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Pharm 2 Exam > ch 44 > Flashcards

ch 44 Flashcards

1
Q

Risk for atherosclerotic cardiovascular disease (ASCVD) is directly related to

A

increased levels of LDLs (low-density lipoproteins)

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2
Q

The preferred method for lowering LDL is

A

modification of diet combined with exercise. Drugs employed when this is not sufficient

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3
Q

good cholesterol

A

HDL

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4
Q

when we want to reduce cholesterol levels, it is more important to

A

reduce intake of saturated fats as opposed to reducing intake of cholesterol itself

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5
Q

VLDLs contain mainly

A

triglycerides (unclear of the link) - probably contribute to atherosclerosis

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6
Q

VLDL increases risk for

A

pancreatitis

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7
Q

HDLs promote

A

cholesterol removal by getting them from tissues to liver

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8
Q

approved for treating dyslipidemia in children and adolescents

A

lovastatin
atorvastatin
pravastatin
simvastatin

avoid in children younger than 10

“These kids need to run some laps”

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9
Q

approved for treating dyslipidemia in pregnant

A

no

Ezetimibe (Zetia) and fibrates can be used but benefit outweigh risk

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10
Q

approved for treating dyslipidemia in breastfeeding

A

not studied in this group

same as pregnancy

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11
Q

approved for treating dyslipidemia in older adults

A

in pt 65 and old, statins significantly reduced risk for stroke . take cost into consideration

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12
Q

what tool is used to categorize risk for ASCVD

A

Framingham risk prediction score

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13
Q

what factors is considered in the Framingham risk prediction score

A 
age
total cholesterol
HDL
smoking status
systolic BP
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14
Q

The ACC/AHA cholesterol guidelines defines high ASCVD risk as

A

20% or more

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15
Q

The ACC/AHA cholesterol guidelines defines very high risk are pt with

A

existing clinical ASCVD

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16
Q

To assess ASCVD risk we need what info

A

1) Identify ASCVD risk factors
2) Calculate 10 yr ASCVD risk
3) Identify ASCVD risk equivalents

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17
Q

low intensity statin therapy options

A

daily dose lowers LDL-C on average <30%

Pravastatin: 10-20mg
Lovastatin: 20mg
Simvastatin: 10mg

(PLS let this work)

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18
Q

Moderate intensity therapy

A

daily dose lowers LDL-C on average <30% to <50%

Lovastatin: 40mg
Atorvastatin: 10mg
Pravastatin: 40mg
Simvastatin: 20-40mg
Rosuvastatin: 10mg

(LAPS-R for mod)

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19
Q

High intensity therapy

A

daily dose lowers LDL-C on average > equal to 50%

Atorvastatin 40-80mg
Rosuvastatin: 20mg

(RA)

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20
Q

Therapeutic lifestyle therapy for hyperlipidemia

A

diet
exercise
weight control
smoking cessation

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21
Q

how long is statin treatment

A

lifelong

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22
Q

what drug class is most effective agent for hyperlipidemia

A

HMG-CoA reductase inhibitors (statins)

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23
Q

metabolic syndrome (syndrome x)

A 
metabolic abnormalities associated 
increased r/o ASCVD
Type 2DM
high blood gludcose
high TGs 
high apolipoprotein B
low HDL
small LDL particles
prothrombotic state
proinfammatory state
HTN
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24
Q

diagnostic criterion for metabolic syndrome

A

3 or more
High TG levels - 150 or higher
low HDL - below 40 for men or below 50 for women
hyperglycemia - fasting blood glucose 100+
High BP - systolic 130+ diastolic 85+
waist circumference 40in plus men
35 in plus women

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25
Q

treatment goal for metabolic syndrome

A

reducing risk for atherosclerosis

reducing risk of type 2 DM

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26
Q

med goals for metabolic syndrome

A

lower BP and TG levels

should take low dose ASA to reduce r/o thrombosis unless at risk for intracranial bleeds

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27
Q

high triglyceride levels are associated with

A 
metabolic syndrome
inactive lifestyle
cigarette smoking
excessive alcohol
type 2 dm
certain genetic disorders
high carb intake (>60% of caloric intake)
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28
Q

how do you treat high TG

A

diet mods
statins

if still remain high fibrates may be needed

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29
Q

when fibrates are combined with statins, the adverse effects of cholesterol lowering agents may

A

be intensified

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30
Q

most effective drugs for lowering LDL and total cholesterol They can raise HDL and lower TGs in some pts

A

HMG coA reductase inhibitors (Statins)

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31
Q

How long does it take to statins to work

A

significant within 2 weeks
max within 4-6 weeks
serum cholesterol levels will return if you stop taking med. This is lifelong.

