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Dyslipidemia Flashcards

1
Q

How is LDL calculated using the Friedwald equation?

A

LDL= TC-HDL- (TG/5)

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2
Q

What is a desirable non-HDL?

A

<130

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3
Q

What is a desirable LDL-C?

A

<100

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4
Q

What is a desirable HDL?

A

Men: ≥40
Women: ≥50

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5
Q

What is a desirable TG?

A

<150

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6
Q

What are risk factors for calulating 10 year ASCVD risk of first CV event?

A
  1. sex, age (20-79), race
  2. Smoking
  3. TC, HDL, LDL, and statin use
  4. SBP and antihypertensive treatment
  5. Hx DM
  6. aspirin use
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7
Q

When does ASCVD not need to be calculated and statin therapy immediately initiated?

A
  1. clinical ASCVD
  2. DM
  3. LDL≥190
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8
Q

What drugs increase LDL and TG?

A
  1. Diuretics
  2. Efavirenz
  3. Immunosuppressants (cyclosporine/tacrolimus)
  4. Atypical antipsychotics
  5. Protease inhibitors
  6. retinoids
  7. systematic steroids
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9
Q

What drugs increase LDL?

A
  1. Fibrates
  2. Fish oils (not Vascepa)
  3. anabolic steroids
  4. progestins
  5. SGLT2i
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10
Q

What drugs increase TG?

A
  1. IV lipid emulsions
  2. Propofol
  3. Clevidipine
  4. Bile acid sequestrants (~5%)
  5. estrogen
  6. tamoxifen
  7. beta blockers
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11
Q

What conditions increase LDL and/or TG?

A
  1. Obesity
  2. Poor diet (high saturated fat)
  3. Alcohol use disorder
  4. Hypothyroidism
  5. Smoking
  6. Diabetes
  7. Renal/Liver disease
  8. Nephrotic syndrome
  9. pregnant
  10. PCOS
  11. anorexia
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12
Q

When is coronary artery calcium score used?

A

Help determine if statins should be initiated in ASCVD risk 7.5-19.9; score ≥100 statin is indicated

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13
Q

What lifestyle modifications can lower cholesterol?

A
  1. BMI: 18.5-24.9
  2. High fiber fruits/veg/whole grain
  3. Healthy protein: low-fat dairy, poultry, fish, nuts
  4. Limit saturated fat (5-6% calories), trans fat, sweets, sugar sweetened drinks
  5. Aerobic physical exercise 3-4x/week
  6. Avoid tobacco/limit alcohol
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14
Q

What natural products can lower cholesterol?

A
  1. Red yeast rice (natural HMGCoA inhibitor)
  2. Plant sterols/stanols/fiber
  3. OTC fish oil (may increase LDL)
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15
Q

What is the statin benefit group 1? What intensity statin is indicated?

A
  1. Clinical ASCVD; secondary prevention
  2. High
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16
Q

What is statin benefit group 2?

A
  1. Primary severe dyslipidemia: LDL≥190
  2. High
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17
Q

What is statin benefit group 3? What intensity statin is indicated?

A
  1. Diabetes ages 40-75
  2. High: multiple RFs
    Moderate: regardless of risk
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18
Q

What is statin benefit group 4? What intensity statin is indicated?

A
  1. 40-75y/o and LDL 70-189
  2. High: ASCVD risk ≥20%
    Moderate: ASCVD risk 7.5-19.9% and RFs
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19
Q

What doses of statins are equivalent?

A

Pitavastatin 2mg
Rosuvastatin 5mg
Atorvastatin 10mg
Simvastatin 20mg
Lovastatin 40mg
Pravastatin 40mg
Fluvastatin 80mg
Pharmacists Rock At Saving Lives Preventing Fatty deposits

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20
Q

How does muscle damage present with statins?

A

Presents as muscle soreness, tiredness, or weakness that is symmetrical in large muscle groups (legs/back/arms), usually occurring within 6 weeks of starting a statin

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21
Q

What is the difference between myalgia/myositis/myopathy/rhabdomyolysis?

