, fluvastatin (“Sam Loathes the Flu”)
atorvastatin (Lipitor): equiv dose = 10. Does not need dose reduction when CrCl <30.
simvastatin (Zocor), Vytorin (simvastatin/ezetimibe): equiv dose = 20. 3A4 substrate (avoid inhibitors)
rosuvastatin (Crestor): equiv dose = 5
pravastatin (Pravachol): equiv dose = 40
lovastatin (Mevacor, Altoprev): equiv dose = 40. with food. 3A4 substrate (avoid inhibitors)
fluvastatin (Lescol): equiv dose = 80. with food, may increase INR in patients taking warfarin
pitavastatin (Livalo): equiv dose = 2. Reduce dose when CrCl <60. minimal CYP metabolism. CI with cyclosporine. monitor PT/INR after dose initiation of dose change of warfarin
How should Welchol tablets be administered?
A. On an empty stomach
B. With a meal and liquid
C. At bedtime
D. With liquids only
E. Without regards to meals
B. Welchol tablets should be administered with a meal and liquid.
Bile Acid Sequestrants/Bile Acid Binding Resins: binds bile acids in the intestine forming a complex that is excreted in the feces to reduce LDL (10-30%), but increase HDL (3-5%)/TG (5%). SE: constipation, dyspepsia, nausea, abdominal pain, cramping, gas, bloating, hypertriglyceridemia, esophageal obstruction, increase LFTs. Do not use when TG ≥300. Separate by 4 hours between other medications
cholestyramine (Questran): with meals. CI in complete biliary obstruction. pregnancy (C)
colesevelam (Welchol): take with meal or liquid. CI : bowel obstruction, TG>500, history of hypertriglyceridemia-induced pancreatitis. pregnancy (B)
colestipol (Colestid): pregnancy (C)
A patient gave the pharmacist a prescription for Mevacor 40 mg PO nightly with dinner. Which of the following is an appropriate generic substitution for Mevacor?
A. Atorvastatin
B. Lovastatin
C. Pravastatin
D. Simvastatin
E. Rosuvastatin
B. The generic name of Mevacor is lovastatin.
atorvastatin (Lipitor)
pravastatin (Pravachol)
simvastatin (Zocor)
rosuvastatin (Crestor)
Adjunct to diet, Myalept is indicated to treat:
A. Hypertriglyceridemia without congenital or acquired generalized lipodystrophy
B. Leptin deficiency with congenital or acquired generalized lipodystrophy
C. Leptin deficiency without congenital or acquired generalized lipodystrophy
D. HIV-related dystrophy
E. Metabolic disease
B. Myalept is indicated in leptin deficiency with congenital or acquired generalized lipodystrophy
Which fibrate has an indication for use with a statin?
A. Trilipix
B. Tricor
C. Lofibra
D. Lipofen
E. Fibricor
A. Only Trilipix has the indication to be used with a statin.
Jerry is a 70 year-old patient who was started on immediate-release niacin therapy. He is taking his medicine with food, and using an aspirin prior to the evening dose, but still gets hot, flushed and itchy. He asks if there is any form of niacin which would cause less flushing and itching. Which of the following niacin formulations have less flushing and itching? (Select ALLthat apply.)
A. Red yeast rice
B. Slo-Niacin
C. Niacor
D. Nicotine
E. Niaspan
B, E. Sustained-release and extended-release niacin have less (but still significant) flushing and itching.
Niacin: decreases rate of hepatic synthesis of VLDL and LDL to decrease LDL (5-25%) and TG (20-50%), and increase HDL (15-35%). Mainly used to decrease TG. Also known as nicotinic acid or vitamin B3. CI: active liver disease, active PUD, arterial bleeding, arterial hemorrhage. Warning: caution in unstable angina or acute phase of MI, hepatoxicity. SE: flushing (take ASA prior), pruritis, NVD, GI distress, hyperglycemia, hyperuricemia, cough, hepatotoxicity, orthostatic hypotension, hypophosphatemia. Take with food, but avoid hot liquids and spicy food which can worsen flushing.
niacin IR (Niacor): higher incidence of flushing (can take ASA prior)
niacin ER (Niaspan): best SE profile
niacin CR/SR (Slo-Niacin): high incidence of increase LFTs (monitor LFTs)
Which of the following patient types would benefit from high-intensity statin therapy according to the ACC/AHA Blood Cholesterol Guidelines? (Select ALL that apply.)
A. A 60 year old patient who is S/P MI
B. A 35 year old with a LDL of 140 mg/dL and no other comorbidies
C. A 80 year old patient who is S/P MI
D. A 45 year old patient with diabetes and a LDL of 140 mg/dL and no other comorbidities; 10-year ASCVD risk score is 6.5%
E. A 32 year old with a LDL of 195 mg/dL and no other comorbidites
A, E. Choices 1 and 5 represent the patient types that benefit from high-intensity statin treatment.