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32
Q

Low levels of HDL

A

below 40 mg/dL

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33
Q

goal is to raise levels of HDL to

A

50 mg/dL or more

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34
Q

Do we prescribe statins to lower TGs

A

No, but it is a good side effect that has been documented

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35
Q

Statins also help with

A

reducing the risk for CV events such as

risk for a-fib
risk for thrombosis
stabilizes plaque
reducing inflammation
suppresses production of thrombin (key factor in clot formation
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36
Q

what statin is approved for reducing the risk for CV events in people with normal levels of LDL and no clinically evident ASCVD but do have an increased risk based on advancing age, high levels of CRP and at least one other risk factor for CV disease such as HTN , Low HDL or LDL

A

rosuvastatin (crestor)

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37
Q

For many pt the goal is to drop LDL cholesterol to below

A

100mg/dL

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38
Q

For pt with very high CV risk, a target LDL of ____ may be appropriate

A

70 mg/dL

39
Q

Post MI and statins

A

Automatically start on Statin - better late than never

40
Q

what antihypertensive may raise LDLs

A

B blockers

41
Q

Diabetics and cholesterol

A

controlling HTN and high cholesterol is as important as controlling glucose. CV disease is the primary cause of death in people with DM

American Diabetes Association recommends a statin for all patients 40 and older whose LDL cholesterol is greater than 100 mg/dL

American college of physicians recommend a statin for

1) all pt with type 2 dm plus diagnosed ASCVD even if they don’t have high cholesterol
2) all adults with Type 2DM plus one additional risk factor such as HTN, smoking, older than 55) even if they do not have high cholesterol

42
Q

which statins undergo clinically significant excretion in urine

A

lovastatin
pitavastatin
pravastatin
simvastatin

43
Q

Statins metabolized by CYP3A4

A

atorvastatin
lovastatin
simvastatin

levels of these drugs can be lowered by agents that induce CYP synthesis and speed up metabolism

or statin levels can be increased by agents that inhibit CYP3A4

44
Q

what statin reaches abnormally high levels in people of Asian heritage

A

Rosuvastatin

if you have to use this - start with lowest available dosage and monitor diligently

45
Q

side effects of Statins

A

headache
rash
GI disturbances - dyspepsia, cramps, flatulence, constipation, abd pain
usually transient and mild

46
Q

Serious adverse effects of statins

A

Hepatotoxicity, myopathy, rhabdomyolysis

47
Q

symptoms of rhabdomyolysis

A

muscle aches
tenderness
weakness

48
Q

what lab will show elevation in rhabdomyolysis

A 
Creatine Kinase (CK) - released by injured muscle
will be greater than 10 times the upper limit

elevation of free myoglobin

49
Q

Muscle releases what when injured

A

CK and Potassium

50
Q

high levels of CK can cause

A

renal impairment because excess CK can plug up the glomeruli thereby preventing normal filtration

51
Q

what factors increase risk for myopathy

A

advanced age
small body frame
frailty
multisystem disease (chronic renal insufficiency, esp associated with diabetes)
use of statins in high doses
low vit d
low coenzyme q levels
concurrent use of fibrates (which can also cause myopathy)
use of drugs that can raise statin levels
hypothyroidism

52
Q

while taking statins, if muscle pain develops what other labs should be checked

A

thyroid function

53
Q

while taking statins, pt develops myopathy
ck levels are greater than 10xs the normal limit
what should you do

A

d/c statin

if less than 10xs statin can be continued by with symptoms, ck levels are followed weekly
however this is costly and inconvenient. Consider stopping and reevaluate therapy
routine monitoring of CK in asymptomatic pt is unnecessary

54
Q

what statin poses the highest risk for rhabdomyolysis

A

Rosuvastatin (Crestor)

55
Q

Additional strategies for mgmt of myalgia with statins

A

Vit D and Coenzyme Q can help reduce myalgias in pt with low levels. Try another statin

56
Q

adverse effect of statins with liver

A

LFT test recommended prior to starting treatment for baseline

then repeat if clinically indicated after starting

if transaminase levels rise to 3 times the Upper limit normal and remain there - d/c statins. levels should decline to pretreatment levels after drug withdrawal

57
Q

What liver problem is a contraindication for taking a statin

A

viral or alcoholic hepatitis

58
Q

can you use statins in pt with nonalcoholic fatty liver disease?d

A

yes - statins reduce cholesterol levels and may also decrease liver inflammation, improve LFTs and reduce steatosis (fatty infiltration in liver)

59
Q

what endocrine problem does statins increase risk for developing

A

diabetes

however these pts were pre-diabetic

60
Q

combining statins with other lipid lowering drugs

A

can increase risk of muscle injury, liver injury, kidney injury

primarily for fibrates (gemfibrozil, fenofibrate)

61
Q

inhibitors of CYP for lovastatin, simvastatin, atorvastatin include what meds
risk for tox

A 
macrolide abx (erythromycin)
azole antifungal drugs (ketoconazole, itraconazole)
HIV protease inhibitors (ritonavir)
Amiodarone (antidysrhythmics)
cyclosporine (immunosuppressant)

reduce dosage of stain if these drugs are used

62
Q

What food should you avoid due to CYP inhibition for statins (lovastatin, simvastatin, atorvastatin)