A
  1. Myalgia: muscle soreness/tenderness
  2. Myopathy: muscle weakness +/- CPK elevation
  3. Myositis: muscle inflammation
  4. Rhabdomyolysis: muscle symptoms with very high CPK + muscle protein in the urine (myoglobinuria) may lead to acute renal failure
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22
Q

How are myalgias managed?

A
  1. Hold statin, check CPK, consider other causes
  2. After 2-4 weeks rechallenge with the same statin at the same dose
  3. If myalgia returns, D/C statin
  4. Once muscle symptoms resolve, use a low dose of a different statin and gradually titrate up
  5. If unable to tolerate after 2 attempts consider non-stain
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23
Q

How are myalgias prevented?

A
  1. Avoid drug interactions (check OTC)
  2. Avoid Simvastatin 80mg/d
  3. Do Not use gemfibrozil +statin
  4. Supplement with Coenzyme Q10
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24
Q

What increases the risk of myalgias with statins?

A
  1. Higher doses
  2. Advanced age
  3. Concurrent use Niacin or Fibrates
  4. Hypothyroidism (uncontrolled)
  5. Renal imapirment
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25
Q

What are CIs with statins?

A
  1. Liver disease (includes unexplained high LFTs)
  2. Breastfeeding
  3. Strong CYP3A4 inhibitors with lovastatin/simvastatin
  4. Cylosporine + pitavastatin
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26
Q

What are warnings with statins?

A
  1. Muscle damage with elevated CPK +/- acute renal failure
  2. Avoid use in pregnancy; may continue if at high risk of CV events
  3. Elevates A1C/ fasting BG
  4. Hepatotoxicity with elevated LFTs (rare)
  5. hemorrhagic stroke; if recent stroke/TIA (Atorvastatin)
  6. proteinuria/hematuria usually transient (Rosuvastatin)
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27
Q

What are SEs with statins?

A

Myalgia/Myopathy

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28
Q

What should be monitored with statins?

A
  1. Lipid panel (baseline, 4-12 weeks after starting/changing therapy, then every 3-12 months; usually annually)
  2. LFTs at baseline and if sx of hepatotoxicity occur
  3. CPK if symptoms of muscle damage
  4. Scr/BUN if decreased urine output
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29
Q

What effects do statins have on lipid panel?

A
  1. Decrease LDL ~20-55%
  2. Increase HDL ~5-15%
  3. Decrease TGs ~10-30%
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30
Q

Which statins can be taken at any time of day?

A
  1. Rosuvastatin
  2. Atorvastatin
  3. Pitavastatin
  4. Lescol XL (fluvastatin)
  5. Pravastatin
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31
Q

Which statins need dosed at night?

A
  1. Fluvastatin (IR)
  2. Simvastatin
  3. Lovastatin
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32
Q

Which statins require renal dose adjustments?

A

CrCl<30: use lower starting dose of lovastatin/simvastatin/lovastatin
eGFR<60: use lower starting dose of pitavastatin

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33
Q

Which statin should be taken on an empty stomach?

A

FloLipid (simvastatin oral suspension)

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34
Q

Which stain should be taken with the evening meal?

A

IR lovastatin

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35
Q

Which statin may require a lower dose in asain patients due to exposures being 2x higher?

A

Rosuvastatin

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36
Q

What drugs interact with statins?

A

CYP3A4:
Grapefruit
Protease inhibitors
Azole antifungals
Cyclosporine/Cobicistat
Macrolides (not azythromicin)
Amiodarone
Non-DHP CCBs

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37
Q

What drugs cannot be used with simvastatin or lovastatin due to increased risk of rhabdo?

A
  1. Grapefruit
  2. Protease inhibitors
  3. Azole antifungals
  4. Cyclosporine/Cobicistat
  5. Macrolides (not azythromicin)
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38
Q

What is the max dose of simvastain/lovastatin that can be given to someone on Amiodarone?

A
  1. Simvastatin: 20mg/d max
  2. Lovastatin: 40mg/d max
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39
Q

What is the max dose of simvastain/lovastatin that can be given to someone on a Non-DHP CCB?

