Dyslipidemia Flashcards
Which BAS does not increase TGs?
Colesevelam (Welchol)
Name 3 Bile Acid Sequestrants
Cholestyramine (Questran)
Colestipol (Colestid)
Colesevelem (Welchol)
What is an absolute contraindication (CI) to BAS therapy?
severe hypertriglyceridemia (super high TGs)
What are the common side effects of BAS?
Constipation
Bloating
What are the three formulations of nicotinic acid (niacin)?
IR *causes the most flushing but the least hepatotoxicity
ER (Niaspan)
SR (Slo-Niacin) *causes more hepatotoxicity
What formulation is the least likely to be hepatotoxic?
Immediate Release (IR)
What are the common side effects of nicotinic acid?
FLUSHING itching hyperglycemia gout hepatotoxicity
Name 2 fibric acid derivatives.
Gemfibrozil
Fenofibrate
What are absolute CIs to niacin therapy?
people with liver insufficiency (LFTs > 2-3 x ULN) (niacin can cause hepatotoxicity) persistent hyperglycemia acute gout unexplained abdominal of GI problems new onset of wt loss or A. fib (NOT sure about answer)
Which fibrate may be used most safely in combination with statins?
fenofibrate
Which fibrates MUST be taken with food?
fenofibrate formulations:
LoFibra
original TriCor
Lipofen
What is the mechanism of action of statins?
They inhibit HMG CoA reductase, which is the rate-limiting step in cholesterol synthesis. By inhibiting this enzyme, intracellular cholesterol decreases and the liver increases LDL-R & HMG CoA reductase expression resulting in more plasma cholesterol uptake into the cells (decreases plasma chol levels)
What is the MOA of Niacin?
niacin inhibits adenylyl cyclase (inhibits ATP –> cAMP) which in turn inhibits TGs in adipocytes from breaking down into free FAs. Less FFAs –> less TG synthesis in liver, decrease in VLDL synthesis & decrease in LDL in circulation
What is the MOA of fibrates?
Fibrates (+) PPAR-alpha –> decrease in plasma TGs
What are the common side effects of fibrates?
myalgia
GI problems (N/V)
gallstones
What is the MOA of ezetimibe?
ezetimibe blocks NCP1L1 which decreases cholesterol ABSORPTION and leads to CMs low in cholesterol
Liver response: upregulates LDL-R & HMG-CoA reductasej
What is a cholesterol absorption inhibitor (CAI)?
Zetia (ezetimibe)
Contraindications of fibrate therapy?
people with . . .
previous/ pre-existing gallbladder disease
renal failure
liver failure
What is the name of the combination product with a CAI in it?
Vytorin (Zetia + Simvastatin)
Name the 7 statins currently on the market.
rosuvastatin (crestor) pitavastatin (Livalo) atorvastatin lovastatin fluvastatin simvastatin pravastatin "random pictures always look funny, silly & preposterous"
What are the common side effects of a CAI?
Ezetimibe can cause
joint pain, abdominal pain, diarrhea
(it is usually well tolerated)
What are the common side effects of statins?
myopathy liver failure (rare)
Which statins may be used most safely in combination with fibrates?
gemfibrozil: no statin
fenofibrate: all except Fluvastatin & Rosuvastatin (b/c they are metabolized by CYP2C9)
Contraindications to statin therapy?
pregnancy
previous muscle disorder
excess alcohol use
Which statin works best at lowering TGs?
Atorvastatin (can decrease TGs ~50%)
Which statin MUST be taken with food to be absorbed?
Fluvastatin
Which statins must be taken at night/bedtime to work best?
Fluvastatin (take with evening meal)
Simvastatin
Pravastatin
Lovastatin
Which statins should you avoid taking with large volumes of grapefruit juice?
Lovastatin
Simvastatin
perhaps Atorvastatin (only minorly metabolized by CYP3A4)
What % can cholestyramine and colestipol increase TGs?
Cholestyramine 12-25%
colestipol 12-15%
BAS can decrease LDLs by _______ %?
Colestipol & Cholestyramine: 15-30 % decrease
Colesevelam: 8-15% decrease
What is the usual daily dose of Cholestyramine?
4-16g
max dose = 24 g
What is the usual daily dose of Colesevelam?
2.6-3.8 g
max = 4.4 g
What is the usual daily dose of Colestipol?
5-20 g
max = 30 g
Counseling for BAS?
Take BAS 4 hours before other medications
Mix powders with non-carbonated beverages. Add fluid to powder.
Stir and Drink immediately
Drink powders in divided doses BID before meals
Drink a large glass of water with tablets ( >7 oz)
Titrate dose to minimize side effects
BAS are infamous for drug-drug interactions
Which lipid lowering drug is almost always given in combination with a statin?
Ezetimibe (Zetia)
What are 3 drugs that interact with Zetia?
Gemfibrozil
Cyclosporin
Cholestyramine (BAS)
What is the usual dose for ezetimibe?
10 mg
max = 10 mg
How much can IR niacin decrease LDLs?
10-25%
How much can SR niacin (Slo-Niacin) decrease LDL’s?
15-26%
How much can ER niacin (Niaspan) decrease LDL’s?
20-40%
True or False. Tolerance to niacin will not improve overtime.
False. it will improve.
How can you minimize flushing in patients taking niacin?
Take an enteric-coated Aspirin 325 mg 30 min before taking Niacin
Do you take Niacin with food?
Yes
What do you tell a patient to do if they miss a dose?
SKIP IT. DO NOT DOUBLE DOSE!!
