ch 44 Flashcards
1
Q
Risk for atherosclerotic cardiovascular disease (ASCVD) is directly related to
A
increased levels of LDLs (low-density lipoproteins)
2
Q
The preferred method for lowering LDL is
A
modification of diet combined with exercise. Drugs employed when this is not sufficient
3
Q
good cholesterol
A
HDL
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
5
Q
VLDLs contain mainly
A
triglycerides (unclear of the link) - probably contribute to atherosclerosis
6
Q
VLDL increases risk for
A
pancreatitis
7
Q
HDLs promote
A
cholesterol removal by getting them from tissues to liver
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”
9
Q
approved for treating dyslipidemia in pregnant
A
no
Ezetimibe (Zetia) and fibrates can be used but benefit outweigh risk
10
Q
approved for treating dyslipidemia in breastfeeding
A
not studied in this group
same as pregnancy
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
12
Q
what tool is used to categorize risk for ASCVD
A
Framingham risk prediction score
13
Q
what factors is considered in the Framingham risk prediction score
A
age total cholesterol HDL smoking status systolic BP
14
Q
The ACC/AHA cholesterol guidelines defines high ASCVD risk as
A
20% or more
15
Q
The ACC/AHA cholesterol guidelines defines very high risk are pt with
A
existing clinical ASCVD
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
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)
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)
19
Q
High intensity therapy
A
daily dose lowers LDL-C on average > equal to 50%
Atorvastatin 40-80mg
Rosuvastatin: 20mg
(RA)
20
Q
Therapeutic lifestyle therapy for hyperlipidemia
A
diet
exercise
weight control
smoking cessation
21
Q
how long is statin treatment
A
lifelong
22
Q
what drug class is most effective agent for hyperlipidemia
A
HMG-CoA reductase inhibitors (statins)
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
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
25
treatment goal for metabolic syndrome
reducing risk for atherosclerosis
| reducing risk of type 2 DM
26
med goals for metabolic syndrome
lower BP and TG levels
| should take low dose ASA to reduce r/o thrombosis unless at risk for intracranial bleeds
27
high triglyceride levels are associated with
```
metabolic syndrome
inactive lifestyle
cigarette smoking
excessive alcohol
type 2 dm
certain genetic disorders
high carb intake (>60% of caloric intake)
```
28
how do you treat high TG
diet mods
statins
if still remain high fibrates may be needed
29
when fibrates are combined with statins, the adverse effects of cholesterol lowering agents may
be intensified
30
most effective drugs for lowering LDL and total cholesterol They can raise HDL and lower TGs in some pts
HMG coA reductase inhibitors (Statins)
31
How long does it take to statins to work
significant within 2 weeks
max within 4-6 weeks
serum cholesterol levels will return if you stop taking med. This is lifelong.
32
Low levels of HDL
below 40 mg/dL
33
goal is to raise levels of HDL to
50 mg/dL or more
34
Do we prescribe statins to lower TGs
No, but it is a good side effect that has been documented
35
Statins also help with
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
```
36
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
rosuvastatin (crestor)
37
For many pt the goal is to drop LDL cholesterol to below
100mg/dL
38
For pt with very high CV risk, a target LDL of ____ may be appropriate
70 mg/dL
39
Post MI and statins
Automatically start on Statin - better late than never
40
what antihypertensive may raise LDLs
B blockers
41
Diabetics and cholesterol
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
which statins undergo clinically significant excretion in urine
lovastatin
pitavastatin
pravastatin
simvastatin
43
Statins metabolized by CYP3A4
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
what statin reaches abnormally high levels in people of Asian heritage
Rosuvastatin
if you have to use this - start with lowest available dosage and monitor diligently
45
side effects of Statins
headache
rash
GI disturbances - dyspepsia, cramps, flatulence, constipation, abd pain
usually transient and mild
46
Serious adverse effects of statins
Hepatotoxicity, myopathy, rhabdomyolysis
47
symptoms of rhabdomyolysis
muscle aches
tenderness
weakness
48
what lab will show elevation in rhabdomyolysis
```
Creatine Kinase (CK) - released by injured muscle
will be greater than 10 times the upper limit
```
elevation of free myoglobin
49
Muscle releases what when injured
CK and Potassium
50
high levels of CK can cause
renal impairment because excess CK can plug up the glomeruli thereby preventing normal filtration
51
what factors increase risk for myopathy
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
while taking statins, if muscle pain develops what other labs should be checked
thyroid function
53
while taking statins, pt develops myopathy
