Dyslipidemia

Question 1

Non-pharm: Physical Activity

Answer 1

-Aerobic exercise, moderate intensity (brisk walk/light jog)
-150 min each week (30 min/day)
-Weight loss: 200-300 min/week

Question 2

Non-pharm: Diet

Answer 2

DASH, Mediterranean, Vegetarian
-fruits/vegs, variety
-whole grains
-healthy proteins
-plant oils
-minimally processed
-low sugar/salt/alc

Question 3

Dietary Supplements

Answer 3

1. Soluble fiber (oat bran, psyllium)
   -reduce TC/LDL
2. Red Yeast Rice (MK identical to lovastatin)
   -avoid use with statin, get from reputable source

Question 4

Group 1: Clinical ASCVD

Answer 4

1. Not very high risk
   - <=75: high statin (if max therapy and LDL 70+ then ezetimibe)
   - 75+: mod or high statin
2. Very high risk*
   - Statin
   - If max therapy and LDL 70+ then ezetimibe
   - Then PSCK9I (LDL 70+/non HDL 100+)

*major cardio events, diabetes, 65+, bypass surg, ckd, htn, hf

Question 5

Statins (HMG-CoA Reductase Inhibitors) ae, mon, ci

Answer 5

Side Effects (SAD LAB)
-SAMS (myopathy, myalgias, rhabdomyolysis)
-Elevated hepatic transaminases (primarily ALT)
-New onset diabetes
*CK/ALT/AST monitored as indicated

Monitoring
-Fasting lipids 4-12 weeks after initiation/dose adj and every 3-12 months thereafter

CI:
-Active/acute liver disease (chronic disease ok)
-Pregnancy? (Risk vs benefit)
-Breastfeeding

Question 6

Simvastatin: FDA-recommended restrictions, contraindications, dose limitations

Answer 6

• Simvastatin 80 mg should only be continued in patients who have tolerated dose for > 12 months (no new starts)
• Avoid large quantities of grapefruit juice (> 1 quart daily)

DV10 ARA20

CI (PACNG MD)
- azoles
- mycins
- HIV protease inhibitors
- nefazodone
- gemfibrozil
- cyclosporine
- danazol

10 mg limit for: verapamil, diltiazem

20 mg limit for: amiodarone, amlodipine, ranolazine

Question 7

Statin Classifications

Answer 7

HIGH (50%+) A48R24
-Atorvastatin 40 – 80 mg
-Rosuvastatin 20 – 40 mg

MOD (30-50%)
-Atorvastatin 10 - 20 mg
-Rosuvastatin 5 – 10 mg
-Simvastatin 20 – 40 mg
-Pravastatin 40 – 80 mg
-Lovastatin 40 mg
-Fluvastatin XL 80 mg
-Fluvastatin 40 mg BID
-Pitavastatin 2 – 4 mg

LOW (<30%) S1P12L2
-Simvastatin 10 mg
-Pravastatin 10 – 20 mg
-Lovastatin 20 mg
-Fluvastatin 20 – 40 mg
-Pitavastatin 1 mg

Question 8

Statin Equivalents

Answer 8

-RO 20 to ATOR 80

-RO 5/10 to ATOR 20 to SIM 40 to PRAV/LOVA 80

RASP

Question 9

Consider non-statins in high-risk patients:

Answer 9

• Have less-than-anticipated response (LDL-C ≥ 70 mg/dL)
• Unable to tolerate less-than recommended statin dose
• Are deemed completely statin intolerant

Question 10

Ezetimibe

Answer 10

LDL: ↓ 10 – 18% (monotherapy)
↓ 34 – 61% (with statins)

AE: diarrhea

10 mg PO daily with or without food

Question 11

PCSK9 Inhibitors

Answer 11

LDL: ↓ up to 60% in statin-treated patients

AE: FINI
-Injection site reactions
-Flu-like symptoms, upper respiratory tract infections, nasopharyngitis
*No evidence of increase in cognitive adverse effects

Alirocumab 75 mg every 2 wk
Evolocumab 140 mg every 2 wk

Question 12

Group 2: Primary
Severe Hypercholesterolemia (LDL-C ≥ 190 mg/dL)

Answer 12

1. Max tolerated statin
2. If 50% reduction and/or LDL-C < 100 mg/dL not achieved, add ezetimibe
3. If 50% reduction not achieved and fasting TG ≤ 300 mg/dL, add bile acid sequestrants

