Ch 48: Dyslipidemia

Question 1

Friedewald Equation

Answer 1

LDL = TC - HDL - (TG/5). Do not use if TG >400 mg/dL.

Question 2

Red Yeast Rice

Answer 2

natural HMG-CoA reductase inhibitor. Do not recommend d/t inconsistencies in manufacturing.

Question 3

OTC Fish Oils on Cholesterol

Answer 3

lower TG. sometimes lower LDL.

Question 4

Non-HDL Classification and Goals

Answer 4

<130 desirable. 130-159 above desirable. 160-189 borderline high. 190-219 high. >220 very high.

Question 5

LDL Classification and Goals

Answer 5

<100 desirable. 100-129 above desirable. 130-159 borderline high. 160-189 high. >190 very high.

Question 6

HDL Classification and Goals

Answer 6

<40 men low. <50 women low.

Question 7

TG Classification and Goals

Answer 7

<150 normal. 150-199 borderline high. 200-499 high. >500 very high.

Question 8

Statin Benefit Groups

Answer 8

1) clinical ASCVD, 2) LDL >190. 3) Diabetes, 40-75 YO, LDL 70-189. 4) 10-yr ASCVD risk >7.5%, 40-75 YO, LDL 70-189. (repeat ASCVD risk q4-6yrs for low risk pts)

Question 9

Clinical ASCVD

Answer 9

coronary heart disease (ACS, s/p MI, stable or unstable angina, coronary or other arterial revascularization), stroke, TIA, peripheral arterial disease thought to be of atherosclerotic origin

Question 10

Metreleptin

Answer 10

Myalept. Recombinant human leptin analog. Adjunct to diet for leptin deficiency with lipodystrophy. Warnings: development of leptin abs, lymphoma risk. REMS drug, restricted use.

Question 11

AST/ALT considerations

Answer 11

monitor LFTs with cholesterol lowering therapies. Normal range is 10-40 for each. DC drug if LFTS >3x ULN

Question 12

rhabdomyolysis

Answer 12

muscle sx + CPK > 10,000 (normal 22-198) + muscle protein in urine (myoglobinuria) –> acute renal failure

Question 13

Statins to take specifically at night (brand + generic)

Answer 13

Lescol (Fluvastatin) IR. Altoprev (Lovastatin ER) and Mevacor (Lovastatin IR). Take Mevacor with food.

Question 14

Asian considerations

Answer 14

Rosuvastatin exposures are 2x higher in Asian patients. consider 5 mg starting dose.

Question 15

Statin DDIs

Answer 15

Avoid GPACMAN (CYP 3a4 inhibitors) with simvastatin and lovastatin (Mevacor/Altoprev) d/t contraindication. Others have max dose with DDIs. Avoid gemfibrozil.

Question 16

Ezetimibe MOA, brand, DDIs

Answer 16

inhibits cholesterol absorption in GI. Zetia. separate from bile acid sequestrants. avoid with gemfibrozil d/t cholelithiasis.

Question 17

Statin MOA, contraindications

Answer 17

inhibit HMG-Coa reductase, preventing the conversion of HMG-CoA to mevalonate (rate limiting step for cholesterol synthesis). active liver disease, preg, lactation.

Question 18

Vytorin

Answer 18

simvastatin + ezetimibe

Question 19

Liptruzet

Answer 19

atorvastatin + ezetimibe

Question 20

Bile Acid Sequestrants: Names (brand + generic), ADRs, lipid effects

Answer 20

cholestyramine (Questran), Colesevelam (Welchol) with meal and liquid, less DDIs. Colestipol (Colistid). ADRs: constipation (dose reduce), abd pain, cramping, gas, inc TGs (by ~5%). dec LDL 10-30%. inc HDL 3-5%.

Question 21

Fibrates: Names (brand + generic), ADRs unique, lipid effects, MOA (class)

Answer 21

fenofibrate - take fenoglide, lofibra (cap not tab), lipofen with food. gemfibrozil (lopid) before food. ADRs: dyspepsia. dec TG 20-50%, inc HDL 15%, dec LDL 5-20%. may inc LDL when TG is high. peroxisome proliferator receptor alpha activators. many DDIs with lopid.

Question 22

Niacin: MOA, warning, ADRs, lipid effects

Answer 22

dec hepatic synthesis of VLDL (dec TG) and LDL. aka vit b3. warning: hep tox. ADRs: flushing, pruritis, NVD, hyperglycemia, hyperuricemia (gout), cough. IR (niacor) more flushing/itching, ER more hep tox. niaspan less tox all around, most costly. IR /ER not interchangeable. reduce flushing with asa 325 mg or ibu 200 mg 30-60 min before dose. dec LDL 5-25%. inc HDL 15-35%. dec TG 20-50%.

Question 23

Fish oils: indication, brand + generic, warning, lipid effects

Answer 23

adjunct to diet with TG >500. omega-3-FA (lovaza). may prolong bleeding time. inc LDL up to 44%. Vascepa (icosapent ethyl) does not inc LDL.

Question 24

PCSK9 Inhibitors: MOA, name (brand + generic), lipid effects

Answer 24

proprotein convertase subtilisin kexin type 9 inhibitors. PCSK9 binds LDLR to degrade it. When inhibited LDLR conc inc and degrades more LDL. Alirocumab (Praluent) and Evolocumab (Repatha, Pushtronex) SC - inj site rxns. dec LDL 60%. dec nonHDL 35%. dec TC 36%.

Question 25

when to consider PCSK9 inhibitors

Answer 25

1) 2ndary ppx for pts on max tolerated statin +/- zetia with LDL >70 or nonHDL >100. 2) very high risk pts who are intolerant to statins and not at goal despite use of other lipid agents. 3) pts with FH (hetero both, homo repatha) and LDL pre-tx of >190 depending on age, on-treatment lipids, and other risk factors.

Question 26

Lomitapide: brand, BBW, contraindications, warnings, DDIs

Answer 26

Juxtapid cap. BBW: hep tox. REMS, medguide. contraindicated in preg. VD and embyro fetal tox for warnings. DDIs: GPACMAN, dose adjust for weak inhibitors

Question 27

Mipomersen: brand, BBW, contraindications.

Answer 27

kynamro. prefilled syringe, SC. BBW: hep tox, medguide, REMS. contraindication: active liver disease.

Question 28

Caduet

Answer 28

atorvastatin + amlodipine

Question 29

Liptruzet

Answer 29

atorvastatin + ezetimibe