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Dyslipidemia Flashcards

0
Q

Types of dyslipidemia?

A

Primary (familial)

Secondary (acquired)

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1
Q

What’s a major risk factor for the development of coronary heart dx (CHD)?

A

Abnormalities of plasma lipoproteins resulting in predisposition to coronary, cerebrovascular, and peripheral arterial dx

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2
Q

List the secondary causes of hyperlipidemia

A

Diet - saturated or Trans fat

Drugs - diuretics, cyclosporine, Tacrolimus, glucocorticoids,
amiodarone

Diseases - biliary obstruction, nephrotic syndrome

Disordered & altered states of metabolism - hypothyroidism obesity etc

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3
Q

What’s the formula to calculate LDL if pt didn’t fast? When can’t this formula be used?

A

Friedewald eqn: LDL = TC - HDL - (TG/5)

Can’t be used when TG is > 400mg/dL

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4
Q

List natural pdts used for dyslipidemia

A

Red yeast rice

Garlic

OTC fish oils (used to lower TG when TG is >= 500)

Plant sterols/stanols

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5
Q

When is OTC fish oils used in dyslipidemia?

A

used to lower TG when TG is >= 500

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6
Q

What’s the key point of the new ATP guidelines!

A

There’s no evidence to support continued use of specific LDL or HDL tx targets.

Statins (primarily). Dosed at the appropriate intensity, are used in at-risk pts

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7
Q

When do u use nonstatin therapies in dyslipidemia?

A

When statins are NOT tolerated

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8
Q

What’re the 4 key pt groups for statin benefit?

A

Clinical atherosclerotic cardiovascular dx (ASCVD), including coronary heart dx (ACS, S/P MI, stable or unstable angina, coronary or other arterial revascularization), stroke, TIA, or peripheral artery dx thot to be of atherosclerotic origin

Primary elevations of LDL >= 190mg/dL

Diabetes + 40-75 yrs of age + LDL btw 70-189 mg/dL

40-75 yrs + LDL btw 70-189 mg/dL + estimated 10-yr ASCVD risk of >= 7.5% (using global risk assessment)

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9
Q

In what dx states should statin therapy by initiated?

A

Clinical atherosclerotic cardiovascular dx (ASCVD), including coronary heart dx (ACS, S/P MI, stable or unstable angina, coronary or other arterial revascularization),

stroke,

TIA,

peripheral artery dx thot to be of atherosclerotic origin

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10
Q

Whats the value of LDL req to start statin therapy?

A

Primary elevations of LDL >= 190mg/dL

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11
Q

What’s the other criteria that goes along with diabetes to start statin?

A 
Diabetes
\+
40-75 years
\+
LDL btw 70-189mg/dL
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12
Q

What’s the other criteria that goes along with 10yr ASCVD to start statin?

A 
40-75 yrs
\+
LDL btw 70-189 mg/.dL
\+
Estimated 10-yr ASCVD risk >= 7.5% (using the global risk assessment tool)
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13
Q

Other factors may be useful in making a decision to start statin, if the 4 key factors results in inconclusive decision
Wrt LDL?

A

LDL >= 160mg/dL
Or
Other evidence of genetic hyperlipidemia

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14
Q

Other factors may be useful in making a decision to start statin, if the 4 key factors results in inconclusive decision
Wrt FH?

A

FH of premature ASCVD with onset
< 55 yrs in a first degree male relative
Or
< 65 yrs in first degree female relative

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15
Q

Other factors may be useful in making a decision to start statin, if the 4 key factors results in inconclusive decision
Wrt C-reactive protein?

A

High sensitivity C-reactive protein > 2 mg/dL

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16
Q

Other factors may be useful in making a decision to start statin, if the 4 key factors results in inconclusive decision
Wrt coronary artery Ca score?

A

Coronary artery Ca score >= 300 Agatston units
Or
>= 75 percentile for age, sex and ethnicity

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17
Q

Other factors may be useful in making a decision to start statin, if the 4 key factors results in inconclusive decision
Wrt Ankle Brachial index?

A

Ankle Brachial index < 0.9

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18
Q

What’s the 10-yr ASCVD score that indicates statin therapy needs to be started?

A

> = 7.5%

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19
Q

What statin tx should be started in primary elevation of LDL >= 190mg/dL?