ck levels are greater than 10xs the normal limit
what should you do
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
what statin poses the highest risk for rhabdomyolysis
Rosuvastatin (Crestor)
55
Additional strategies for mgmt of myalgia with statins
Vit D and Coenzyme Q can help reduce myalgias in pt with low levels. Try another statin
56
adverse effect of statins with liver
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
What liver problem is a contraindication for taking a statin
viral or alcoholic hepatitis
58
can you use statins in pt with nonalcoholic fatty liver disease?d
yes - statins reduce cholesterol levels and may also decrease liver inflammation, improve LFTs and reduce steatosis (fatty infiltration in liver)
59
what endocrine problem does statins increase risk for developing
diabetes
| however these pts were pre-diabetic
60
combining statins with other lipid lowering drugs
can increase risk of muscle injury, liver injury, kidney injury
primarily for fibrates (gemfibrozil, fenofibrate)
61
inhibitors of CYP for lovastatin, simvastatin, atorvastatin include what meds
risk for tox
```
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
What food should you avoid due to CYP inhibition for statins (lovastatin, simvastatin, atorvastatin)
Grapefruit juice
63
can you use statins in pregnancy
no
64
if a 30% - 40% reduction in LDL is sufficient what statin
any will do
65
if LDL needs to be lowered more than 40%
atorvastatin
| simvastatin
66
for pat with significant renal impairment that needs a statin
atorvastatin
fluvastatin
are preferred (no renal dosing needed)
67
what category of med is used as adjunct to statins
bile acid sequesterants
- Colesevelam (Welchol)
- cholestyramine
- colestipol
68
Benefits of using Colesevalam (Welchol)
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
Colesevelam vs statins
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
cholestyramine and colestipol and absorption
decrease fat absorption so may decrease uptake of fat soluble vitamins
71
what meds have the risk of forming complexes with Colesevalam so need to space either 1 hr before or 4 hours after
Thiazide
digoxin
warfarin
some ABX
72
how does Ezetimibe (Zetia) work
reduces plasma cholesterol by blocking cholesterol absorption
can be used as monotherapy or as adjunct with statin
73
what cholesterol does Ezetimibe (Zetia) work on
```
reduce plasma levels of total cholesterol
LDL
TGs
apolioprotein B
small increase in HDL
```
74
adverse effects of Ezetimibe (Zetia)
```
myopathy
rhabdomyolysis
hepatitis
pancreatitis
thrombocytopenia
```
NO GI SIDE EFFECTS
75
in pt taking a statin, adding Ezetimibe (Zetia) slightly increases r/o
```
liver damage (watch for elevated transaminase levels)
get baseline LFTs and repeat when clinically indicated
```
myopathy
76
Ezetimibe (Zetia) and fibrates (gemfibrozil and fenofibrate) can increase r/o
can increase the cholesterol content of bile which increases r/o gallstones
myopathy
77
______ and possibly _____ can significanty decrease the absorption of Ezetimibe (Zetia)
Cholestyramine and colestipol
administer Ezetimibe (Zetia) at least 2 hours prior or more than 4 hours after
78
_________ may greatly increase levels of Ezetimibe (Zetia)
Cyclosporine
| careful monitoring is needed
79
Pt with moderate to severe renal impairment and Ezetimibe (Zetia)
do not use, not enough data
80
most effective drugs for lowering TG levels
can raise HDL
little or no effect on HDL
Fibric Acid derivatives (fibrates)
81
Fibrates can increase r/o bleeding in pt taking ____
Warfarin
82
Fibrates can increase r/o _______ in pt taking statins
rhabdomyolysis
83
Fibrates are considered _____-line for managing lipid disorders
third
84
gemfibrozil (lopid)
fenofibrate (Tricor)
fenofibric acid (TriLipix, Fibricor)
what fibrates are approved
85
most common adverse effects of Gemifibrozil
rash
| GI disturbances such as nausea, abd pain, diarrhea
86
Gembribrozil increases r/o
gallstones
87
symptoms of gallbladder disease
upper abd discomfort
intolerance of fried foods
bloating
88
who should not take Gemribrozil
pt with pre-existing gallbladder disease
89
serious adverse effects Gemfibrozil
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
drug interactions for gemfibrozil
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
Monoclonal antibodies (Proprotein convertase subtilisin/kexin type 9 (kPCSK9) inhibitors
used as adjunct to diet mod and max tolerated statin therapy for reducing total LDL
92
Alirocumab (Praluent)
| Evolocumab (Repatha)
Monoclonal antibodies (Proprotein convertase subtilisin/kexin type 9 (kPCSK9) inhibitors
93
Monoclonal antibodies (Proprotein convertase subtilisin/kexin type 9 (kPCSK9) inhibitors are administered
subcutaneously
94
hypersensitivity reactions for Monoclonal antibodies (Proprotein convertase subtilisin/kexin type 9 (kPCSK9) inhibitors
vasculitis
rash
urticarial requiring hospitalization
