Dyslipidemia Flashcards
Cholesterol (Lipoprotein) Types
Total Cholesterol (TC) includes
-High-density liproprotein (HDL): good cholesterol, high HDL lowers ASCVD risk
-Non-HDL contributes to ASCVD risk (LDL, VLDL, lipoprotein a): strong predictor of ASCVD
* Non-HDL calculation: non-HDL = TC - HDL
-High TGs is also associated with high ASCVD risk
* TGs > 500 mg/dL = acute pancreatitis
-Treatment of dyslipidemia: lowering LDL by 1% reduces ASCVD risk by 1%
Determining LDL Cholesterol
Lipid panels best taken after 9-12 hour fast (primarily for TG, which can be falsely elevated after eating)
Friedewald equation for LDL:
LDL = TC - HDL - ( TG / 5 )
^ Not used when TGs > 400 mg/dL (bc can result in falsely LOW LDL)
Classification of Cholesterol/TG Levels
Non-HDL: < 130 desired
LDL: < 100 desired, 190+ very high
HDL: 40+ men, 50+ women desired
TG: < 150 desired, 500+ very high
Calculating ASCVD Risk
Estimate of an individual’s risk of having a CV event during the next 10 years
Input the pt’s:
-Sex, age (20-79), race, smoking status
-TC, HDL, LDL, use of statin
-BP, use of anti-HTN
-Diabetes history, use of aspirin
Key Drugs That Elevate Both LDL/TG
-Diuretics*
-Efavirenz*
-IS (tacro, cyclo)*
-Atypical antipsychotics*
-Protease inhibitors*
-Retinoids
-Systemic steroids
BOTH GET RE-PAIDS
Key Drugs That Elevate LDL Only
-Fibrates*
-Fish oils (except Vascepa)*
-Anabolic steroids
-Progestins
-SGLT2 inhibitors
take the L SePAFF
Key Drugs That Elevate TG Only
-IV lipid emulsions*
-Propofol*
-Clevidipine*
-Bile acid sequestrants*
-Estrogen
-Tamoxifen
-Beta blockers
TaG to C my BB PETE
Risk Score Not Needed For
-Clinical ASCVD
-Diabetes
-LDL 190+
as all these pts should be started on a statin
CAC Score
Coronary artery calcium score
-If deciding if statins should be initiated in those with a 10-year ASCVD risk of 7.5 - 19.9%
-If the CAC score is ≥ 100 Agatston units, a statin is indicated
Non-Drug Treatment
-Maintain healthy weight of BMI 18.5-24.9
-Diet: veg, fruits, whole grains, high fiber, protein
-Limit: sat fat, trans fat, sweets, sugar beverages
-Aerobic activity 3-4x/wk, 40 min/session (decreases LDL by 3-6)
-Avoiding tobacco, limiting alcohol
Natural Products
-Red yeast rice (natural occurring HMG coA reductase inhibitors)
-Plant stanols, sterols, fibrous foods
-OTC fish oils (for TG lowering)
*Garlic is not considered effective for dyslipidemia
Overall Drug Treatment
- Statins (DOC)
- Ezetimibe or PCSK9i
- Bempedoic acid or inclisiran
Liver Damage in Dyslipidemia
-Niacin, fibrates, potentially statins and ezetimibe can cause liver damage
-These should not be used if the AST or ALT is > 3 times ULN
-LFTs should be monitored during treatment
Determining Statin Treatment Intensity Based on Patient Risk
High Intensity: CADS
-Clinical ASCVD: CHD, stroke, TIA, PAD (secondary prevention)
-Severe dyslipidemia (LDL 190+)
-Diabetes + Age 40-75 + multiple ASCVD risk factors
-Age 40-75 with LDL 70-189 + ASCVD risk 20%+
Moderate Intensity:
-Diabetes + Age 40-75 + regardless of 10-yr ASCVD risk (RAD)
-Age 40-75 with LDL 70-189 + ASCVD risk 7.5-19.9% + risk enhancing factors (ALA)
MOD RAD ALA
Statin HIGH Intensity Definitions/Options
-Atorvastatin 40-80 mg
-Rosuvastatin 20-40 mg
Statin MODERATE Intensity Definitions/Options
-Pitavastatin 1-4 mg
-Rosuvastatin 5-10 mg
-Atorvastatin 10-20 mg
-Simvastatin 20-40 mg
-Lovastatin 40 mg
-Pravastatin 40-80 mg
-Fluvastatin 40 mg BID/80 mg XL
Pharmacists Rock At Saving Lives and PReventing Fatties (double each time)
Statin LOW Intensity Definitions/Options
-Simvastatin 10 mg
-Lovastatin 20 mg
-Pravastatin 10-20 mg
-Fluvastatin 20-40 mg
Saving Lives (is 1st = 1 option) and PReventing Fatties (is 2nd = 2 options/range)
(all ~half of mod intensities)
Statin Equivalent Doses
-Pitavastatin 2 mg
-Rosuvastatin 5 mg
-Atorvastatin 10 mg
-Simvastatin 20 mg
-Lovastatin 40 mg
-Pravastatin 40 mg
-Fluvastatin 80 mg
Pharmacists Rock At Saving Lives and Preventing Fatties
Muscle Damage from Statins + Management
-Myalgia, myopathy, myositis, rhabdomyolysis (CPK >10k)
*within first 6 weeks usually, but can be at any time of tx
*symmetrical
Reducing Myalgia
-Avoid DDIs, Simvastatin 80, gemfibrozil + statins together
-IF occurs: hold, check CPK, after 2-4 weeks - re-challenge at same/lower dose
*If myalgia returns: d/c, sx resolve, then use lower dose (titrate gradually)
*If pt unable to tolerate after 2+ attempts: consider non-statin tx
Evening Statins
-Fluvastatin (IR in evening)
-Lovastatin (IR with meal, love food)
-SImvastatin (no >80 mg)
Note
-Can take rosuvastatin, atorvastatin, pitavastatin, Lescol XL (fluva) and pravastatin at any time of day
EYE III FLS at night
Statins: CI/Warning
CI
-Breastfeeding, liver disease
Warnings
-Do not use during pregnancy generally (can consider continuing use if high risk for CV events)
-Can increase A1C/FBG
PBL AF
Statins: Lipid Effects
-Decrease LDL 20-55%
-Decrease TG 10-30%
-Increase HDL 5-15%
Statins: Monitoring
-Lipid panel: baseline, 4-12 weeks after starting or adjusting then annually
-LFTs, sx of hepatotoxicity
-Myalgia, CPK
Statins: DDIs
In general: rosuva/prava have less DDIs
G <3 PACMAN
Do not use with Sim/Lova
-Grapefruit
-Protease inhibitors
-Azole antifungals
-Cyclosporine, cobicistat
-Macrolides (not azithromycin)
-Amiodarone: simva 20/lova 40 max
-Non-DHP CCB: simva 10/lova 20 max
*Amlodipine can increase concentration of atorva/lova/simva (SALAm is 20)
-Max 20 mg/day
