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Naplex 2023 > Dyslipidemia > Flashcards

Dyslipidemia Flashcards

1
Q

statin MOA

A

HMG-CoA reductase inhibitor = rate-limiting step in cholesterol synthesis
reduces formation of cholesterol
reduces ASCVD risk

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2
Q

ezetimibe MOA

A

blocks cholesterol absorption

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3
Q

colesevelam MOA

A

bile acid sequestrant
blocks enterohepatic circulation

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4
Q

HDL benefit

A

lowers ASCVD risk

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5
Q

hypertriglyceridemia risk

A

pancreatitis if >500

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6
Q

drugs that increase LDL and TG

A

diuretics
efavirenz
steroids
immunosuppressants (cyclosporine, tacrolimus)
atypical antipsychotics
protease inhibitors

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7
Q

drugs that inc LDL only

A

fish oils (except vascepa)

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8
Q

drugs that inc TG only

A

IV lipid emulsions
propofol
bile acid sequestrant

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9
Q

conditions that inc hyperlipidemia

A

obesity
poor diet
hypothyroidism
alcoholism
smoking
diabetes
renal disease
liver disease
nephrotic syndrome
pregnancy
polycystic ovarian syndrome
anorexia

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10
Q

Friedewald equation

A

LDL = TC - HDL - (TG/5)
do not use when TG >400

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11
Q

inputs into ASCVD risk calculator

A

TC
HDL
SBP
antihypertensive use
diabetes status
smoking status

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12
Q

ASCVD risk-enhancing factors

A

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

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13
Q

non-drug treatment

A

BMI 18.5-24.9
veggies, fruits, whole grains, high fiber, fish
limit saturated fat, trans fat, cholesterol
aerobic 3-4 times/week

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14
Q

natural products

A

red yeast rice - has naturally occurring HMG-CoA reductase inhibitors
OTIC fish oils - lower TG

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15
Q

drug treatment

A

DOC: statin: high non-HDL and LDL
ezetimibe and PCSK9 inhibitors over other non-statin drugs

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16
Q

Liver damage from cholesterol lowering drugs

A

niacin
fibrates
potentially statins
do not use if AST or ALT is >3 times ULN

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17
Q

high-intensity statin indications

A

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

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18
Q

moderate-intensity statin indications

A

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

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19
Q

statin equivalent doses

A

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

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20
Q

statin side effects

A

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)

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21
Q

managing myalgia

A

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

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22
Q

statin CI

A

pregnancy
breastfeeding
liver disease
CYP3A4 inhibitors (with simvastatin and lovastatin)

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23
Q

statin warnings

A

muscle damage: inc CPK; higher risk with high dose, advanced age, niacin, gemfibrozil, CYP3A4 inhibitors
diabetes: inc A1C/FBG

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24
Q

statin monitoring

A

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

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25
Q

statin notes

A

take lovastatin (Altoprev) with evening meal and simvastatin (Zocor) in evening
lipid effects: dec LDL; inc HDL; dec TG

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26
Q

statin DI

A

interact with CYP3A4

do not use statins with gemfibrozil

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27
Q

which statins have less DI

A

rosuvastatin

pravastatin

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28
Q

which drugs can you not use with simvastatin or lovastatin

A

G <3 PACMAN

Grapefruit
PIs
Azoles
Cyclosporine, Cobicistat
Macrolides (except Azithromycin)
Amiodarone
Non-DHPs