A

Grapefruit juice

63
Q

can you use statins in pregnancy

A

no

64
Q

if a 30% - 40% reduction in LDL is sufficient what statin

A

any will do

65
Q

if LDL needs to be lowered more than 40%

A

atorvastatin

simvastatin

66
Q

for pat with significant renal impairment that needs a statin

A

atorvastatin
fluvastatin
are preferred (no renal dosing needed)

67
Q

what category of med is used as adjunct to statins

A

bile acid sequesterants

  • Colesevelam (Welchol)
  • cholestyramine
  • colestipol
68
Q

Benefits of using Colesevalam (Welchol)

A

1) better tolerated (less GI effects)
2) does not reduce absorption of fat soluble vitamins (A, D, E, K)
3) does not sig reduce absorption of statins, digoxin, warfarin
4) helps control hyperglycemia in pt with Type 2DM

69
Q

Colesevelam vs statins

A

Colesevelam (Welchol) does not work as well but safer bc they do not have systemic effects

main complaint is constipation. minimized by increasing dietary fiber and fluids

also bloating, indigestion, nausea

70
Q

cholestyramine and colestipol and absorption

A

decrease fat absorption so may decrease uptake of fat soluble vitamins

71
Q

what meds have the risk of forming complexes with Colesevalam so need to space either 1 hr before or 4 hours after

A

Thiazide
digoxin
warfarin
some ABX

72
Q

how does Ezetimibe (Zetia) work

A

reduces plasma cholesterol by blocking cholesterol absorption

can be used as monotherapy or as adjunct with statin

73
Q

what cholesterol does Ezetimibe (Zetia) work on

A 
reduce plasma levels of total cholesterol
LDL
TGs 
apolioprotein B
small increase in HDL
74
Q

adverse effects of Ezetimibe (Zetia)

A 
myopathy
rhabdomyolysis
hepatitis
pancreatitis
thrombocytopenia

NO GI SIDE EFFECTS

75
Q

in pt taking a statin, adding Ezetimibe (Zetia) slightly increases r/o

A 
liver damage (watch for elevated transaminase levels)
get baseline LFTs and repeat when clinically indicated

myopathy

76
Q

Ezetimibe (Zetia) and fibrates (gemfibrozil and fenofibrate) can increase r/o

A

can increase the cholesterol content of bile which increases r/o gallstones

myopathy

77
Q

______ and possibly _____ can significanty decrease the absorption of Ezetimibe (Zetia)

A

Cholestyramine and colestipol

administer Ezetimibe (Zetia) at least 2 hours prior or more than 4 hours after

78
Q

_________ may greatly increase levels of Ezetimibe (Zetia)

A

Cyclosporine

careful monitoring is needed

79
Q

Pt with moderate to severe renal impairment and Ezetimibe (Zetia)

A

do not use, not enough data

80
Q

most effective drugs for lowering TG levels
can raise HDL
little or no effect on HDL

A

Fibric Acid derivatives (fibrates)

81
Q

Fibrates can increase r/o bleeding in pt taking ____

A

Warfarin

82
Q

Fibrates can increase r/o _______ in pt taking statins

A

rhabdomyolysis

83
Q

Fibrates are considered _____-line for managing lipid disorders

A

third

84
Q

gemfibrozil (lopid)
fenofibrate (Tricor)
fenofibric acid (TriLipix, Fibricor)

A

what fibrates are approved

85
Q

most common adverse effects of Gemifibrozil

A

rash

GI disturbances such as nausea, abd pain, diarrhea

86
Q

Gembribrozil increases r/o

A

gallstones

87
Q

symptoms of gallbladder disease

A

upper abd discomfort
intolerance of fried foods
bloating

88
Q

who should not take Gemribrozil

A

pt with pre-existing gallbladder disease

89
Q

serious adverse effects Gemfibrozil

A

myopathy - warn pt of muscle injury such as tenderness, weakness or unusual muscle pain

liver injury - hepatotoxic
risk for liver cancer

periodic LFTs recommended

90
Q

drug interactions for gemfibrozil

A

displaces warfarin from plasma albumin
increases anticoagulant effects

monitor Prothrombin time should be measured frequently to asses coagulation status.

warfarin dosage may need to be reduced

combined with statin - increases r/o myopathy

91
Q

Monoclonal antibodies (Proprotein convertase subtilisin/kexin type 9 (kPCSK9) inhibitors

A

used as adjunct to diet mod and max tolerated statin therapy for reducing total LDL

92
Q

Alirocumab (Praluent)

Evolocumab (Repatha)

A

Monoclonal antibodies (Proprotein convertase subtilisin/kexin type 9 (kPCSK9) inhibitors

93
Q

Monoclonal antibodies (Proprotein convertase subtilisin/kexin type 9 (kPCSK9) inhibitors are administered

A

subcutaneously

94
Q

hypersensitivity reactions for Monoclonal antibodies (Proprotein convertase subtilisin/kexin type 9 (kPCSK9) inhibitors

A

vasculitis
rash
urticarial requiring hospitalization

Pharm 2 Exam (18 decks)

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