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NAPLEX > Dyslipidemia > Flashcards

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
Q

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

A

Moderate-intensity statin

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25
Q

List conditions that req High-intensity statin

A

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)

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26
Q

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

A

High-intensity

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27
Q

List conditions that req Moderate-to-High intensity statin

A

40-75yrs + LDL btw 70-189mg/dL + estimated 10-yr ASCVD risk >= 7.5%

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28
Q

List conditions that req Moderate-intensity statin

A

Diabetes + 40-75yrs + LDL btw 70-189mg/dL + estimated 10-yr ASCVD risk < 7.5%

Clinical atherosclerotic cardiovascular dx ASCVD risk > 75yrs

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29
Q

List high-intensity statins

A

Atorvastatin (Lipitor) 40-80 mg daily

Rosuvastatin (Crestor) 20-40 mg daily

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30
Q

Effect of high-intensity statins (Atorvastatin (Lipitor) 40-80 mg/d and Rosuvastatin (Crestor) 20-40 mg/d) on LDL?

A

Reduces LDL >= 50%

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31
Q

List moderate-intensity statins

A 
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
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32
Q

Effect on moderate-intensity statin on LDL?

A

Daily dose reduces LDL 30-40%

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33
Q

List low-intensity statins

A 
Simvastatin 10 mg/d
Pravastatin 10-20 mg/d
Lovastatin 20 mg/d
Fluvastatin 20-40 mg/d
Pitavastatin 1mg/d
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34
Q

What criteria is needed to use non-pharmacologic therapy?

A

Adults < 80yrs +/- CVD

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35
Q

Increase Vegs, fruits, and whole grains

A

True

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36
Q

Calories from saturated fat (non-pharmacologic therapy)?

A

5-6% of calories from saturated fat

Reduce % of calories from Trans fat

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37
Q

Aerobic activity (non-pharmacologic therapy)?

A

3-4 session/wk; lasting 40 mins/session + moderate-to-vigorous intensity

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38
Q

Effect of increased physical activity on LDL?

A

Can reduce LDL 3-6 mg/dL

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39
Q

Preferred BMI (non-pharmacologic therapy)?

A

18.5 - 24.9 kg/m2

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40
Q

Tobacco pdt (non-pharmacologic therapy)?

A

Avoid tobacco pdts

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41
Q

What’s the drug of choice in treating elevated LDL?

A

Statins

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42
Q

What’s used to determine appropriate statin intensity chosen?

A

Pts level of risk

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43
Q

What SE is common to many of the drugs used in dyslipidemia?

A

Potentially hepatotoxic

T4 liver enzymes should be monitored

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44
Q

When should dyslipidemia therapy be d/c?

A

AST (8-48 units/L)
Or
ALT (7-55 units/L)

Become > 3 times the upper limit of normal

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45
Q

Mgt of mild-to-moderate muscle sx associated with statin use?

A

D/c statin and evaluate sx

Check for other conditions/ meds that can cause muscle damage

Restart, if sx resolves

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46
Q

MOA of statins?

A

Inhibit the enzyme 3-hydroxy-3-methylglutaryly coenzyme (HMG-CoA) reductase

Thus prevention conversion of HMG-CoA to mevalonate

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47
Q

What’s the rate-limiting step in cholesterol synthesis?

A

Conversion of HMG-CoA to mevalonate (which is the step prevented by statins)

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48
Q

List main statins

A

Atorvastatin (Lipitor)

Simvastatin (zocor)

Rosuvastatin (Crestor)

Pravastatin (Pravachol)

Lovastatin (Mevacor, Altoprev)

Fluvastatin (Lescol, Lescol XL)

Pitavastatin (Livalo)

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49
Q

What’s the brand name of Atorvastatin?

A

Lipitor

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50
Q

What’s the brand name of Simvastatin + Ezetimibe?

A

Vytorin

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51
Q

Whats the brand name of Rosuvastatin?

A

Crestor

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52
Q

What’s the equivalent dose of Atorvastatin (Lipitor)?

A

10mg

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53
Q

What’s the equivalent dose of Simvastatin (Zocor)?