4 Groups indicated for Statin Therapy:
- Clinical ASCVD: coronary heart disease (ACS, MI, angina, coronary revascularization), cerebral vascular disease (stroke, TIA), peripheral artery disease (PAD). ≤75 y/o = high intensity. >75 y/o = moderate intensity
- Primary elevations of LDL ≥190mg/dL. high intensity
- Diabetes and 40-75 year old with LDL 70-189mg/dL. 10-year ASCVD risk: ≥7.5% = high intensity, <7.5% = moderate intensity
- 40-75 year old with LDL 70-189mg/dL and estimated 10-year ASCVD risk of ≥7.5% (using Global Risk Assessment Tool). moderate-to-high intensity, if <7.5% can consider risk benefit
Which of the following cholesterol-lowering agents can increase bleeding risk and should be used cautiously in at-risk patients?
A. Questran
B. Vascepa
C. Lipitor
D. Tricor
E. Trilipix
B. There is a theoretical risk of heightened bleeding risk which was not seen in clinical studies. To be on the safe side, watch for patients with increased bleeding risk and counsel on symptoms of bleeding. With warfarin use, the INR and bleeding signs and symptoms should be monitored. Use fish oils cautiously with the use of aspirin or other antiplatelets. The risk may be higher with higher doses.
Fish Oils: may be due to reduction of hepatic synthesis of TG. Reduce TG (45%) and increase HDL (9%). Indicated as adjunct to diet in patients with TG ≥500. Warning: caution with known hypersensitivity to fish/shellfish. SE: eructation (burping), dyspepsia, taste perversions (Lovaza, Epanova), arthralgias (Vascepa), pregnacy (C), can increase LDL. Stop prior to elective surgery (increase bleed risk)
Lovaza: may increase LDL. possible recurrences of Afib
Vascepa: taken following meals
Epanova: may increase LDL
Omtryg: take with meals
SJ is a 40 year old female being for evaluated for her dyslipidemia. She has an estimated ASCVD risk of 6.4%.
Current Medications:
Hydrochlorothiazide 25 mg daily
Ambien 5 mg QHS PRN
Levothyroxine 112 mcg daily
Prenatal MVI daily
Past Medical History:
Dyslipidemia
Hypertension
Insomnia
Hypothyroidism
Vitals:
Height: 5’6” Weight: 160 lbs
BP: 140/80 mmHg HR: 85 BPM RR: 20 BP
Temp: 98.6ºF Pain: 1/10
AST (units/L) = 24 (10 - 40)
ALT (units/L) = 21 (10 - 40)
CH, T (mg/dL) = 242 (125-200)
TG (mg/dL) = 189 (< 150)
HDL (mg/dL) = 38 ( > 40)
LDL (mg/dL) = 166 (< 100)
GLU (mg/dL) = 108 (65 - 99)
Na (mEq/L) = 141 (135 - 145)
K (mEq/L) = 4.2 (3.5 - 5)
Cl (mEq/L) = 100 (95 - 103)
HCO3 (mEq/L) = 28 (24 - 30)
BUN (mg/dL) = 18 (7 - 20)
SCr (mg/dL) = 0.9 (0.6 - 1.3)
Mg (mEq/L) = 1.9 (1.3 - 2.1)
PO4 (mg/dL) = 4.4 (2.3 - 4.7)
Ca (mg/dL) = 9.5 (8.5 - 10.5)
TSH (mIU/L) = 2.2 (0.3 - 3.0)
hCG+
What statin therapy is most appropriate for her?
A. Simvastatin 10 mg daily
B. Lovastatin 20 mg daily
C. Atorvastatin 20 mg daily
D. Rosuvastatin 20 mg daily
E. Statin therapy is not appropriate
E. Patient is hCG+, statins are pregnancy category X and should not be given to pregnant patients.
4 Groups indicated for Statin Therapy:
- Clinical ASCVD: coronary heart disease (ACS, MI, angina, coronary revascularization), cerebral vascular disease (stroke, TIA), peripheral artery disease (PAD). ≤75 y/o = high intensity. >75 y/o = moderate intensity
- Primary elevations of LDL ≥190mg/dL. high intensity
- Diabetes and 40-75 year old with LDL 70-189mg/dL. 10-year ASCVD risk: ≥7.5% = high intensity, <7.5% = moderate intensity
- 40-75 year old with LDL 70-189mg/dL and estimated 10-year ASCVD risk of ≥7.5% (using Global Risk Assessment Tool). moderate-to-high intensity, if <7.5% can consider risk benefit
What are the individual medicines included in the combination drug Vytorin?
