Chapter 27: Dyslipidemia Flashcards
1
Q
Atherosclerosis is the formation of ____ from a buildup of fats, cholesterol, and other substances on the inner walls of arteries
A
plaque
2
Q
Atherosclerosis leads to ____, which includes MI, stroke/TIA, angina, and peripheral arterial disease
A
ASCVD
3
Q
Total cholesterol (TC) includes which 3 major lipoproteins
A
LDL, HDL and VLDL
4
Q
High HDL (increases/lowers) ASCVD risk
A
lowers
5
Q
______ is associated with high ASCVD risk
A
hypertriglyceridemia
6
Q
TGs > ___ mg/dL can cause acute pancreatitis
A
500
7
Q
____ hypercholesterolemias are genetic defects that cause severe cholesterol elevations
A
Primary (familial)
8
Q
Severe elevations, including LDL >/= ___ and TG > ___ mg/dL, are very high risk and must be treated
A
190
500
9
Q
Key Drugs that ↑ LDL & TG
A
o Diuretics o Efavirenz o Steroids o Immunosuppressants o Atypical antipsychotics o Protease inhibitors
10
Q
Key Drugs that ↑ TG only
A
o IV lipid emulsions
o Propofol
o Bile acid sequestrants (~5%)
11
Q
Conditions that can increase cholesterol
A
Obesity poor diet hypothyroidism alcoholism smoking diabetes renal/liver disease nephrotic syndrome
12
Q
How to calculate LDL using the Friedewald equation
A
LDL = TC – HDL – (TG/5)
***this formula is not used when TGs are >/= 400 mg/dL
13
Q
Desirable non-HDL level
A
< 130
14
Q
Desirable LDL level
A
< 100
15
Q
Very high LDL level
A
> / = 190
16
Q
Desirable HDL in men
A
> / = 40
17
Q
Desirable HDL in women
A
> / = 50
18
Q
Desirable TG level
A
< 150
19
Q
If not fasting before blood work, the TG level can be falsely ____
A
elevated
20
Q
Which guideline provides recommendations for cholesterol management
A
American College of Cardiology and the American Heart Association (ACC/AHA)
21
Q
ASCVD calculation provides an estimate of an individual’s risk of having first CV event during the next ____
A
10 years
22
Q
The online ASCVD risk calculator inputs what info
A
- Gender, age (20-79 yrs), race
- TC & HDL
- SBP and whether antihypertensive treatment is used
- Presence of diabetes and smoking status
23
Q
How often should ASCVD risk assessment be repeated for low-risk patients
A
Every 4-6 years
24
Q
ASCVD score is not needed in patients who have which conditions, since these groups should be started on a statin
A
Clinical ASCVD, diabetes, or LDL >/= 190 mg/dL
25
What score can be helpful in deciding if statins should be initiated in those with 10-year ASCVD risk of 7.5-19.9%
Coronary artery calcium score (CAC)
26
Non-drug treatment for cholesterol management
- Maintain BMI 18.5-24.9 kg/m2
- Diet rich in vegetables, fruits, whole grains, and high-fiber
- Fish with high fat content
- Limit intake of saturated fat, trans fat, and cholesterol
- Aerobic physical activity 3-4 times per week
27
Natural products for cholesterol
* Red yeast rice contains naturally occurring HMG-CoA reductase inhibitors in low amounts
* OTC fish oils can be used to lower TG
28
Drugs of choice for treating high non-HDL and LDL
Statins
29
Which cholesterol-lowering drugs can cause liver damage
Niacin, fibrates, potentially statins and ezetimibe
30
Drugs can that cause liver damage should not be used if the AST or ALT are > __ times ULN
3
31
MOA of statins
inhibit synthesis of HMG-CoA reductase, which prevents the conversion of HMG-CoA to mevalonate
32
What is the rate-limiting step in cholesterol synthesis
Conversion of HMG-CoA reductase to mevalonate
33
Statin-benefit group for secondary prevention of patients with coronary heart disease, stroke, TIA, or PAD
High-intensity statin
34
Statin-benefit group for primary prevention of a patient with LDL >/= 190 mg/dL
High-intensity statin
35
Statin-benefit group for primary prevention of a patient with diabetes and age 40-75 years with LDL between 70-189 mg/dL and has multiple ASCVD risk factors
