Dyslipidemia

Question 1

When do we decide to treat dyslipidemia? (LDL and TG level)

Answer 1

When:
LDL >= 190 and/or
TG >= 500

Question 2

What are the 4 benefit groups for statin use?

Answer 2

1) Clinical ASCVD (High Intensity)
2) LDL >= 190 (High Intensity)
3) Diabetes + Age 40-75 + LDL 70-189
- Multiple ASCVD risk (High Intensity)
- Regardless of risk (Moderate Intensity)
4) Age 40-75 + LDL 70-189
- ASCVD >20% (High Intensity)
- ASCVD 7.5-19% (Moderate Intensity)

Question 3

What drugs are used to treat dyslipidemia?

Answer 3

1) Statins
2) Ezetimibe
3) Bile Acid Sequestrants
4) Fibrates
5) Niacin
6) Fish Oils
7) PCSK9 Inhibitors

Question 4

What are the High Intensity Statins?

Answer 4

Atorvastatin 40-80 mg
Rosuvastatin 20-40 mg

*These lower LDL by > 50%

Question 5

What to do if a patient is already on a maximized dose of a statin, and not at goal?

Answer 5

Add:
-Ezetimibe (Zetia) - $
-PCSK9 inhibitor - $$$

Question 6

How do statins work?

Answer 6

They inhibit rate-limiting step (HmgCoA Reductase) of cholesterol synthesis. It lowers LDL by 20-55%, TG by 10-30%, and increase HDL by 5-15%

Question 7

What are the contraindications of Statins?

Answer 7

• Active Liver disease
• Pregnancy
• Breastfeeding

Question 8

What are the side effects of Statins?

Answer 8

• “H” Hepatotoxicity
• “M” Myalgia (muscle soreness), Myositis (muscle inflammation), rhabdoMyolysis (breakdown of muscle; Increase CPK)
• “G” Glucose changes (Increase BG and A1c)

Question 9

What are the equivalent doses of statins?

Answer 9

“Pharmacists Rock At Saving Lives and Preventing Flu”

Pitavastatin 2 mg =
Rosuvastatin 5 mg =
Atorvastatin 10 mg =
Simvastatin 20 mg =
Lovastatin 40 mg =
Pravastatin 40 mg =
Fluvastatin 80 mg

Question 10

What to do if a patient presents with myalgia?

Answer 10

1) Hold statin and check CPK
2) Rechallenge after 2-4 weeks (same or lower dose)
3) If myalgia returns, d/c statin

Question 11

Contraindications of simvastatin and lovastatin

Answer 11

-CYP 3A4 Inhibitors
-Conivaptan
-Gemfibrozil

Do not use more than 40 mg of Simvastatin

Question 12

How does Ezetimibe work?

Answer 12

It inhibits reabsorption of cholesterol in the small intestines.

It lowers LDL by 18-23% and TG by 5-10%

Question 13

How do Bile Acid Sequestrants work?

Answer 13

These bind bile acids in the intestine, forming a complex that is excreted int he feces.

It lowers LDL by 10-30%, but increases TG by 5% and HDL by 3-5%

Question 14

What are the Bile Acid Sequestrant drugs?

Answer 14

Cholestyramine, Colesevalam, Colestipol

Question 15

How does Niacin work?

Answer 15

Niacin decreases the rate of hepatic synthesis of VLDL (decreases TG) and LDL.

These lower TG by 20-50% and Increase HDL by 15-35%.

Side effect: flushing, hepatotoxicity

Question 16

What other name is Niacin known by?

Answer 16

Vitamin B3 or Nicotinic Acid

Question 17

How do Fibrates work?

Answer 17

They activate PPARa, which eliminates and decrease synthesis of VLDL, TG and increase HDL.
- Gemfibrozil
- Fenofibrate

They lower TG by 20-50%! So they are mainly used to lower TGs

Question 18

How do PCSK9 inhibitors work?

Answer 18

PCSK9 inhibitors block the degradation of LDL receptors.

These lower LDL by 60%, non-HDL by 35% and TG by 36%

Question 19

What are the PCSK9 inhibitor drugs?

Answer 19

1) Alirocumab (Praluent) q2weeks
2) Evolocumab (Repatha) q2weeks or q1mth

Question 20

What is the Freidewald equation?

Answer 20

LDL = TC - HDL - (TG/5)