[SATA] In which of the following should you titrate the dose?
A. Nicotinic Acid
B. BAS
C. Statins
A & B
What is the effect of fibrates on….
LDL
HDL
TGs
LDL: either an increase or decrease of ~30% (severe hypertriglyceridemia pts usually have an increase in LDLs when on fibrates, while mild hypertriglyceridemia patients usually have no effect or a decrease in LDLs)
HDL: increase 10-30%
TG: decrease by 30-50%
What is the dose regimen for LoFibra?
67, 134, 200 mg
What is the dose regimen for original TriCor?
What about new Tricor?
original: 54, 160 mg
new: 48, 145 mg
What is the dose regimen for Lipofen?
50, 100, 150 mg
What is the dose regimen for Antara?
43, 130 mg
What is the dose regimen for Triglide?
50, 160 mg
What is the dose regimen for Trilipix?
45, 135 mg
Which formulation of fenofibrate should not be taken if the tablet is chipped or broken?
Triglide (50 mg or 160mg)
What is the brand name for omega 3 Fatty Acids?
LOVAZA
What is the dose of EPA + DHA needed to be effective in decreasing TGs?
2-4 g (can decrease TGs by 35%)
What can you do to minimize the fishy burping due to Lovaza?
refrigerate Lovaza
What does a Class I recommendation mean in the guidelines?
Benefit»_space;» Risk
SHOULD BE DONE
What is the typical “sig” for Lovaza?
2 tab po TID
What does a Class II recommendation mean in the guidelines?
Benefit»_space; Risk
REASONABLE TO DO
(should be done unless there is a reason not to)
What does a Class IIb recommendation mean in the guidelines?
Benefit ≥ Risk
SHOULD BE CONSIDERED
(there might be more reasons not to, but it should have more benefit than risk)
What does a Class III recommendation mean in the guidelines?
No benefit or harm
SHOULD NOT BE DONE
DON’T DO IT!!
What does a Level of Evidence “A” mean?
Data came from MULTIPLE POPULATIONS (from multiple randomized trials or meta-analyses)
What does a Level of Evidence “B” mean?
data came from LIMITED POPULATIONS (single RCT or non-RCT study)
What does a Level of Evidence “C” mean?
data came from VERY LIMITED POPULATIONS
consensus opinion, expert, case studies or standard of care
What does “consensus opinion” mean?
everyone sitting at the table thought it was a good idea
What estimates the 10 year hard ASCVD risk of 1st event?
Pooled Cohort Equation
The Pooled Cohort Equation is BEST used in. . . A. Non-hispanic Caucasians & Asians B. African Americans & Native Americans C. Non-hispanic Caucasians & AAs D. Asians & Native Americans
C
What age range (in years) does the Pooled Cohort Equation work best in? A. 45-75 B. 35-79 C. 40-79 D. 40-70
C. 40-79
What LDL levels does a patient need for the Pooled Cohort Equation to work best?
70-189
In what races does the Pooled Cohort Equation overestimate risk?
Hispanics & Asians
In what races does the Pooled Cohort Equation underestimate risk?
Native Americans (American Indians)
What are the Novel Risk Markers for Dyslipidemia?
- Premature CVD in FH: 1st ˚ relative (male < 55 yo or female < 65 yo)
- hsCRP > or equal to 2 mg/L
- CAC score > or equal to 300 Agaston units or > or equal to 75th percentile for age, sex or ethnicity
- ABI < 0.9
ABI
Ankle Brachial Index
What novel risk marker is the most useful for decision making?
CAC score
What are the Traditional Risk Factors for Dyslipidemia?
Age: men ≥45 & women ≥55 Premature FH of ASCVD: men ≤55 or female ≤65 Current Smoker Diabetes Elevated systolic BP use of anti-HTN medications Sex (male > female) TC > 200 HDL < 40
If a patient is between 20 & 79 WITHOUT ASCVD, how do you screen or manage the risk of dyslipidemia?
assess traditional risk factors q 4-6 years
counsel on controlling those and staying healthy
If a patient is between 40 & 79 WITHOUT ASCVD, how do you screen or manage the risk of dyslipidemia?
do the pooled cohort equation q 4-6 years
risk ≥ 7.5% –> counsel via cholesterol guidelines
risk < 7.5% –> counsel via lifestyle guidelines
Patient M.K. has an ASCVD risk score of 8.2%, has no HTN, has a (+) FH for CVD, is positive for DM and has a TC level of 242 and an HDL level of 75. What is your first step towards treatment?
Cholesterol Guidelines
TC
total cholesterol
ASCVD
Atherosclerotic Cardiovascular Disease
Patient A.S. has an ASCVD risk score of 6.5% (-) for smoking (+) HTN (-) FH of CVD (-) DM TC = 206 HDL = 42 What is your first step toward treatment?
Counsel on lifestyle management
What is critical component of healthy living before and along with cholesterol lowering drug therapies?
Lifestyle modification
What does Lifestyle modifications (∆) include?
Heart healthy diet
regular exercise
smoking cessation and tobacco use
weight maintenance
If you start a patient in a statin when should You follow up?
1-3 months
After you patient is steady on a statin, when should you follow up?
3-12 months
Which guideline was a secondary prevention trial?
A. Asteroid
B. Meteor
C. AIM-HIGH
A
SATA: Which trial used rosuvastatin 40 mg in studying its effect?
A. Asteroid
B. Meteor
C. AIM-HIGH
A, B
Which trial showed that Crestor slowed progression but had no regression in carotid intima-media thickness (CIMT)?
Meteor