Dyslipidemia

Question 1

What is the Friedewald equation?

Answer 1

LDL = TC - HDL - (TG/5)

Do not use when TG > 400

Question 2

If a patient’s cholesterol is tested but they were not fasting, what can be falsely high/low?

Answer 2

TG can be falsely elevated which results in a falsely low calculated LDL using Friedewald equation

Question 3

Desirable LDL?

Answer 3

< 100

Question 4

Desirable HDL?

Answer 4

> 40 (men)

> 50 (women)

Question 5

Desirable TG?

Answer 5

< 150

Question 6

Desirable non-HDL cholesterol?

Answer 6

< 130

Question 7

What are the 4 statin benefit groups?

Answer 7

(1) Clinical ASCVD
(2) LDL > 190
(3) Diabetes age 40-75 with LDL between 70-189
(4) Patients 40-75 with LDL between 70-180 and estimated 10-year ASCVD risk > 7.5%

Question 8

Expected LDL reduction with each class of statins

Answer 8

High intensity: Reduction > 50%
Moderate intensity: Reduction 30-49%
Low intensity: Reduction < 30%

Question 9

Define rhabdo

Answer 9

Muscle symptoms + very high CPK > 10,000 + muscle protein in the urine (myoglobinuria) which leads to acute renal failure

Question 10

Why don’t we use gemfibrozil + statin

Answer 10

Risk of rhabdo

Question 11

Why do we monitor AST/ALT’s? When do we stop statins?

Answer 11

Statins (and niacin, fibrates, ezetimibe) can cause liver damage
Stop when AST or ALT are > 3 times the upper limit of normal

AST and ALT normal: 10-40 units/L

Question 12

Role of PCSK9 inhibitors, name them

Answer 12

Alirocumab (Praluent) and evolocumab (Repatha)

Used in familial hypercholesterolemia and for patients with ASCVD who require additional LDL lowering

Decreases LDL by ~60%

Question 13

How are PCSK9 inhibitors given

Answer 13

SC injections

Question 14

Statin equivalent doses

Answer 14

Pitavastatin 2mg
Rosuvastatin 5 mg
Atorvastatin 10 mg
Simvastatin 20 mg
Lovastatin 40 mg
Pravastatin 40 mg
Fluvastatin 80 mg

2 5 10 20 40 40 80

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Question 15

How do statins work?

Answer 15

Inhibit HMG-CoA reductase

This is the rate limiting step of cholesterol synthesis

Question 16

Statins: Contraindications, warnings, side effects, monitoring, notes

Answer 16

CI: Active liver disease, pregnancy, breastfeeding
Warnings: skeletal muscle effects (myopathy, rhabdo)
Side effects: myalgias, arthralgias, myopathy
Monitoring: LFTs at baseline
Obtain a lipid panel 4-12 weeks after initiation or inc in dose
Note: Can take Crestor, Lipitor, Livalo, Lescol XL, and Pravachol any time of day

Crestor = rosuvastatin
Lipitor = atorvastatin
Livalo = pitavastatin
Lescol XL = Fluvastatin
Pravachol = Pravastatin

Question 17

Crestor

Answer 17

Rosuvastatin

Question 18

Lipitor

Answer 18

Atorvastatin

Question 19

Mevacor

Answer 19

Lovastatin

Question 20

Altoprev

Answer 20

Lovastatin

Question 21

Pravachol

Answer 21

Pravastatin

Question 22

Zocor

Answer 22

Simvastatin

Question 23

Vytorin

Answer 23

Simvastatin + ezetimibe

Question 24

Drugs where simvastatin max dose 10 mg/day

Answer 24

Verapamil
DIltiazem
Dronedarone
(CYP3A4 inhibitors)

Question 25

Drugs where simvastatin max dose 20 mg/day

Answer 25

Amiodarone
Amlodipine
Lomitapide
Ranolazine
(CYP3A4 inhibitors/substrates)

Question 26

Drugs where lovastatin max 20 mg/day

Answer 26

Danazol
Diltiazem
Dronedarone
Verapamil
Amlodipine 
(CYP3A4 inhibitors/substrates)

Question 27

Drugs where lovastatin max 40 mg/day

Answer 27

Amiodarone
Ticagrelor
(CYP3A4 inhibitors/substrates)

Question 28

Ezetimibe MOA, brands, contraindications

Answer 28

Inhibits absorption of cholesterol at the brush border of the small intestine
Usually added to moderate intensity statins bc IMPROVE-IT stud showed additional benefit in lowering risk of cardiovascular events

Zetia (alone)
Vytorin (+ simvastatin)
Contraindicated in active liver disease, pregnancy/breastfeeding

Question 29

Colesevelam brand, drug class, dose, contraindications, side effects
Why is it preferred over other drugs in its class?

Answer 29

Welchol
Bile acid sequestrant
Contraindicated in bowel obstruction, TG > 500, history of hypertrigclyceridemia-induced pancreatitis
Side effects: constipation, abdominal pain, cramping, gas, bloating, increased TG

Less drug intx
For cholestyramine and colestipol, have to take ALL other drugs 1-4 hours before or 4-6 hours after the bile acid sequestrants
Only certain drugs have to be taken 4 hours before colesevelam: sulfonylureas, levothyroxine, olmesartan, phenytoin, oral contraceptives