A
  1. Simvastatin: 10mg/d max
  2. Lovastatin: 20mg/d max
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40
Q

Which statins interact with amlodipine, elevating statin concentrations?

A
  1. Simvastatin 20mg/d max
  2. Atorvastatin
  3. Lovastatin
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41
Q

Which statins have the least amount of drug interactions?

A
  1. Rosuvastatin
  2. Pravastatin
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42
Q

Atorvastatin

A

Lipitor
Atorvaliq (oral suspension)

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43
Q

Fluvastatin

A

Lescol XL

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44
Q

Lovastatin

A

Altoprev

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45
Q

Atorvastatin + Amlodipine

A

Caduet

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46
Q

Pitavastatin

A

Livalo
Zypitamag

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47
Q

Pravastatin

A

Pravachol

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48
Q

Rosuvastatin

A

Crestor
Ezallor Sprinkle

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49
Q

Simvastatin

A

Zocor
FloLipid (suspension)

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50
Q

Simvastatin + Ezetimibe

A

Vytorin

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51
Q

When is add on treatment apporpriate for someone is statin benefit group 1?

A

LDL >55

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52
Q

When is add on treatment apporpriate for someone is statin benefit group 2?

A

LDL >70

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53
Q

When is add on treatment apporpriate for someone is statin benefit group 3?

54
Q

When is add on treatment apporpriate for someone is statin benefit group 4?

A

LDL ≥100

55
Q

What is the MOA of ezetimebe?

A

inhibits absorption of cholesterol in the small intestine

56
Q

What are warnings with ezetimbe?

A
  1. Avoid use in moderate/severe hepatic impairment (LFTs 3x ULN)
  2. Skeletal muscle effects; risk increases when used with statins
  3. Pregnancy: risk unknown
  4. Breast feeding: avoid
57
Q

What are SEs with ezetimibe?

A
  1. Myalgia
  2. arthalgia
  3. pain in extremities
  4. URTIs
  5. sinusitis
58
Q

What should be monitored while on ezetimibe?

A

LFTs (baseline and when clinically indicated)

59
Q

How does ezetimibe effect cholesterol?

A
  1. Decreases LDL 18-23%
  2. Increases HDL 1-3%
  3. Decreases TGs 5-10%
60
Q

What drugs interact with ezetimibe?

A
  1. Elevated levels of ezetimibe and cyclosporine when used together
  2. Bile acid sequestrants decrease ezetimibe; give zetia 2h before or 4 h after
  3. Increased risk of cholelithiasis when used with fibrates/gemfibrozil
61
Q

What is the MOA of PCSK9 monoclonal antibodies?

A

block degradation of LDL receptors by PCSK9, decreasing LDL

62
Q

What are warnings with PCSK9i?

A

Allergic reaction

63
Q

What are SEs with PCSK9i?

A
  1. Injection site reactions
  2. nasopharingitis/influenza/URTIs
  3. UTIs
  4. back pain (evolocumab)
  5. elevated LFTs (alirocumab)
64
Q

What should be monitored with PCSK9i?

A

LDL (baseline and 4-8 weeks)

65
Q

How is PCSK9i administered?

A

Prior to administration allow prefilled pen to warm to room temperature; inject SQ every 2 weeks or monthly

66
Q

How are PCSK9i stored?

A
  1. Store in the refrigerator in the original container to protect from light
  2. Up to 30 days at room temperature, then discard
67
Q

Alirocumab

68
Q

Evolocumab

A

Repatha
Repatha SureClick
Pushtronex

69
Q

How do PCSK9i effect cholesterol?

A

Decrease LDL 60%

70
Q

What is the MOA of bile acid sequestrants?

A

bind and form complex with bile acids that is excreted in the feces

71
Q

What are CIs with bile acid sequestrants?

A
  1. Cholestyramine: complete biliary obstruction
  2. Colesevelam: Bowel obstruction, TG>500, TG induced pancreatitis
72
Q

What are warnings with bile acid sequestrants?

A
  1. Some formulations contain phenylalanine; do not use in PKU
  2. Increased bleeding risk due to Vit K deficiency
73
Q

What are SEs with bile acid sequestrants?