A

High-intensity statin

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20
Q

What statin tx should be started in Diabetes + 40-75yrs + LDL btw 70-189mg/dL + estimated 10-yr ASCVD risk < 7.5%?

A

Moderate-Intensity statin

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21
Q

What statin tx should be started in 40-75yrs + LDL btw 70-189mg/dL + estimated 10-yr ASCVD risk < 7.5%?

A

Consider risk benefit

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22
Q

What statin tx should be started in 40-75yrs + LDL btw 70-189mg/dL + estimated 10-yr ASCVD risk >= 7.5%?

A

Moderate-to-high intensity

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23
Q

What statin tx should be started in Clinical atherosclerotic cardiovascular dx ASCVD risk < = 75yrs?

A

High-intensity statin

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24
What statin tx should be started in Clinical atherosclerotic cardiovascular dx ASCVD risk > 75yrs?
Moderate-intensity statin
25
List conditions that req High-intensity statin
Primary elevation of LDL > 190mg/dL Diabetes + 40-75yrs + LDL btw 70-189mg/dL + estimated 10-yr ASCVD risk >= 7.5% Clinical atherosclerotic cardiovascular dx ASCVD risk < = 75yrs (2nd prevention)
26
What statin tx should be started in Diabetes + 40-75yrs + LDL btw 70-189mg/dL + estimated 10-yr ASCVD risk >= 7.5%?
High-intensity
27
List conditions that req Moderate-to-High intensity statin
40-75yrs + LDL btw 70-189mg/dL + estimated 10-yr ASCVD risk >= 7.5%
28
List conditions that req Moderate-intensity statin
Diabetes + 40-75yrs + LDL btw 70-189mg/dL + estimated 10-yr ASCVD risk < 7.5% Clinical atherosclerotic cardiovascular dx ASCVD risk > 75yrs
29
List high-intensity statins
Atorvastatin (Lipitor) 40-80 mg daily Rosuvastatin (Crestor) 20-40 mg daily
30
Effect of high-intensity statins (Atorvastatin (Lipitor) 40-80 mg/d and Rosuvastatin (Crestor) 20-40 mg/d) on LDL?
Reduces LDL >= 50%
31
List moderate-intensity statins
``` Atorvastatin (Lipitor) 10-20 mg/d Rosuvastatin (Crestor) 5-10 mg/d Simvastatin 20-40 mg/d Pravastatin 40-80 mg/d Lovastatin 40 mg/d Fluvastatin XL 80 mg/d Fluvastatin 40 mg bid Pitavastatin 2-4 mg/d ```
32
Effect on moderate-intensity statin on LDL?
Daily dose reduces LDL 30-40%
33
List low-intensity statins
``` Simvastatin 10 mg/d Pravastatin 10-20 mg/d Lovastatin 20 mg/d Fluvastatin 20-40 mg/d Pitavastatin 1mg/d ```
34
What criteria is needed to use non-pharmacologic therapy?
Adults < 80yrs +/- CVD
35
Increase Vegs, fruits, and whole grains
True
36
Calories from saturated fat (non-pharmacologic therapy)?
5-6% of calories from saturated fat Reduce % of calories from Trans fat
37
Aerobic activity (non-pharmacologic therapy)?
3-4 session/wk; lasting 40 mins/session + moderate-to-vigorous intensity
38
Effect of increased physical activity on LDL?
Can reduce LDL 3-6 mg/dL
39
Preferred BMI (non-pharmacologic therapy)?
18.5 - 24.9 kg/m2
40
Tobacco pdt (non-pharmacologic therapy)?
Avoid tobacco pdts
41
What's the drug of choice in treating elevated LDL?
Statins
42
What's used to determine appropriate statin intensity chosen?
Pts level of risk
43
What SE is common to many of the drugs used in dyslipidemia?
Potentially hepatotoxic T4 liver enzymes should be monitored
44
When should dyslipidemia therapy be d/c?
AST (8-48 units/L) Or ALT (7-55 units/L) Become > 3 times the upper limit of normal
45
Mgt of mild-to-moderate muscle sx associated with statin use?
D/c statin and evaluate sx Check for other conditions/ meds that can cause muscle damage Restart, if sx resolves
46
MOA of statins?
Inhibit the enzyme 3-hydroxy-3-methylglutaryly coenzyme (HMG-CoA) reductase Thus prevention conversion of HMG-CoA to mevalonate
47