High-intensity statin
36
Statin-benefit group for primary prevention of a patient with diabetes and age 40-75 years with LDL between 70-189 mg/dL regardless of 10-year ASCVD risk
Moderate-intensity statin
37
Statin-benefit group for primary prevention of a patient age 40-75 years with LDL between 70-189 mg/dL & 10-year ASCVD risk >/= 20%
High-intensity statin
38
Statin-benefit group for primary prevention of a patient age 40-75 years with LDL between 70-189 mg/dL & 10-year ASCVD risk 7.5-19.9% + risk-enhancing factors
Moderate-intensity statin
39
Which two statins are high-intensity
Atorvastatin (40-80 mg) and Rosuvastatin
40
What are the statin equivalent doses
```
*remember: Pharmacists Rock At Saving Lives & Preventing Fatty-deposits*
o Pitavastatin 2 mg
o Rosuvastatin 5 mg
o Atorvastatin 10 mg
o Simvastatin 20 mg
o Lovastatin 40 mg
o Pravastatin 40 mg
o Fluvastatin 80 mg
```
41
Most important ADE of statins
Muscle damage
42
Symptoms of muscle damage usually occur within ___ weeks of starting treatment
6 weeks
43
How does muscle damage from statins present
o Myalgias
o Myopathy
o Myositis
o Rhabdomyolysis
44
muscle soreness & tenderness
Myalgias
45
muscle weakness + CPK levels
Myopathy
46
muscle inflammation
Myositis
47
muscle sx with very high CPK (> 10,000) + muscle protein in the urine (myoglobinuria), which can lead to acute renal failure
Rhabdomyolysis
48
How can you reduce risk of myalgias
- do not use simvastatin 80 mg/day
| - Do not use gemfibrozil + statin
49
How to manage myalgias
- hold statin, check CPK. Investigate other possible causes
- After 2-4 weeks, re-challenge with same stain at same or ↓dose.
- If myalgias return, d/c statin. Once muscle symptoms resolve, use a low dose of a different statin & gradually ↑ dose
50
Atorvastatin brand name
Lipitor
51
Lovastatin brand name
Altoprev
52
What time of day is Fluvastatin taken
Evening
53
How is Lovastatin IR taken
with evening meal
| *remember - i lov to eat in the evening*
54
Pravastatin brand name
Pravachol
55
Rosuvastatin brand name
Crestor
56
Simvastatin brand name
Zocor
57
What time of day is simvastatin taken
Evening
58
Statin CIs
- Do not use in pregnancy, breastfeeding
| - Do not use with liver disease
59
Do not use strong CYP3A4 inhibitors with which 2 statins
simvastatin and lovastatin
60
Statin warnings
- muscle damage: increased CPK; higher risk with higher dose, advanced age, niacin and 3A4 inhibitors
- Diabetes: increased A1C/FBG
61
How often should a lipid panel be monitored when patient is on a statin
4-12 weeks after starting treatment and then annually
62
Which statins can be taken at any time of day
```
Crestor (rosuvastatin)
Lipitor (atorvastatin)
Livalo (Pitavastatin)
Lescol XL (Fluvastatin XL)
Pravachol (pravastatin)
```
63
What are the lipid effects of statins
Decreases LDL, increases HDL, decreases TG
64
Which two statins have less drug interactions compared to the others
Rosuvastatin and pravastatin
65
Which meds/drug classes should not be used with simvastatin and lovastatin
```
Grapefruit
Protease inhibitors
Azole antifungals
Cyclosporine, cobicistat
Macrolides (except azithromycin)
```
66
Max daily dose of simvastatin with Amiodarone
20 mg/day
67
Max daily dose of lovastatin with Amiodarone
40 mg/day
68
Max daily dose of simvastatin with non-DHP CCBs
10 mg/day
69
Max daily dose of lovastatin with non-DHP CCBs
40 mg/day
70
Add on therapy for Very high risk [Multiple ASCVD events or one ASCVD event in a high-risk patient (i.e. diabetes)], statin at max dose & LDL remains > 70 mg/dL
Ezetimibe (preferred) or PCSK9 Inhibitor
71
Add on therapy for Primary hypercholesterolemia (LDL > 190 mg/dL), statin at max dose & LDL remains > 100 mg/dL
Ezetimibe (preferred) or PCSK9 Inhibitor
72
Ezetimibe MOA
inhibits absorption of cholesterol in the small intestine
