Dyslipidemia Flashcards
Lipoproteins
Chylomicrons, VLDL, LDL and HDL
- Chylomicrons & VLDL: triglyceride rich
- LDL is cholesterol rich
- HDL is protein rich
Chylomicrons
Contain large amount of lipid and very little protein
HDL
More protein and small amount of lipid (good lipid)
- Picks up extra cholesterol from tissue
- helps remove LDL preventing it from building up in arteries
Lipoproteins
Are large carriers proteins to help transport (water soluble)
Etiology
- Two types: Primary/Familial or secondary
- Primary/Familial: genetic defect that can cause increase or decrease in lipoproteins.
- Secondary: Diet, drugs, disorder, disease
ASVCD Risk
- LDL: Dominant atherogenic cholesterol, delivers cholesterol to the cells
- VLDL: Main carrier of TG to the cells
Statin Benefit Groups
- clinical ASCVD, LDL-c >190mg/dL
- Diabetes, age 40-75 with LDL-C 70-189
- Primary prevention-no ascvd or diabetes with LDL-C 70-189 mg/dL and 10 yr ASCVD risk >7.5%
Total cholesterol
measures the combination of LDL, HDL and VLDL (VLDL is a precursor of LDL)
LDL
Low density lipoproteins
- Most of the cholesterol in the blood is carried by LDL
- LDL combines with other substances clogging arteries
- High saturated fat and trans fat diets increase LDL cholesterol
LDL score
-For most people, an LDL score below 100 is healthy, but people with heart disease may need to aim lower
Total Cholesterol Score
-Score of under 200 is considered healthy
HDL score
higher the level of HDL cholesterol the better. Too little-more likely to develop heart disease
Triglycerides
- Body converts excess calories, sugar, and alcohol into triglycerides
- Causes of high triglycerides
- -Obesity
- -smoking
- -physical inactivity
- -drugs (steroids, protease inhibitors, estrogen)
- genetics
- excess alcohol
- high carb diets
Triglyceride Scores
Normal <150 mg/dL
Borderline high 150-199
High 200-499
Very high >500
Very high trigylcerides
turns first to prevention of acute pancreatitis, more likely to occur when triglycerides are >1000 mg/dL.
Triglyceride lowering agents
- Fibrate or nicotinic acid
- First line therapy: although statins can be used to lower LDL cholesterol to reach the LDL goal
Priorities for tx of diabetic dyslipidemia:
1. LDL cholesterol lowering
- Lifestyle interventions
- HMG CoA reductase inhibitor (statin)
others: - -Bile acid binding resin (resin), cholesterol absorption inhibitor, fenofibrate or niacin
Priorities for tx of diabetic dyslipidemia:
2. HDL cholesterol raising
- Lifestyle modifcations
- Nicotinic acid or fibrates
Priorities for tx of diabetic dyslipidemia:
3. Triglyceride lowering
- Lifestyle modifcations
- Glycemic control
- fibric acid derivative
- Niacin
- High dose statins
Priorities for tx of diabetic dyslipidemia:
4. Combined hyperlipidemia
- First choice (improved glycemic control plus high dose statin)
- Second choice (improved glycemic control plus statin plus fibric acid derivative)
- Third choice (improved glycemic control plus statin plus nicotinic acid)
Non-Statins
- Cholesterol absorption inhibitor (Ezetimibe)
- Bile acid sequestrants
- PCSK9 inhibitors
- Nicotinic acid (niacin) (trig lowering)
- Fibric acid derivatives (trig lowering)
Statin drugs
Atorvastatin Fluvastatin Lovastatin Pravastatin Rosuvastatin Simvastatin
Statins
- Drug of choice for elevated LDL
- Prevents cardiovascular and cerebrovascular events
- Contraindicated in active or chronic liver disease, pregnancy, and lactation
- Adverse effects include myopathy and increase in liver transaminases
Side effects of Statin Therapy
-Myalgias, myopathy and rhabdomyolysis
-Elevated creatine kinase (CK) levels may indicate statin-induced muscle damage (myopathy/rhabdo)
-Muscle weakness/pain without CK elevation
may indicate statin-induced muscle damage (myalgias)
Ezetimibe
- Non-statin
- Safe and effective adjunct to statins when further LDL lowering is required
- Contraindicated in patients with active liver disease or unexplained persistent transaminase elevations
- Adverse effects include GI complaints
PCSK9 Inhibitors
- Evolocumab (Repatha) & Alirocumab (Praluent)
- Lowers LDL
- Expensive
- Injectable monoclonal antibody
- High risk prevention secondary prevention of ASCVD
- Familial hypercholesterolemia
Niacin
Non statin
-Uniquely effective in atherogenic dyslipidemia
Useful in nearly all dyslipidemias and adjunctive therapy for mixed dyslipidemias
Contraindicated in chronic liver disease, severe gout, active peptic ulcer disease
Adverse effects: flushing, hyperglycemia, hyperuricemia, hepatotoxicity
Bile Acid Sequestrants
- Non-statin
- Colesevelam, cholestyramine, colestipol
- Indicated for moderate hypercholesterolemia, in younger patients with elevated LDL, and women with elevated LDL who are considering pregnancy
- Adverse effects include constipation, flatulence and decreased absorption of other drugs like digoxin, warfarin, HCTZ, beta blockers, thyroxine and penicillin G
Fibrates
- Non-statin
- Gemfibrozil, Fenofibrate, Clofibrate
- Indications: hypertriglyceridemia, atherogenic dyslipidemia
- Contraindications: severe hepatic or renal dysfunction, primary biliary cirrhosis and gall bladder disease
Fibrate Safety
Before initiation check serum creatinine; impaired renal function is present, prescribe gemfibrozil (unless taking a statin), or a lower starting dose of fenofibrate (48 mg is most commonly available). Routine monitoring of creatinine is not required.
Omega-3 Fatty Acids
Fish oils
-Major use: Hypertriglyceridemia greater than 500
Key concepts
-First-line therapy: therapeutic lifestyle changes
-Statins are drug of choice for first line treatment due to potency and cost-effectiveness.
Non-statins, which include cholesterol absorption inhibitors, niacin, bile acid sequestrants, fibrates, and omega-3 fatty acids, probably help improve patient outcomes, although strong evidence remains lacking.
Triglycerides are now considered an independent risk factor ASCVD.