A
  1. Constipation (reduce dose or laxative)
  2. Abdominal pain
  3. Cramping
  4. Bloating
  5. Gas/ Dyspepsia
  6. Elevated TGs
  7. nausea
  8. esophageal obstruction
  9. teeth discoloration/erosion of enamel/decay (cholestyramine packet)
74
Q

How are cholestyramine packets administered?

A
  1. Mix powder in 2-6oz water/non-carbonated liquid
  2. Do not sip or hold the resin in the mouth for prolonged periods
  3. Take with a meal and liquid
75
Q

How are Colesevelam packets/tablets administered?

A
  1. Empty 1 packet into a glass; add 8oz water, fruit juice, or diet soft drink and mix well
  2. Take with meal and a liquid
76
Q

How are Colestipol packets administered?

A

Empty 1 packet into 3oz of liquid and store until mixed

77
Q

How do bile acid sequestrants effect cholesterol?

A
  1. Dcrease LDL 10-30%
  2. Raise HDL
  3. May increase TG; do not start if TG>300
78
Q

What bile acid sequestrant is safe in pregnancy?

A

Colesvelam

79
Q

What bile acid sequestrant is also used as an antihyperglycemic?

A

Colesvelam

80
Q

Colesvelam

81
Q

Cholestyramine

82
Q

Colestipol

83
Q

What are DIs with bilie acid sequestrants?

A
  1. Separate drugs by 1-4 hours before and 4-6 hours after
  2. monitor INR
  3. decrease absorption of ADEK
  4. increase metformin ER
84
Q

Ezetimibe + bempidoic acid

85
Q

What drugs should be taken 4 hours prior to Welchol?

A
  1. cyclosporine
  2. SU
  3. Levothyroxine
  4. olmesartan
  5. phenytoin
  6. oral contraceptives
86
Q

What is the MOA of fibrates?

A

PPAR alpha agonists; increase lipoprotein lipase activity and catabolism of VLDL particles decreasing TGs

87
Q

What are CIs with fibrates?

A
  1. Severe liver disease (including primary biliary cirrhosis)
  2. Gallbladder disease
  3. severe renal disease (CrCl≤30)
  4. breastfeeding
  5. use with repaglinide/simvastatin (gemfibrozil)
88
Q

What are the warnings with fibrates?

A
  1. Myopathy (Increased risk with a statin in older adults, diabetes, hypothyroidism, renal failure)
  2. cholelithiasis
  3. transient reversible elevated SCr >2
89
Q

What are SEs with fibrates?

A
  1. Dyspepsia (gemfibrozil)
  2. Elevated LFTs (dose-related)
  3. abdominal pain
  4. elevated CPK
  5. URTIs
90
Q

What is monitored with fibrates?

A
  1. LFTs
  2. renal function
91
Q

How is fenofibrate renally dosed?

A

Reduce dose of CrCl 31-80

92
Q

Which fenofibrates are taken with meals?

A

Fenoglide
Lipofen

93
Q

How is gemfibrozil administered?

A

600mg BID 30 min before breakfast and dinner

94
Q

How do fibrates effect cholesterol?

A
  1. Decrease TGs 20-50%
  2. Can increase LDL when TGs are high (usually lowers LDL)
95
Q

What drugs interact with fibrates?

A
  1. Do not use gemfibrozil with statins/zetia
  2. Inrease effects of SUs and warfarin
  3. Chochicine can increase myopathy
96
Q

Fenofibrate/ Fenofibric Acid

A
  1. Tricor
  2. Trilipix
  3. Fenoglinide
  4. Fibricor
  5. Lipofen
97
Q

Gemfibrozil

98
Q

What is the MOA of Niacin?

A

Decreases the rate of hepatic synthesis of VLDL (TG) and LDL

99
Q

What are CIs with niacin?

A
  1. acute liver disease
  2. active PUD
  3. arterial bleeding
100
Q

What are warnings with niacin?

A
  1. Rhabdomyolysis with doses ≥1g/d when combined with statins
  2. Hepatotoxicity (CR worst)
  3. Elevated BG and uric acid
  4. low phosphate
  5. caution in unstable angina/ acute phase of MI
101
Q

What are SEs with niacin?