What's the rate-limiting step in cholesterol synthesis?
Conversion of HMG-CoA to mevalonate (which is the step prevented by statins)
48
List main statins
Atorvastatin (Lipitor) Simvastatin (zocor) Rosuvastatin (Crestor) Pravastatin (Pravachol) Lovastatin (Mevacor, Altoprev) Fluvastatin (Lescol, Lescol XL) Pitavastatin (Livalo)
49
What's the brand name of Atorvastatin?
Lipitor
50
What's the brand name of Simvastatin + Ezetimibe?
Vytorin
51
Whats the brand name of Rosuvastatin?
Crestor
52
What's the equivalent dose of Atorvastatin (Lipitor)?
10mg
53
What's the equivalent dose of Simvastatin (Zocor)?
20mg
54
What's the equivalent dose of Rosuvastatin (Crestor)?
Equiv dose = 5 mg
55
What's the equivalent dose of Lovastatin and Pravastatin?
40 mg
56
What's the equivalent dose of Fluvastatin?
80mg
57
What's the equivalent dose of Pitavastatin?
2
58
Which statin is used in the evening?
Simvastatin Mevacor (Lovastatin immediate release)
59
Which statin is used at bedtime?
Fluvastatin (Lescol) Altoprev (Lovastatin ext-release)
60
CI to statin use?
Active liver dx (including any unexplained elevations in hepatic Transaminases) Pregnancy
61
Warnings associated with statin use?
Skeletal muscle effects (e.g. Myopathy, including risk of rhabdomyolysis)
62
Factors that increase risk of Skeletal muscle effects (e.g. Myopathy, including risk of rhabdomyolysis)?
Higher doses of statins Concomitant use of certain medicines >= 65 yrs Female Uncontrolled hypothyroidism Renal impairment
63
Effect of statin on A1C?
Statin can cause an increase in A1C and FBG But benefits of statin therapy far outweigh the risk of hyperglycemia
64
SEs of statins?
Myalgia Arthralgias Myopathy Diarrhea Increased CPK Rhabdomyolysis (increase risk with higher dose) Cognitive impairment (memory loss, confusion - reversible) Increased BG Increased A1c Possible increase risk of cataracts Increase LFTs
65
Monitoring of statins?
LFTs at baseline and as clinically indicated thereafter Lipid panel 4-12 wks after initiation or up titration, then Q 3-12 months thereafter
66
What's the preg cat of statin?
X
67
Which statins can be taken anytime of the day?
Crestor (Rosuvastatin) Lipitor (Atorvastatin) Livalo (Pitavastatin) Lescol XL (Fluvastatin) Pravachol (Pravastatin)
68
Which statins don't need renal dose adjustment?
Lescol (Fluvastatin) Lipitor (atorvastatin)
69
Which statin do u dose adjust when CrCl is < 60 ml/min
Livalo (Pitavastatin)
70
Which other dyslipidemia agent use is CI with statin?
Fibrates esp, Gemfibrozil
71
Effect of niacin pdt containing >= 1gm and statin? (And statin + colchine)
Increase risk of myopathies
72
Are Lovastatin, simvastatin and atorvastatin 3A4 inducers, inhibitors, substrates?
3A4 substrates
73
Effect of Lovastatin, simvastatin and atorvastatin being 3A4 substrates?
LAS, undergo extensive first-pass metabolism by CYP 3A4
74
What dose of simvastatin should a pt not be started on? (Pts that are currently on this dose, may continue)
80mg / day
75
What meds should u not exceed simvastatin 10mg/day with?
Verapamil Diltiazem Dronedarone
76
What meds should u not exceed simvastatin 20mg/day with?
Amiodarone Amlodipine Ranolazine
77
If pt is on Verapamil/ Diltiazem/ Dronedarone, what dose of simvastatin may also be used in this pt?
No more than 10mg/ day of simvastatin
78
If pt is on amiodarone/ amlodipine/ Ranolazine, what dose of simvastatin may also be used in this pt?
No more than 20mg/ day of simvastatin
79
What meds should u not exceed lovastatin 20mg/day with?
Danazol Diltiazem Dronedarone Verapamil
80
What meds should u not exceed lovastatin 40mg/day with?
Amiodarone
81
If pt is on amiodarone, what dose of lovastatin may also be used in this pt?
No more than Lovastatin (Mevacor) 40mg/d
