Dyslipidemia Flashcards
Explain enterohepatic recycling
bile acids from the liver travel through the bile ducts along with cholesterol into the small intestine where they help with fat absorption.
Intestines have an acidic environment so the bile acids are converted to bile salts here which are recycled from the intestine and then return to the liver
How does disrupting the enterohepatic recyling process lead to lowered cholesterol?
By blocking absorption of free cholesterol in the intestine (ezetimibe) or the enterohepatic recirculation of bile salts (colesevelam) cholesterol then decreases
How do statins help with cholesterol?
they reduce the formation of cholesterol by inhibiting HMG-CoA reductase to stop conversion of HMG-CoA to mevalonate (rate limiting step in cholesterol synthesis)
Describe HDL
good cholesterol
delivers cholesterol from blood to the liver where it is removed from the body
want Hdl to be High
describe lipoprotein
genetic variant of LDL, when elevated=elevated ASCVD risk
At what level can TGs cause pancreatitis
> 500 mg/dl
What are primary hypercholesterolemias
genetic defect that causes cholesterol elevations
HeFH and HoFH
When is LDL considered severely elevated?
> 190
What is the Friedewald equation?
LDL = Tc - HDL - (TG/5)
*only use if TG is <400
Desirable HDL levels
men: >/= 40
women: >/= 50
What is the desirable level for TGs?
<150
What does ASCVD risk tell us?
estimate of patient’s risk of having their first CV event in the next 10 years
What are parameters are assessed when calculating ASCVD risk?
gender, age, race TC and HDL Systolic blood pressure use of HTN meds diabetes smoking status
What CAC score indicates a statin should be initiated?
CAC >/= 100
Drug of choice for high non-HDL and LDL
statins!
Drug options if statin-intolerant or additional cholesterol-lowering needed
ezetimibe
PCSK9 inhibitors
What lab parameter should be monitored when patients are using cholesterol-lowering medication due to side effect profile
AST and ALT
liver damage is possible
What drugs can cause liver damage?
niacin, fibrates, statins, ezetimibe
When should we not initate cholesterol medication in regards to liver function
AST or ALT are >3x upper normal limit
High intensity statin indications
clinical ASCVD
LDL >/=190
diabetes + age 40-75 + LDL >70 + multiple risk factors
40-75yo + LDL >70 + ASCVD risk >/= 20%
moderate intensity statin indications
diabetes + age 40-75 + LDL >70
40-75yo + LDL >70 + ASCVD risk >7.5% + risk factors
High intensity statins
Atorva: 40 +
Rosuva: 20 +
moderate intensity statins
atorv 10 - 20 rosuva 5-10 simvastatin 20+ pravastatin 40+ lovastatin 40+ pitavastain: 2 +
low intensity statins
sim: 10
prav: 10-20
lova 20
pita: 1
statin equivalents
Pharmacists Rock At Saving Lives & Preventing Fatty-deposits
pita: 2
rosu: 5
ator: 10
simva: 20
lova: 40
prava: 40
fluvastatin: 80
Is statin-induced muscle soreness symmetrical or asymmetrical?
symmetrical
What CPK value can indicate rhabdomyolysis
CPK > 10,000 + muscle in urine
What can rhabdomyolysis lead to?
acute kidney failure
Can we rechallenge with a statin if myalgias occur?
yes after 2- 4 weeks of holding with same statin at same or lower dose
CIs of statin therapy
pregnancy, breastfeeding
liver disease or unexplained elevated LFT
use with cyclosporine
which statins interact with CYP34A inhibitors
simva
lova
Which drug needs to be started at a low dose in Asian patients due to risk of higher exposure
rosuvastatin
which statins should be taken in the evening
fluvastatin
lovastatin
simvastatin
which statins have less drug interactions
rosuvastatin
pravastatin
Statin drug interactions
Ghosts love PACMAN Grapefruit Protease inhibitors Azole Cyclosporine/Cobicistat Macrolides Amiodarone Non-DPH CCBs
Side effects with ezetimibe
myalgias
diarrhea
sinusitis
Which drug should not be used with ezetimibe due to risk of cholelithiasis
gemfibrozil
fenofibrate (caution)
PCSK9 Inhibitor MOA
Mabs that block PCSK9 from binding to LDL receptors and therefore increases LDL degradation by decreasing their receptor degradation
Bile acid sequestrants MOA
bind bile acids in the intestine forming a complex that’s excreted in feces, disruption enterohepatic circulation
List of bile acid sequestraants
cholestyramine
colesevelam
colestipol
Which drug can be considered for cholesterol control in a pregnant patient?
colesevelam
Counseling points for bile acid sequestrant
good oral hygeine needed due to possilbe tooth decay
separate from other meds by about 4 hours
take a multivitamin and separate from these meds
Fibrates MOA
PPAR alpha activators: increase expression of apolipoprotein and thus lipase activity. This leads to catabolism of VLDL particles and decreases TG
CI fibrates
liver disease gallbladder disease renal disease breastfeeding use with simvastatin!
What fibrate can not be given with ezetimibe or statins
gemfibrozil
niacin MOA
decreases synthesis of VLDL and LDL and increases the rate of TG removal from plasma
other names for niacin
B3
nicotinic acid
Is niacin a good options for patients with hepatic dysfunction?
NO! CI!
When are fish oils indicated
when TG > 500 they can be used as an adjunct to diet changes
Interaction concern with fish oils
warfarin, they can prolong bleeding so watch INR
How long can PCSK9s be kept out of the fridge?
30 days
