Dyslipidemia Flashcards
statin MOA
HMG-CoA reductase inhibitor = rate-limiting step in cholesterol synthesis
reduces formation of cholesterol
reduces ASCVD risk
ezetimibe MOA
blocks cholesterol absorption
colesevelam MOA
bile acid sequestrant
blocks enterohepatic circulation
HDL benefit
lowers ASCVD risk
hypertriglyceridemia risk
pancreatitis if >500
drugs that increase LDL and TG
diuretics
efavirenz
steroids
immunosuppressants (cyclosporine, tacrolimus)
atypical antipsychotics
protease inhibitors
drugs that inc LDL only
fish oils (except vascepa)
drugs that inc TG only
IV lipid emulsions
propofol
bile acid sequestrant
conditions that inc hyperlipidemia
obesity
poor diet
hypothyroidism
alcoholism
smoking
diabetes
renal disease
liver disease
nephrotic syndrome
pregnancy
polycystic ovarian syndrome
anorexia
Friedewald equation
LDL = TC - HDL - (TG/5)
do not use when TG >400
inputs into ASCVD risk calculator
TC
HDL
SBP
antihypertensive use
diabetes status
smoking status
ASCVD risk-enhancing factors
very high LDL
FH of premature ASCVD
metabolic syndrome
chronic kidney disease
preeclampsia or premature menopause
chronic inflammatory disorders (esp. if 10-yr ASCVD risk 7.5-19.9%; if CAC 100 or more = start statin
high CRP
high CAC score
abnormal ankle brachial index
non-drug treatment
BMI 18.5-24.9
veggies, fruits, whole grains, high fiber, fish
limit saturated fat, trans fat, cholesterol
aerobic 3-4 times/week
natural products
red yeast rice - has naturally occurring HMG-CoA reductase inhibitors
OTIC fish oils - lower TG
drug treatment
DOC: statin: high non-HDL and LDL
ezetimibe and PCSK9 inhibitors over other non-statin drugs
Liver damage from cholesterol lowering drugs
niacin
fibrates
potentially statins
do not use if AST or ALT is >3 times ULN
high-intensity statin indications
clinical ASCVD (ACS, MI, stable/unstable angina, coronary or other revascularization), stroke, TIA, PAD of atherosclerotic origin
LDL 190 or more
DM age 40-75 with LDL 70-189 and multiple ASCVD risk factors
40-75 with LDL 70-189 and 10-yr ASCVD risk 20% or more
moderate-intensity statin indications
DM age 40-75 with LDL 70-189 without multiple ASCVD risk factors
age 40-75 with LDL 70-189 and 10-yr ASCVD risk 7.5-19.9% and risk-enhancing factors
statin equivalent doses
Pharmacists Rock At Saving Lives and Preventing Fat
Pitava: 2 mg
Rosuva: 5 mg
Atorva: 10 mg
Simva: 20 mg
Lova: 40 mg
Prava: 40 mg
Fluva: 80 mg
statin side effects
muscle damage: symmetrical; usu within 6 weeks
myalgia: sore/tender
myopathy: weak w or wo CPK inc
myositis: muscle inflammation
rhabdo: symptoms + very high CPK (>10,000) + myoglobinuria (can lead to renal failure)
managing myalgia
reduce risk:
avoid DI
don’t use simvastatin 80 mg
do not use gemfibrozil + statin
manage:
hold statin, check CPK, investigate other causes
re-challenge in 2-4 weeks with same at same or lower dose
if myalgias return, dc statin; once resolve, use low dose of different statin and gradually inc
statin CI
pregnancy
breastfeeding
liver disease
CYP3A4 inhibitors (with simvastatin and lovastatin)
statin warnings
muscle damage: inc CPK; higher risk with high dose, advanced age, niacin, gemfibrozil, CYP3A4 inhibitors
diabetes: inc A1C/FBG
statin monitoring
lipid panel 1-3 mo after starting; then annually
if myalgia: check CPK
if little/no urine: check SCr/BUN
if abd pain/jaundice: LFTs for hepatotoxicity
statin notes
take lovastatin (Altoprev) with evening meal and simvastatin (Zocor) in evening
lipid effects: dec LDL; inc HDL; dec TG
statin DI
interact with CYP3A4
do not use statins with gemfibrozil
which statins have less DI
rosuvastatin
pravastatin
which drugs can you not use with simvastatin or lovastatin
G <3 PACMAN
Grapefruit
PIs
Azoles
Cyclosporine, Cobicistat