A

20mg

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54
Q

What’s the equivalent dose of Rosuvastatin (Crestor)?

A

Equiv dose = 5 mg

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55
Q

What’s the equivalent dose of Lovastatin and Pravastatin?

A

40 mg

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56
Q

What’s the equivalent dose of Fluvastatin?

57
Q

What’s the equivalent dose of Pitavastatin?

58
Q

Which statin is used in the evening?

A

Simvastatin

Mevacor (Lovastatin immediate release)

59
Q

Which statin is used at bedtime?

A

Fluvastatin (Lescol)

Altoprev (Lovastatin ext-release)

60
Q

CI to statin use?

A

Active liver dx (including any unexplained elevations in hepatic Transaminases)

Pregnancy

61
Q

Warnings associated with statin use?

A

Skeletal muscle effects (e.g. Myopathy, including risk of rhabdomyolysis)

62
Q

Factors that increase risk of Skeletal muscle effects (e.g. Myopathy, including risk of rhabdomyolysis)?

A

Higher doses of statins

Concomitant use of certain medicines

> = 65 yrs

Female

Uncontrolled hypothyroidism

Renal impairment

63
Q

Effect of statin on A1C?

A

Statin can cause an increase in A1C and FBG

But benefits of statin therapy far outweigh the risk of hyperglycemia

64
Q

SEs of statins?

A

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
Q

Monitoring of statins?

A

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
Q

What’s the preg cat of statin?

67
Q

Which statins can be taken anytime of the day?

A

Crestor (Rosuvastatin)

Lipitor (Atorvastatin)

Livalo (Pitavastatin)

Lescol XL (Fluvastatin)

Pravachol (Pravastatin)

68
Q

Which statins don’t need renal dose adjustment?

A

Lescol (Fluvastatin)

Lipitor (atorvastatin)

69
Q

Which statin do u dose adjust when CrCl is < 60 ml/min

A

Livalo (Pitavastatin)

70
Q

Which other dyslipidemia agent use is CI with statin?

A

Fibrates esp, Gemfibrozil

71
Q

Effect of niacin pdt containing >= 1gm and statin? (And statin + colchine)

A

Increase risk of myopathies

72
Q

Are Lovastatin, simvastatin and atorvastatin 3A4 inducers, inhibitors, substrates?

A

3A4 substrates

73
Q

Effect of Lovastatin, simvastatin and atorvastatin being 3A4 substrates?

A

LAS, undergo extensive first-pass metabolism by CYP 3A4

74
Q

What dose of simvastatin should a pt not be started on? (Pts that are currently on this dose, may continue)

A

80mg / day

75
Q

What meds should u not exceed simvastatin 10mg/day with?

A

Verapamil

Diltiazem

Dronedarone

76
Q

What meds should u not exceed simvastatin 20mg/day with?

A

Amiodarone

Amlodipine

Ranolazine

77
Q

If pt is on Verapamil/ Diltiazem/ Dronedarone, what dose of simvastatin may also be used in this pt?

A

No more than 10mg/ day of simvastatin

78
Q

If pt is on amiodarone/ amlodipine/ Ranolazine, what dose of simvastatin may also be used in this pt?

A

No more than 20mg/ day of simvastatin

79
Q

What meds should u not exceed lovastatin 20mg/day with?

A

Danazol

Diltiazem

Dronedarone

Verapamil

80
Q

What meds should u not exceed lovastatin 40mg/day with?

A

Amiodarone

81
Q

If pt is on amiodarone, what dose of lovastatin may also be used in this pt?

A

No more than Lovastatin (Mevacor) 40mg/d

82
Q

If pt is on danazol/ Dronedarone/ Diltazem/ verapamil, what dose of lovastatin may also be used in this pt?

A

No more than Lovastatin (Mevacor) 20mg/d

83
Q

What meds should be avoided with Atorvastatin (Lipitor)?

A

Cyclosporine

Tipranivir + Ritonavir or Telaprevir

84
Q

What meds should u not exceed atorvastatin 20mg/day with?

