Dyslipidemia Flashcards
High Intensity Statin Therapy
Atorvastatin
Rosuvastatin
Moderate Intensity Statin Therapy
Atorvastatin Rosuvastatin Simvastatin Pravastatin Lovastatin Fluvastatin
Low-Intensity Statin Therapy
Pravastatin
Lovastatin
Simvastatin
Fluvastatin
Pitivastatin
Lipoprotein Lowering Medications
Bile acid sequestrates:
Cholestyramine (Questran), colestipol, colesevelam
Nicotinic Acid
Fibric acid derivatives (incrase breakdown of VLDLs): Gembibrozil, Fenofibrate, Clofibrate
Ezetimibe (Zetia)- inhibits cholesterol absorption from BB
Combo therapy: Statin and Ezetimibe; Statin and bile acid sequestrate; statin and fibrin acid derivatives; statin and niacin
Drug interactions
Lovastatin & Simvastatin Itraconazole (Sporanox) Ketoconazole (Nizoral) Erythromycin Clarithromycin (Biaxin) Gemfibrozil Grapefruit juice
Other drug combinations with statins
Niacin Gemfibrozil Cyclosporin HIV protease inhibitors Verapamil Amiodarone
Drugs to avoid with pregnant or nursing women
Statins Ezetimibe Niacin Fibric acid derivatives Bile acid-binding resins are currently the only lipid-lowering medication safe to use during pregnancy
Potential Future Therapies
Cholesteryl ester transfer protein inhibitors (CETP)
Exchanges lipoprotein particles in a reverse cholesterol transport process
Significant ↓ in LDL & ↑ in HDL
Anacetrapib & Dalcetrapib
Eprotirome
Thyroid hormone analog
Mediates lipid-lowering activity of thyroid hormone
Up to 30+% reduction of LDL (& other lipoproteins) in patients on statins
Microsomal triglyceride transfer protein inhibitor
Reduces the secretion of VLDL (precursor to LDL) in the liver
Up to 50% reduction in plasma LDL levels
Mipomersen
May reduce plasma levels of lipoprotein A
Being tested in severe hypercholesterolemia & statin-intolerant patients
Intensity of Statin Therapy is based on
Presence of Clinical ASCVD
Risk of Developing ASCVD
Presence of Diabetes with/without hyperlipidemia
Presence of isolated hyperlipidemia (genetic component)
Combination medications for lipoprotein lowering medications
Statin & Ezetimibe Approximately 25% reduction in LDL Statin & Bile Acid Sequestrant Approximately 8 -16% reduction in LDL Statin & Fibric Acid Derivatives Primarily assist in ↓ triglycerides ↑ risk of myopathies Contraindicated with severe hepatic disease Statin & Niacin ↑ risk of hepatic dysfunction
Hyperlipidemia
Hypercholesterolemia
Hypertriglyceridemia
Elevated LDL
Physical Examination
Xanthelasma Circumferential arcus Peripheral vascular disease Shiny extremities Discoloration of skin Hairlessness Thickened Achilles Hypertension
Cholesterol Levels
Total Cholesterol Level Desirable < 200 mg/dl Borderline 200 to 239 mg/dl High > 240 mg/dl HDL Level Low < 40 High >60 LDL Cholesterol Optimal < 100 Near optimal 100-129 Borderline High 130-159 High 160-189 Very High >190
Primary Hyperlipidemia
Genetic (or inherited) heterozygous condition resulting in elevated total cholesterol level or triglyceride level.
Total cholesterol usually > 200, triglycerides often > 500
Often referred to as
Familial hypercholesterolemia
Familial hypertriglyceridemia
Necessary to obtain a thorough family history
Secondary Hyperlipidemia
Diabetes Hypothyroidism Obstructive liver disease Chronic renal failure Drugs that ↑ LDL & ↓ HDL Progestins Corticosteroids Anabolic steroids
Dietary influences
HDL:
Elevated by alcohol, saturated fats, weight loss
Lowered by low fat diet, sugar, excess calories, excess polyunsaturated fats
LDL:
Elevated by saturated fat, trans fatty acids, & dietary cholesterol
Lowered by MUFAs, complex carbohydrates, & soy
Total cholesterol:
Elevated by saturated fats & trans fatty acids
Lowered by substituting MUFAs & complex carbohydrates for saturated fats; lowered by soy
Triglycerides:
Elevated by alcohol, sugar, high carbohydrate diet, & excess calories
Lowered by weight loss & fish oils
Four main categories established for statin therapy for secondary prevention of ASCVD
Clinical ASCVD
LDL ≥ 190
Diabetes
≥ 7.5% Estimated 10-yr ASCVD risk
Benefits of statin therapy
Moderate intensity statin therapy
~30-50% reduction in LDL
High intensity statin therapy
≥50% reduction in LDL
Statin therapy in general reduces the risk of ASCVD across the spectrum for all those with LDL > 70
Statin therapy recommended for all those who would experience a net benefit of ASCVD risk reduction & the potential for adverse effects
Statin therapy
Lovastatin (Mevacor) Rosuvastatin (Crestor) Simvastatin (Zocor) Pravastatin (Pravachol) Atorvastatin (Lipitor) Fluvastatin (Lescol)
Statin therapy goals
Inhibit the rate-limiting enzyme in the formation of cholesterol. Effect is to ↓ LDLs, ↓ TGs, & ↑ HDLs
Statin Therapy for Clinical ASCVD
Age ≤ 75 should receive high-intensity statin
Age > 75, or with contraindications to high-intensity therapy should receive moderate-intensity statin
Statin Therapy for Primary Hyperlipidemia
Patients with LDL ≥ 190
Reduction of LDL by 39 mg/dl reduces ASCVD by approx 20%
May require additional use of non-statin lipid lowering agents to achieve acceptable lipid reduction
Assess need for addressing hypertriglyceridemia
Statin Therapy for Diabetes
Data from RCTs is for patients 40-75 with either Type 1 or 2 DM & LDL < 190
Benefits of statin therapy are substantial
Moderate-intensity therapy acceptable
High-intensity therapy if 10yr ASCVD risk > 7.5%
Secondary treatment goals
Treat elevated triglycerides
If triglycerides are > 200 & LDL goal has been achieved, add additional treatment for TGs
Treat low HDLs (<40)