A
  1. Flushing
  2. Puritis
  3. Vomiting/nausea
  4. Diarrhea
  5. Elevated BG
  6. Hyperuricemia/Gout
  7. cough
  8. orthostatic hypotension
  9. low platelets
  10. hypophosphatemia
102
Q

What should be monitored with niacin?

A
  1. LFTs (baseline, every 6-12 weeks for first year, then every 6 months)
  2. BG (DM)
  3. uric acid (gout hx)
  4. INR (warfarin)
  5. lipids
103
Q

How can flushing with niacin be reduced?

A
  1. ER formulation (less flushing/hepatotoxicity)
  2. Aspirin 325mg/ ibuprofen 200mg 30-60min before dose
  3. Take with food (NOT spicy food, alcohol, hot beverages)
104
Q

How is niacin dosed?

A

250mg-3000 titrated slowly;
Take with food

105
Q

How is Niacin administered?

A

IR: 3 divided doses with food
ER: at bedtime after a low-fat snack
CR/SR: QD with food

106
Q

How does niacin affect cholesterol?

A
  1. Increased HDL 15-30%
  2. Decrease TG 20-30%
  3. Decrease LDL 5-25%
107
Q

What are DIs with niacin?

A

Take niacin 4-6 h after bile acid sequestrants

108
Q

What fish oil is approved for ASCVD risk reduction when TGs are 135-499 and using statin?

A

Icosapent ethyl (Vascepa)

109
Q

When are fish oils indicated?

A

Adjunct to diet when TGs ≥500

110
Q

What are warnings with fish oils?

A
  1. HSR to fish/shellfish
  2. Monitor LFTs with hepatic impairment and LDL
  3. Can increase LDL levels; possible association with frequent recurrence of Afib/flutter in patients with afib in the first months of initiation (Lovaza)
  4. Stop prior to elective surgeries due to bleeding risk
111
Q

What are SEs with fish oils?

A
  1. Eructation (burping)
  2. Dyspepsia
  3. Taste perversion (Lovaza)
  4. arthalgia (Vascepa)
112
Q

How do fish oils affect cholesterol?

A
  1. Decrease TG 45%
  2. Can Increase LDL 44% (Lovaza)
113
Q

Omega-3 Acid Ethyl Esters (EPA/DHA)

114
Q

Icosapent ethyl (ethyl ester of EPA)

115
Q

How is Vascepa administered?

A

2g BID with food

116
Q

What are DIs with fish oils?

A

Prolong bleeding time; monitor INR with warfarin

117
Q

What is the MOA if bempidoic acid?

A

inhibits cholesterol synthesis in the liver upstream of HMGCoA

118
Q

What are SEs with bempidoic acid?

A
  1. hyperuricemia
  2. tendon rupture
119
Q

When is bempidoic acid apporived?

A

As an add on in HeFH or ASCVD in combinaion with a statin

120
Q

Bempidoic Acid

121
Q

What is the MOA of Inclisiran?

A

Inhibits intracellular production of PCSK9

122
Q

What is Inclisiran used for?

A

Add on for HeFH or primary hyperlipidemia with a statin
DO NOT use with PCSK9 mab due to over lapping MOA

123
Q

What are SEs with Inclisiran?

A
  1. Injection site reaction (SC)
  2. arthalgia
124
Q

Inclisiran

125
Q

What are SEs with lomitapide (Juxtapid)?

A

Hepatotoxicity (BBW with REMS program)

126
Q

What are CIs with Juxtapid?

A
  1. active liver disease
  2. pregnancy
  3. use of mod-strong CYP3A4 inhibitors
127
Q

What is the MOA of Juxtapid?

A

prevents assembly of apoB containing lipoprotein by inhibiting TG transfer protein

128
Q

Lomitapide

129
Q

Evinacumab

130
Q

What is the MOA of evinacumab?

A

monocloal antibody inhibits angiopoietin like 3 resulting in increased lipid metabolism

131
Q

What are SEs with evinacumab?

A
  1. HSR (IV administration)
  2. Anaphylaxis

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