82
If pt is on danazol/ Dronedarone/ Diltazem/ verapamil, what dose of lovastatin may also be used in this pt?
No more than Lovastatin (Mevacor) 20mg/d
83
What meds should be avoided with Atorvastatin (Lipitor)?
Cyclosporine Tipranivir + Ritonavir or Telaprevir
84
What meds should u not exceed atorvastatin 20mg/day with?
Clarithromycin Itraconazole Lopinavir + Ritonavir Darunavir + Ritonavir Fosamprenavir +/- Ritonavir
85
What meds should u not exceed atorvastatin 40mg/day with?
Nelfinavir Boceprevir
86
What types of meds are to be avoided with simvastatin and Lovastatin (Mevacor)?
Itraconazole, Ketoconazole, Posaconazole, Voriconazole Erythromycin, Clarithromycin, Telithromycin HIV protease Inhibitors Boceprevir, Telaprevir Nefazodone Cyclosporine Gemfibrozil Danazol (with simvastatin) Grapefruit juice
87
Sx of liver damage from statin use?
Brown or dark colored urine Pale stools Feel more tired than usual Skin and/or whites of eyes become yellow
88
Sx of muscle damage from statin use?
Muscle weakness, tenderness, aching, cramps, stiffness or pain that happens without a good reason, esp if u also have a fever or feel more tired than usual
89
MOA of Ezetimibe?
Inh absorption of cholesterol at the brush border of small intestine
90
Brand name of Ezetimibe?
Zetia
91
Brand name of Ezetimibe + Simvastatin?
Vytorin
92
Preg category of Ezetimibe (Zetia)?
C
93
How do u dose bile acid resins with Ezetimibe (Zetia)?
Give Ezetimibe (Zetia) 2 hrs before OR 4 hrs after bile acid resin
94
What's the concern with Vytorin (Ezetimibe + Simvastatin)?
Increased muscle damage
95
MOA of bile acid sequestrants/ bile acid binding resins?
Binds Bile acids in intestine forming a complex excreted in feces T4 preventing re-absorption
96
List bile acid sequestrants/ bile acid binding resins agents
Cholestyramine (Questran, Prevalite) Colesevelam (Welchol) Colestipol (Colestid)
97
What's the grand name of Colesevelam (bile acid sequestrants/ bile acid binding resins)?
Welchol
98
How do u take Cholestyramine?
Comes in powder Mix with water or non-carbonated liq
99
How do u take Colesevelam (Welchol)?
With a meal + liquid
100
SEs of bile acid sequestrants/ bile acid binding resins?
Constipation (may need dose reduction or laxative) Abdominal pain Cramping Gas Bloating Hypertriglyceridemia
101
When does ATP IV guidelines not recommend the use of bile acid sequestrants/ bile acid binding resins (Cholestyramine, Colesevelam (Welchol), and Colestipol)?
TGs >= 300mg/dL
102
Why does ATP IV guidelines not recommend the use of bile acid sequestrants/ bile acid binding resins (Cholestyramine, Colesevelam (Welchol), and Colestipol)?
Bcuz they have NO effect on TGs and may even increase TGs in some cases
103
Possible SE of cholestyramine (Questran, Prevalite)?
Teeth discoloration, erosion of enamel/ decay Sipping or holding the suspension in mouth for prolonged periods
104
Which bile acid sequestrants/ bile acid binding resins (Cholestyramine, Colesevelam (Welchol), and Colestipol) is considered safest?
Colesevelam (Welchol) Still consider separating other drugs by 1-4 hrs
105
Whys the use of concurrent multivitamin recommended with the use of bile acid sequestrants/ bile acid binding resins (Cholestyramine, Colesevelam (Welchol), and Colestipol)?
They may reduce absorption of fat-soluble vits (A, D, E, K)
106
MOA of fibrates?
Fibrates are peroxisome proliferator receptor alpha (PPARalphasign) activators Resulting in enhanced elimination and reduce synthesis of VLDL (lower TGs) and higher LDL
107
What's the caveat to reducing TGs?
When TGs are high, reducing TGs may result in HIGHER LDL T4 be careful to monitor LDL, when reducing TGs
108
Results of ACCORD lipid study wrt fenofibrate use?