73
Ezetimibe brand name
Zetia
74
Ezetimibe SE
myalgias
75
Ezetimibe lipid effects
decreases LDL
76
What formulation do PCSK-9 inhibitors come in
SC injection
77
PCSK-9 inhibitors lipid effects
Decreases LDL ~60% (but are $$$)
78
Bile acid sequestrant/Bile Acid Binding Resins MOA
bind bile acids in the intestine, forming a complex that is excreted in the feces
79
Which drugs are Bile acid sequestrant/Bile Acid Binding Resins
Cholestyramine, colesevelam, colestipol
80
colesevelam brand name
Welchol
81
colesevelam is also approved for
glycemic control in T2DM
82
How is colesevelam taken
with a meal and liquid
83
colesevelam CI
bowel obstruction
84
BAS/Bile acid resin side effects
Constipation, abdominal pain, cramping, bloating, gas, increased TG
85
Cholestyramine packets may cause
changes in surface of teeth resulting in discoloration, erosion of enamel or decay
86
Which BAS can be considered as an option in pregnant patients
colesevelam
| think of a baby lamb
87
For Cholestyramine or colestipol, take all other drugs at least ____ hours before or ___ hours after the BAS
1-4 hrs before
| 4-6 hours after
88
Which medication should be taken 4 hours prior to colesevelam
Levothyroxine
89
Bile acid sequestrants can decrease the absorption of which vitamins
Fat-soluble (A, D, E, K)
90
Fibrate MOA
PPARa activators, which upregulate the expression of apoC-II and apoA-I. ApoC-II increases lipoprotein lipase activity leading to increased catabolism of VLDL particles, ↓ TG significantly
91
Fenofibrate, Fenofibric Acid brand names
Antara, TriCor, Trilipix
92
Fenofibrate (Fenoglide & Lipofen) are taken how
with meals
93
Gemfibrozil brand name
Lopid
94
Fibrate CI
Severe liver disease including primary biliary cirrhosis, gallbladder disease
95
Fibrate warnings
Myopathy, ↑ when co-administered with a statin
96
Fibrate SE
Dyspepsia (gemfibrozil), ↑ LFTs
97
Fibrate lipid effects
Decreases TGs, but can increase LDL when TG are high
98
Gemfibrozil should not be given with ____ or ____ d/t ↑ risk of myopathies
ezetimibe or statins
99
Fibrates can ↑ the effects of ___ and ____
sulfonylureas & warfarin
100
Niacin MOA
decreases the rate of hepatic synthesis of VLDL (decreases TG) and LDL
101
What are other names for niacin
nicotinic acid or Vitamin B3
102
Special consideration for niacin
Titrate slowly
103
How should niacin IR be taken
with food
104
How should niacin ER be taken
at bedtime after a low-fat snack
105
How should niacin CR/SR be taken
with food
106
Niacin warnings
* Rhabdomyolysis with niacin doses > 1 gram/day combined with statins
* Hepatotoxicity
* ↑ BG, ↑ uric acid
107
Niacin SE
Flushing, pruritis, vomiting, diarrhea, ↑ BG, hyperuricemia (or gout)
108
IR niacin has poor tolerability d/t what side effects
flushing/itching
109
CR/SR niacin has less flushing but more
hepatotoxicity
110
What is the best clinical choice for niacin
ER Niaspan, with less flushing and less hepatotoxicity
111
How to reduce flushing associated with niacin
take ASA 325 mg (or ibuprofen 200 mg) 30-60 min before the dose; take with food, but avoid spicy food, alcohol and hot beverages
112
T/F: Formulations of niacin (IR vs ER) are NOT interchangeable
TRUE
113
Lipid effects of niacin
Increases HDL
114
Take niacin ____ hrs after bile acid sequestrants
4-6 hours
115
Fish oils are indicated as an adjunct to diet when TG > ___ mg/dL
500
116
Omega-3-Acid Ethyl Esters brand name
Lovaza
117
Icosapent ethyl brand name
Vascepa
118
Fish oil SE
Eructation (burping), dyspepsia, taste perversions (Lovaza)
119
Fish oils lipid effects
Decreases TG, can increase LDL (Lovaza only)
120
Omega-3-FA can
prolong bleeding time
121
Which drug approved for use in homozygous familial hypercholesterolemia (HoFH)
Lomitapide
122
Lomitapide BW
hepatotoxicity
123
Lomitapide CI
Active liver disease, pregnancy
