Day 1 Cardiology- Hyperlipidemia Flashcards
Which statin has the most drug interactions? Least?
Cyp3a4 interactions with statins?
Cyp2c9 substrate interactions with statins?
Lovastatin> Simvastatin > Atorvastatin, Pivastatin.
Amiodarone, Dilitiazem, verapamil, azole antifungals
Fluvastatin, Rosuvastatin
Main A/E’s to worry about in statins?
HmG-CoA reductase inhibitors conversion?
Recommendations specific for Simvastatin?
Generally none, GI disturbance, myalgias, increase in CK,fatigue, increase in LFT’s(monitoring no longer needed).
Atorvastatin 10, Lovastatin 40, Pravastatin 40, Simvastatin 20, Fluvastatin 40, Rosuvastatin 5, Pitavastatin 2.
don’t take more than 10 mg if on dilitiazem or verapamil, don’t take more than 20 mg if on amiodarone, amlodipine, or ranolozine. Don’t take PERIOD if on zole’s, mycin’s, HIV protease inhibs, nefazodone, gemfibrozil, cyclosporine or danazol. Never start on 80 mg and only continue for a year if they haven’t had myalgias in the last year.
When are statin’s CI’d?
What statins may need renal adjustment? Can statins be used to treat LFT’s if due to a fatty liver?
When are shorter acting statins administered? What are they?
Active or chronic liver disease(do not start if LFT’s are 3x the normal limit.), Pregnancy, Drug Interactions, grapefruit juice use.
Rosuvastatin, Lovastatin, Pitavastatin, and Simvastatin. YES.
The evening. Everything except simvastatin, atorvastatin, and rosuvastatin.
Major side effects of bile acid sequesterants? When are they contraindicated?
What drug form of bile acid sequesterants should we used and are these drugs in general used often?
How do you dose Niacin?
GI. High triglycerides(definitely over 400, possibly when over 200).
Tablet, and no due to side effects and administration difficulty.
Slowly titrate up to 1-2 grams per day.
What are they major Niacin side effects?
When is Niacin CI’d?
How can you decrease the flushing Niacin causes?
Flushing, GI disturbances, Hepatoxicity(more prevalent with OTC SR), Gout, Hyperglycemia.
Chronic liver disease, Severe Gout, possibly with hyperglycemia, diabetes, and peptic ulcer disease.
Take an NSAID or aspirin 30 minutes before dose, take at night, slowly titrate, take ER version.
What are some adverse effects of fibric acid derivatives?
What fibric acid derivative do you choose when you need to combine with a statin? What is another interaction to note with these drugs?
When are fibric acid derivative’s CI’d?
GI symptoms, Gallstones, Hepatitis, Myopathy.
Fenofibrate, this interaction can increase risk of myopathy but it’s especially true if you choose gemfibrozil. Can displace highly protein bound drugs.
Severe renal disease(SCr> 2.0) For moderate renal adjust Gemfibrozil(10-50 CrCl) to 50% of normal dose and adjust Fenfibrate(>50CrCl) to lower dose. Severe Hepatic dysfunction, use in caution with gallbladder disease and biliary cirrhosis.
Do people with higher triglycerides reduce their triglyceride’s in fibric acid use?
Are fibric acid derivative’s effective at treating athrogenic dyslipidemia? Should we use these generic versions?
What are the A/E’s of fish oil pills? When are they CI’d?
YES
Use alone when LDL is normal, use in combination with a statin if LDL is high. Save on cost.
Dyspepsia, belching fishy taste, flu like symptoms, prolonged bleeding time. Hypersensitivity, use cautiously with coagulopathy and anticoagulation therapy.
Does combination therapy work according to accord trial?
What is the best to use for secondary prevention?
What do you monitor for lipid lowering therapy?
No difference in CHD endpoints in two groups, slight benefit with those with >204 triglycerides).
High potency statin like atorvastatin.
Myopathy(baseline CK for statins and fibric acid derivatives),Liver(repeat more often for Niacin and fibric acids),Fasting lipid profile,fasting blood glucose(niacin and statins),baseline renal function(fibric acids)
What is high cholesterol?
What is the LDL paradigm?
How much higher should the non HDL goal be?
total cholesterol >200 mg,HDL <40, Triglycerides >150, LDL? depends.
Elevated LDL is one of the major risk factors for CHD, 30 mg equals 30% chance, LDL is calculated, treatment is based on patients risk for developing CHD.
30 points higher.
What is the LDL equation? Is there a point where it becomes invalid?
When should FLP be started?
How to treat those with clinical ASCVD?
LDL= TC-HDL-(TG/5). not as accurate as TG’s get higher and closer to 400.
Taken at age 20 and done every 5 years.
high potency statin recommend(unless older than 75),Monitor lipid levels regularly(6 weeks then yearly, should get >50% reduction), statins have an NNT of about 30.
How to treat those with baseline LDL>190?
How to treat those with diabetes?
How to treat those without diabetes or ASCVD of FH?
high potency statin recommended, monitor regularly(50% reduction should be seen)
Higher risk, need to calculate 10 year risk to determine therapy(>7.5 high potency, <7.5 medium).
Determine 10 year risk(>7.5 medium, <7.5 benefit may not outweight risk), monitor lipid levels periodically(305 decrease expected)
What are characteristics predisposing people to A/E’s of statins? What should we do for these patients?
What are the statin monitoring protocols?
How do you handle muscle weakness in statins?
impaired renal or hepatic function, history of previous statin intolerance or muscle disorders, unexplained ALT elevations >3times ULN, >75 years of age, patient characteristics or concomitant drug use affecting statin metabolism. Consider a step down.
Baseline CK and LFT then if symptomatic, regular blood glucose, self monitor for muscle weakness and pain, self monitor for memory loss
Evaluate baseline, rule out rhabdomyolisis and discontinue if severe, if mild-moderate discontinue until you can see a Dr, rule out other causes, restart statin to establish causual relationship, if pain is due to statin d/c and start another at lower dose and titrate.
What is ezetimibes place in therapy?
How do you administer praluent? What are it’s monitoring parameters? Side effects?
What does the improve it trial show? What about the odyssey long term trial?
adjunct therapy in addition to statin and diet restrictions. Monotherapy may be considered.
warm to room temp 30 minutes before injection, inject subq, takes 20 seconds to work. Store in fridge. Measure LDL 4-8 weeks after. 75 mg every 2 weeks. UTI, diarrhea, myalgia.
ezetimibe added to statin therapy is good. Praluent with high dose statin reduced LDL with no increase in adverse events.
Is evolocumab stable up to 30 days? What is it’s dosing?
Yes. 140 mg every 2 weeks.