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29
Q

max statin use with cyclosporine

A

rosuvastatin 5 mg/day max

30
Q

max statin use with cobicistat

A

atorvastatin 20 mg/day max

31
Q

max statin use with amiodarone

A

simvastatin 20 mg/day max
lovastatin 40 mg/day max

32
Q

max statin use with non-DHPs

A

simvastatin 10 mg/day max
lovastatin 20 mg/day max

33
Q

non-statin add-ons that target triglycerides

A

fish oils
fibrates

34
Q

when to add on ezetimibe (preferred) or PCSK9i

A

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

35
Q

ezetimibe MOA

A

inhibit absorption of cholesterol in the small intestine

36
Q

Ezetimibe side effects

A

myalgias

37
Q

Ezetimibe affects on lipid

A

dec LDL

38
Q

PCSK9i (alirocumab/Praluent; evolocumab/Repatha/Pushtronex) MOA

A

MAbs that block PCSK9 from binding LDL = dec LDL

SC injections

39
Q

PCSK9i side effects

A

injection site reactions

40
Q

PCSK9i lipid effects

A

dec LDL 60%

41
Q

bile acid sequestrants/bile acid binding resins (Cholestyramine; Colesevelam/Welchol; colestipol) MOA

A

bind bile acids in intestine = complex excreted in feces

42
Q

bile acid sequestrants CI

A

bowel obstruction

43
Q

Colesevelam/Welchol notes

A

glycemic control in T2DM

take with a meal and liquid

option for pregnant patients

44
Q

bile acid sequestrants side effects

A

constipation
abdominal pain
cramping
bloating
gas
inc TG

45
Q

bile acid sequestrants notes

A

holding Cholestyramine suspension in mouth can change teeth (discoloration, erosion of enamel, decay)

46
Q

bile acid sequestrants lipid effects

A

can inc TG

47
Q

bile acid sequestrants

A

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

48
Q

fibrates (fenofibrate, Antara, Tricor, Trilipix; gemfibrozil/Lopid) MOA

A

PPARalpha activators = inc ApoC-II=inc lipoprotein lipase activity = inc catabolism VLDL=large dec in TG

49
Q

fibrate administration

A

take Fenoglide and Lipofen with meals

50
Q

fibrate CI

A

severe liver disease, including primary biliary cirrhosis

gallbladder disease

51
Q

fibrate warnings

A

myopathy (inc risk with statin)

52
Q

fibrate side effecgs

A

dyspepsia (gemfibrozil)

inc LFT’s

53
Q

fibrate lipid effects

A

dec TG

can inc LDL when TG are high

54
Q

fibrate DI

A

do not take gemfibrozil with ezetimibe or statins

fibrates inc effects of SUs and warfarin

55
Q

niacin/nicotinic acid/vitamin B3 MOA

A

dec hepatic synthesis of VLDL (dec TG) and LDL

56
Q

Niacin dosing

A

titrate slowly

IR: give with food

ER: at bedtime after low-fat snack

CR/SR: give with food

57
Q

Niacin warnings

A

rhabdomyolysis

hepatotoxicity

inc BG and uric acid

58
Q

Niacin side effects

A

flushing
pruritus
vomiting
diarrhea
inc BG
hyperuricemia (gout)

59
Q

Niacin monitoring

A

LFTs

60
Q

Niacin notes

A

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

61
Q

Niacin lipid effects

A

ind HDL

62
Q

Niacin DI

A

monitor for other drugs that are hepatotoxic
take niacin 4-6 hrs after bile acid seqestrants

63
Q

fish oil (omega-3/Lovaza; Isocapent ethyl/Vascepa) indication

A

adjunct to diet with TG >=500

Icosapent ethyl/Vascepa - ASCVD risk reduction

64
Q

fish oil warnings

A

caution with HSN to fish and/or shellfish

65
Q

fish oil side effects

A

eructation (burping)
dyspepsia
taste perversions (Lovaza)

66
Q

fish oil lipid effects

A

dec TG
can inc LDL (Lovaza); not seen inc w Vascepa

67
Q

fish oil DI

A

prolong bleeding time
monitor INR if on Warfarin

68
Q

lomitapide inidcation

A

homozygous familial hypercholesterolemia (HoFH)

69
Q

lomitapide BBW

A

hepatotoxicity

70
Q

lomitapide CI

A

active liver disease
pregnancy

Naplex 2023 (21 decks)

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