*If baseline LDL-C > 220 mg/dL and LDL-C > 130 mg/dL on max tolerated statin and ezetimibe, addition of PCSK9i may be considered

Question 13

Bile Acid Sequestrants (colesevelam, colestipol, cholestyramine)

Answer 13

TG: May ↑! Avoid in TG levels exceeding 300 mg/dL (3.39 mol/L)

AE:
-GI, constipation, bloating, epigastric fullness, nausea, flatulence

DDI:
-Impaired abs. of fat-soluble vitamins A, D, E, and K
-Reduced bioavailability of warfarin, levothyroxine, phenytoin
*Take meds 1 hour before or 4 hours after BAS

CI:
-Bowel obstruction
-Hx of hypertriglyceridemia-induced pancreatitis

SAFE IN PREGNANCY, can lower A1C

Question 14

Group 3: Diabetes

Answer 14

Age 20-39 y and LDL-C 70-189 mg/dL
= MOD STATIN

Age 40-75 y and LDL-C 70-189 mg/dL
= ASCVD risk/50-75 yr = HIGH statin
= NO ASCVD = MOD statin
*If 10-yr ASCVD risk ≥ 20%, consider adding ezetimibe

Question 15

Group 4: Primary Prevention

Answer 15

1. 0-19
   -lifestyle or if familial hypercholesteremia = statin
2. 20-39
   -lifestyle or statin if family hx, premature ASCVD and LDL 160+
3. 40-75 and LDL 70-190 without diabetes
   -5% = lifestyle
   -5-7.5% = risk enhancers = mod statin
   -7.5-20% = risk enh = mod statin
   -20+% = high statin
   *if uncertain = CAC 1-99/100+ = statin

Question 16

Inclisiran

Answer 16

LDL: ↓ Average of 50% in statin-treated patients

AE:
-Injection-site reactions (transient and mild)
-Bronchitis

Question 17

Adenosine triphosphate-citrate lyase (ACL) inhibitors (bempedoic acid)

Answer 17

LDL: ↓ 17-18% in combination therapy with statin
↓ 38% with ezetimibe and statin

AE: BUUMPE
-Upper respiratory tract infection
-Muscle spasms, back pain
-Hyperuricemia
-Abdominal pain/discomfort
-Elevated liver enzymes

Question 18

Nicotinic acid (Niacin)

Answer 18

For HDL increasing

AE: FULI
-Prostaglandin-mediated cutaneous flushing (IR > ER)
-Hepatotoxicity
-Hyperuricemia
-Increase insulin resistance

Question 19

Management of Hypertriglyceridemia

Answer 19

1. high intensity statin (first line)
2. icosapent ethyl

Question 20

Omega-3 Fatty Acids (DHA + EPA)

Answer 20

-Omega-3 acid ethyl esters (Lovaza®)
-Icosapent ethyl (Vascepa®)
-Omega-3 (OTC products)

2 g twice daily

AE:
-Diarrhea, gastrointestinal upset, nausea/vomiting
-Fishy breath
-May increase risk of bleeding

Question 21

Fibrates (gemfibrozil and fenofibrate)

Answer 21

AE:
- Gastrointestinal upset
- May enhance the formation of gallstones (rare)
- Myopathies (especially with gemfibrozil when used with statins – fenofibrate preferred with statin use)

FOR: ≥ 20y with TG ≥ 500 and max statin (25M)

Question 22

Familial Hypercholesterolemia

Answer 22

HeFH: high intensity statins, PCSK9 inhibitors, bempedoic acid

HoFH: Lipoprotein apheresis (removes cholesterol from plasma), evinacumab, lomitapide, evolocumab
-Statins reduce LDL-C modestly even in those who are receptor negative

Question 23

MTP inhibitor (lomitapide)

Answer 23

BBW and REMS
-liver toxicity, steatosis

AE: NVDAP, vitamin deficiency

Question 24

Evinacumab

Answer 24

Nasopharyngitis, rhinorrhea
Influenza-like illness, dizziness
Nausea

Evan my FrieND (FND)

Question 25

Women and pregnancy

Answer 25

Risk vs benefit discussion:
-Consider continuing statin for those with clinical ASCVD or HoFH
-Consider hydrophilic statin (pravastatin)

*BAS are considered safe in pregnancy