Macrolides (except Azithromycin)
Amiodarone
Non-DHPs
max statin use with cyclosporine
rosuvastatin 5 mg/day max
max statin use with cobicistat
atorvastatin 20 mg/day max
max statin use with amiodarone
simvastatin 20 mg/day max
lovastatin 40 mg/day max
max statin use with non-DHPs
simvastatin 10 mg/day max
lovastatin 20 mg/day max
non-statin add-ons that target triglycerides
fish oils
fibrates
when to add on ezetimibe (preferred) or PCSK9i
very high-risk (multiple ASCVD events of ASCVD in high-risk patient (DM) + statin on max dose + LDL still >=70
LDL >=190 + statin at max dose + LDL still >=100
ezetimibe MOA
inhibit absorption of cholesterol in the small intestine
Ezetimibe side effects
myalgias
Ezetimibe affects on lipid
dec LDL
PCSK9i (alirocumab/Praluent; evolocumab/Repatha/Pushtronex) MOA
MAbs that block PCSK9 from binding LDL = dec LDL
SC injections
PCSK9i side effects
injection site reactions
PCSK9i lipid effects
dec LDL 60%
bile acid sequestrants/bile acid binding resins (Cholestyramine; Colesevelam/Welchol; colestipol) MOA
bind bile acids in intestine = complex excreted in feces
bile acid sequestrants CI
bowel obstruction
Colesevelam/Welchol notes
glycemic control in T2DM
take with a meal and liquid
option for pregnant patients
bile acid sequestrants side effects
constipation
abdominal pain
cramping
bloating
gas
inc TG
bile acid sequestrants notes
holding Cholestyramine suspension in mouth can change teeth (discoloration, erosion of enamel, decay)
bile acid sequestrants lipid effects
can inc TG
bile acid sequestrants
separate cholestyramine or colestipol from other drugs by taking other drugs 1-4 hrs before or 4-6 hours after bile acid sequestrant
take levothyroxine four hours before colesevelam
can dec abs of DEAK vitamins; separate multivitamin from bile acid sequestrant
fibrates (fenofibrate, Antara, Tricor, Trilipix; gemfibrozil/Lopid) MOA
PPARalpha activators = inc ApoC-II=inc lipoprotein lipase activity = inc catabolism VLDL=large dec in TG
fibrate administration
take Fenoglide and Lipofen with meals
fibrate CI
severe liver disease, including primary biliary cirrhosis
gallbladder disease
fibrate warnings
myopathy (inc risk with statin)
fibrate side effecgs
dyspepsia (gemfibrozil)
inc LFT’s
fibrate lipid effects
dec TG
can inc LDL when TG are high
fibrate DI
do not take gemfibrozil with ezetimibe or statins
fibrates inc effects of SUs and warfarin
niacin/nicotinic acid/vitamin B3 MOA
dec hepatic synthesis of VLDL (dec TG) and LDL
Niacin dosing
titrate slowly
IR: give with food
ER: at bedtime after low-fat snack
CR/SR: give with food
Niacin warnings
rhabdomyolysis
hepatotoxicity
inc BG and uric acid
Niacin side effects
flushing
pruritus
vomiting
diarrhea
inc BG
hyperuricemia (gout)
Niacin monitoring
LFTs
Niacin notes
IR: poorly tolerated bc flushing/itching
CR/SR have less flushing but more hepatotoxicity
best clinical: Niaspan - less flushing and less hepatotoxicity
reduce flushing with ASA 325 before dose; take with food (not spicy, alcohol, hot beverages)
different formulations not interchangeable
Niacin lipid effects
ind HDL
Niacin DI
monitor for other drugs that are hepatotoxic
take niacin 4-6 hrs after bile acid seqestrants
fish oil (omega-3/Lovaza; Isocapent ethyl/Vascepa) indication
adjunct to diet with TG >=500
Icosapent ethyl/Vascepa - ASCVD risk reduction
fish oil warnings
caution with HSN to fish and/or shellfish
fish oil side effects
eructation (burping)
dyspepsia
taste perversions (Lovaza)
fish oil lipid effects
dec TG
can inc LDL (Lovaza); not seen inc w Vascepa
fish oil DI
prolong bleeding time
monitor INR if on Warfarin
lomitapide inidcation
homozygous familial hypercholesterolemia (HoFH)
lomitapide BBW
hepatotoxicity
lomitapide CI
active liver disease
pregnancy