Study showed no significant difference in experiencing a major cardiac event btw using fenofibrate + simvastatin and fenofibrate alone. But, it found that using the combo of fenofibrate + simvastatin caused worsening of renal fxn
109
List agents under fibrates
Fenofibrate, Fenofibric Acid (TriCor, Trilipix) Gemfibrozil (Lopid)
110
What's the most common brand names of Fenofibrate, Fenofibric acid?
TriCor Trilipix
111
What's the brand name of Gemfibrozil (fibrate)?
Lopid
112
What's the caveat to consider when using fibrates (fenofibrate/ Gemfibrozil) in a pt with high TGs?
Can increase LDL when TGs are high
113
Which fibrate is the ONLY one with an indication to use with a statin?
Trilipix
114
MOA of niacin?
Decreases rate of hepatic synthesis of VLDL (lowers TGs) and LDL
115
What's niacin also known as?
Nicotinic acid Or Vitamin B3 (although doses for cholesterol reduction are much higher than those found in multivitamin pdts)
116
List agents under Niacin
Immediate-Release (crystalline) niacin (Niacor) - OTC Extended-Release Niacin (Niaspan) Controlled-(or sustained) Release Niacin (Slo-Niacin) - OTC
117
What's the brand name of Extended-Release Niacin?
Niaspan
118
In what strength do Extended-Release Niacin (Niaspan) come in?
500mg 750mg 1000mg
119
SE of Niacin use
Flushing Pruritus (itching) Nausea/ vomiting Diarrhea GI distress Hyperglycemia Hyperuricemia (or gout) Increased cough Hepatotoxicity Orthostatic hypotension Hypophosphatemia
120
Monitoring parameters of Niacin use?
Check LFTs (at start of baseline; Q 6-12wks for first yr) BG (if diabetic) Uric gout (if gout) INR (if on warfarin)
121
Which formulation of Niacin has less flushing and less hepatotoxicity? T4 best clinical choice from Niacin Grp?
Niaspan (but, it's most expensive)
122
Are formulations of Niacin interchangeable?
No! (Applicable to regular release v. Extended release)
123
How should u use Niacin in combo with statins?
Stick to lower statin doses
124
How should u use Niacin and Bile acid Sequestrants (Colevelesam (Welchol))?
Take Niacin 4-6 hrs AFTER bile acid sequestrants
125
Use of fish oils?
Adjunct to diet in pts with TGs >= 500mg/dL
126
List agents under fish oil
Omega-3 acid Ethyl Esters (Lovaza) Icosapent ethyl (Vascepa)
127
What's the brand name of Omega-3 Acid Ethyl Esters?
Lovaza
128
SEs of fish oils?
Eructation (burping) Dyspepsia ``` Taste perversions (Lovaza) Arthralgias (Vascepa) ```
129
Which fish oil can increase LDL by up to 44%?
Lovaza ONLY No such increase seen with Vascepa
130
Effect of omega-3-acids (fish oil) on bleeding out?
Lovaza and Vascepa may prolong bleeding time
131
List new agents used for Homozygous Familial Hypercholesterolemia (HoFH)
Lomitapid Mipomersen
132
MOA of Lomitapide?
Lomitapide binds to and inhibits microsomal TG transfer protein (MTP) in the endoplasmic reticulum
133
What's the brand name of Lomitapide?
Juxtapid
134
Pregnancy category of Lomitapide (Juxtapid)?
X
135
MOA of Mipomersen?
Mipomersen is an oligonucleotide inhibitor of apo B-100 synthesis. ApoB is the main component of LDL and VLDL, which is a precursor to LDL
136
What's the brand name of Mipomersen?
Kynamro
137
What's the CI to Mipomersen (Kynamro) use?
Liver dx (including unexplained elevations in hepatic Transaminases)
138
Due to risk of hepatotoxicity, howz Mipomersen (Kynamro) made available?
Only available through a Kynamro Risk Evaluation and Mitigation Strategy (REMS) program
139
What med can be used as a pre-tx to prevent flushing caused by Niacin agents?
325mg aspirin (or 200mg of ibuprofen) 30-60 mins before dose (for a few weeks)
140
List drugs that significantly reduce TGs by > 10%?
Fibrates Fish oils Niacin

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