A

Clarithromycin

Itraconazole

Lopinavir + Ritonavir

Darunavir + Ritonavir

Fosamprenavir +/- Ritonavir

85
Q

What meds should u not exceed atorvastatin 40mg/day with?

A

Nelfinavir

Boceprevir

86
Q

What types of meds are to be avoided with simvastatin and Lovastatin (Mevacor)?

A

Itraconazole, Ketoconazole, Posaconazole, Voriconazole

Erythromycin, Clarithromycin, Telithromycin

HIV protease Inhibitors

Boceprevir, Telaprevir

Nefazodone

Cyclosporine

Gemfibrozil

Danazol (with simvastatin)

Grapefruit juice

87
Q

Sx of liver damage from statin use?

A

Brown or dark colored urine

Pale stools

Feel more tired than usual

Skin and/or whites of eyes become yellow

88
Q

Sx of muscle damage from statin use?

A

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
Q

MOA of Ezetimibe?

A

Inh absorption of cholesterol at the brush border of small intestine

90
Q

Brand name of Ezetimibe?

91
Q

Brand name of Ezetimibe + Simvastatin?

92
Q

Preg category of Ezetimibe (Zetia)?

93
Q

How do u dose bile acid resins with Ezetimibe (Zetia)?

A

Give Ezetimibe (Zetia) 2 hrs before

OR

4 hrs after bile acid resin

94
Q

What’s the concern with Vytorin (Ezetimibe + Simvastatin)?

A

Increased muscle damage

95
Q

MOA of bile acid sequestrants/ bile acid binding resins?

A

Binds Bile acids in intestine forming a complex excreted in feces

T4 preventing re-absorption

96
Q

List bile acid sequestrants/ bile acid binding resins agents

A

Cholestyramine (Questran, Prevalite)

Colesevelam (Welchol)

Colestipol (Colestid)

97
Q

What’s the grand name of Colesevelam (bile acid sequestrants/ bile acid binding resins)?

98
Q

How do u take Cholestyramine?

A

Comes in powder

Mix with water or non-carbonated liq

99
Q

How do u take Colesevelam (Welchol)?

A

With a meal + liquid

100
Q

SEs of bile acid sequestrants/ bile acid binding resins?

A

Constipation (may need dose reduction or laxative)

Abdominal pain

Cramping

Gas

Bloating

Hypertriglyceridemia

101
Q

When does ATP IV guidelines not recommend the use of bile acid sequestrants/ bile acid binding resins (Cholestyramine, Colesevelam (Welchol), and Colestipol)?

A

TGs >= 300mg/dL

102
Q

Why does ATP IV guidelines not recommend the use of bile acid sequestrants/ bile acid binding resins (Cholestyramine, Colesevelam (Welchol), and Colestipol)?

A

Bcuz they have NO effect on TGs and may even increase TGs in some cases

103
Q

Possible SE of cholestyramine (Questran, Prevalite)?

A

Teeth discoloration, erosion of enamel/ decay

Sipping or holding the suspension in mouth for prolonged periods

104
Q

Which bile acid sequestrants/ bile acid binding resins (Cholestyramine, Colesevelam (Welchol), and Colestipol) is considered safest?

A

Colesevelam (Welchol)

Still consider separating other drugs by 1-4 hrs

105
Q

Whys the use of concurrent multivitamin recommended with the use of bile acid sequestrants/ bile acid binding resins (Cholestyramine, Colesevelam (Welchol), and Colestipol)?

A

They may reduce absorption of fat-soluble vits (A, D, E, K)

106
Q

MOA of fibrates?

A

Fibrates are peroxisome proliferator receptor alpha (PPARalphasign) activators

Resulting in enhanced elimination and reduce synthesis of VLDL (lower TGs) and higher LDL

107
Q

What’s the caveat to reducing TGs?

A

When TGs are high, reducing TGs may result in HIGHER LDL

T4 be careful to monitor LDL, when reducing TGs

108
Q

Results of ACCORD lipid study wrt fenofibrate use?

A

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
Q

List agents under fibrates

A

Fenofibrate, Fenofibric Acid (TriCor, Trilipix)

Gemfibrozil (Lopid)

110
Q

What’s the most common brand names of Fenofibrate, Fenofibric acid?