A. Atorvastatin + Niacin
B. Atorvastatin + Ezetimibe
C. Lovastatin + Niacin
D. Simvastatin + Ezetimibe
E. Simvastatin + Niacin
D. Vytorin contains simvastatin and ezetimibe.
A prescriber ordered TriCor 145 mg daily for his patient. The pharmacy did not have this exact strength, but did have Lofibra134 mg. Can the pharmacist substitute Lofibra for the Tricor?
A. No, they are not interchangeable.
B. Yes, if the pharmacist does not have anything better.
C. Yes, because the doses are similar.
D. Yes, because Lofibra 134 mg is bioequivalent to TriCor 145 mg.
E. Yes, because he checked the Red Book.
A. The fenofibrates come in different strengths and often with different delivery mechanisms. If you want to dispense a generic, you may need to call prescriber for a close strength and try to match one with a similar delivery technology. Some formulations, such as the micronized formulations, are used to improve bioavailability.
A patient’s triglycerides were recorded at 282 mg/dL. In which of the following conditions are the fenofibrate agents contraindicated? (Select ALL that apply.)
A. Heart failure
B. Gout
C. Gallbladder disease
D. Pregnancy
E. Severe liver disease
C, E. In addition to the above conditions, these drugs cannot be used in nursing mothers or in severe kidney disease.
Fibrates: peroxisome proliferator receptor alpha (PPARa) activators, which upregulates the expression of apolipoprotein CII and apolipoprotein A-I to reduce TG (20-50%) and LDL (5-20%), and increase HDL (15%). Mainly used to decrease TG. CI: severe liver disease, severe renal disease (CrCl <30), gallbladder disease, nursing mothers. Warning: myopathy, increase risk with statin (elderly, diabetes, renal failure, hypothyroidism). SE: increase LFts, abdominal pain, increase CPK, dyspepsia, URTIs, pregnancy (C)
fenofibrate, fenofibric acid (TriCor, Trilipix):
gemfibrozil (Lopid): taken 30 minutes before breakfast and dinner. CI with repaglinide
Which of the following cholesterol-lowering drug classes require liver enzyme monitoring at baseline due to a risk of hepatotoxicity? (Select ALL that apply.)
A. Fish oils
B. Niacins
C. Fenofibrates
D. Statins
E. Bile acid sequestrants
B, C, D. Niacins, statin, and the fibrates could possibly cause liver damage and liver enzymes should be monitored. In recent years it has been recognized that statins do not cause liver damage worse than placebo in most patients, but the guidelines state to check at baseline and consider if the statin could be contributory if the liver is damaged and no other cause can be identified.
Which of the following medications should be avoided with simvastatin? (Select ALL that apply.)
A. Lopid
B. VFEND
C. Theo-24
D. Plavix
E. Biaxin
A, B, E. Biaxin, Lopid and VFEND should be avoided with simvastatin (and lovastatin) therapy.
simvastatin (Zocor), Vytorin (simvastatin/ezetimibe): equiv dose = 20. 3A4 substrate (avoid inhibitors)
Which of the following drugs could raise lipoprotein levels? (Select ALL that apply.)
A. Montelukast
B. Cyclosporine
C. Amiodarone
D. Prednisone
E. Beta-blockers
B, C, D, E.
Drugs (increase LDL): diuretics, cyclosporine, tacrolimus, glucocorticoids, amiodarone, some progestins, danazol, isotretinoin, thiazolidinediones, anabolic steroids, sodium-glucose cotransporter 2 inhibitors, fibric acids, protease inhibitors, atypical antipsychotics
Drugs (increase TG): oral estrogen, glucocorticoids, bile acid sequestrants, protease inhibitors, retinoids, anabolic steroids, sirolimus, cyclosporine, tacrolimus, raloxifene, tamoxifen, beta blockers (not carvedilol), thiazides, atypical antipsychotics, alpha interferons, propofol
What is the indication for Lovaza?
A. To lower LDL cholesterol in patients with an LDL cholesterol ≥ 200 mg/dL.
B. To lower triglycerides in patients with TGs ≥ 500 mg/dL as an adjunct to diet.
C. To increase HDL in patients with familial-induced low HDL levels.
D. To reduce the risk of statin-induced muscle damage.
E. To lower triglycerides in patients with TGs ≥ 400 mg/dL as an adjunct to diet.
B. Lovaza is indicated in patients with TGs ≥ 500 mg/dL as an adjunct to diet.
Fish Oils: may be due to reduction of hepatic synthesis of TG. Reduce TG (45%) and increase HDL (9%). Indicated as adjunct to diet in patients with TG ≥500. Warning: caution with known hypersensitivity to fish/shellfish. SE: eructation (burping), dyspepsia, taste perversions (Lovaza, Epanova), arthralgias (Vascepa), pregnacy (C), can increase LDL. Stop prior to elective surgery (increase bleed risk)
Lovaza: may increase LDL. possible recurrences of Afib
Vascepa: taken following meals
Epanova: may increase LDL
Omtryg: take with meals