A

TriCor

Trilipix

111
Q

What’s the brand name of Gemfibrozil (fibrate)?

112
Q

What’s the caveat to consider when using fibrates (fenofibrate/ Gemfibrozil) in a pt with high TGs?

A

Can increase LDL when TGs are high

113
Q

Which fibrate is the ONLY one with an indication to use with a statin?

114
Q

MOA of niacin?

A

Decreases rate of hepatic synthesis of VLDL (lowers TGs) and LDL

115
Q

What’s niacin also known as?

A

Nicotinic acid

Or

Vitamin B3 (although doses for cholesterol reduction are much higher than those found in multivitamin pdts)

116
Q

List agents under Niacin

A

Immediate-Release (crystalline) niacin (Niacor) - OTC

Extended-Release Niacin (Niaspan)

Controlled-(or sustained) Release Niacin (Slo-Niacin) - OTC

117
Q

What’s the brand name of Extended-Release Niacin?

118
Q

In what strength do Extended-Release Niacin (Niaspan) come in?

A

500mg

750mg

1000mg

119
Q

SE of Niacin use

A

Flushing

Pruritus (itching)

Nausea/ vomiting

Diarrhea

GI distress

Hyperglycemia

Hyperuricemia (or gout)

Increased cough

Hepatotoxicity

Orthostatic hypotension

Hypophosphatemia

120
Q

Monitoring parameters of Niacin use?

A

Check LFTs (at start of baseline; Q 6-12wks for first yr)

BG (if diabetic)

Uric gout (if gout)

INR (if on warfarin)

121
Q

Which formulation of Niacin has less flushing and less hepatotoxicity? T4 best clinical choice from Niacin Grp?

A

Niaspan (but, it’s most expensive)

122
Q

Are formulations of Niacin interchangeable?

A

No! (Applicable to regular release v. Extended release)

123
Q

How should u use Niacin in combo with statins?

A

Stick to lower statin doses

124
Q

How should u use Niacin and Bile acid Sequestrants (Colevelesam (Welchol))?

A

Take Niacin 4-6 hrs AFTER bile acid sequestrants

125
Q

Use of fish oils?

A

Adjunct to diet in pts with TGs >= 500mg/dL

126
Q

List agents under fish oil

A

Omega-3 acid Ethyl Esters (Lovaza)

Icosapent ethyl (Vascepa)

127
Q

What’s the brand name of Omega-3 Acid Ethyl Esters?

128
Q

SEs of fish oils?

A

Eructation (burping)

Dyspepsia

Taste perversions (Lovaza)
Arthralgias (Vascepa)
129
Q

Which fish oil can increase LDL by up to 44%?

A

Lovaza ONLY

No such increase seen with Vascepa

130
Q

Effect of omega-3-acids (fish oil) on bleeding out?

A

Lovaza and Vascepa may prolong bleeding time

131
Q

List new agents used for Homozygous Familial Hypercholesterolemia (HoFH)

A

Lomitapid

Mipomersen

132
Q

MOA of Lomitapide?

A

Lomitapide binds to and inhibits microsomal TG transfer protein (MTP) in the endoplasmic reticulum

133
Q

What’s the brand name of Lomitapide?

134
Q

Pregnancy category of Lomitapide (Juxtapid)?

135
Q

MOA of Mipomersen?

A

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
Q

What’s the brand name of Mipomersen?

137
Q

What’s the CI to Mipomersen (Kynamro) use?

A

Liver dx (including unexplained elevations in hepatic Transaminases)

138
Q

Due to risk of hepatotoxicity, howz Mipomersen (Kynamro) made available?

A

Only available through a Kynamro Risk Evaluation and Mitigation Strategy (REMS) program

139
Q

What med can be used as a pre-tx to prevent flushing caused by Niacin agents?

A

325mg aspirin (or 200mg of ibuprofen) 30-60 mins before dose (for a few weeks)

140
Q

List drugs that significantly reduce TGs by > 10%?

A

Fibrates

Fish oils

Niacin

NAPLEX (73 decks)

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