Dyslipidemia

Question 1

Triglycerides > _____ can cause pancreatitis

Answer 1

500

Question 2

How to calculate non-HDL cholesterol

Answer 2

Non-HDL = Total - HDL

Question 3

How to calculate LDL cholesterol and when should this equation not be used

Answer 3

LDL = TC - HDL - TG/5

Do NOT use this if TG > 400

Question 4

What drugs can increase LDL and TG?

Answer 4

Diuretics, efavirenz, steroids, immunosuppressants, atypical antipsychotics, protease inhibitors, retinoids

Question 5

What drugs can increase LDL

Answer 5

Fish oils (except Vacepa), anabolic steroids, fibrates, progestins, STLG2 inhibitors

Question 6

What drugs can increase TG

Answer 6

IV lipid emulsions, propofol, bile acid sequestrants (~5%), estrogen, tamoxifen, clevidipine, beta-blockers

Question 7

Goal levels for Non-HDL, LDL, HDL, TG

Answer 7

Non-HDL: <130
LDL: <100 (>190 is very high)
HDL: >40 (men) >50 (women)
TG: <150 (>500 is very high)

Question 8

What lipid test can be falsely elevated if the patient did not fast?

Answer 8

TG

Can cause incorrect LDL calculation

Question 9

What does ASCVD risk calculation estimate? What is the cutoff for a low score?

Answer 9

Risk of having a first CV event in the next 10 years

<7.5% is low

Question 10

A coronary artery calcium score of ____ indicated a statin should be initiated

Answer 10

> 100

Question 11

What 3 patient populations should always have a statin initiated

Answer 11

Clinical ASCVD
Diabetes
LDL > 190

Question 12

OTC fish oils can reduce ____ but raise ____

Answer 12

lower TG

Increase LDL

Question 13

Statins are the drug of choice in treating what?

Answer 13

High non-HDL and LDL

Question 14

What are second line therapies if statins cannot be used?

Answer 14

ezetimibe and PCSK9 inhibitors

Question 15

What are the statin benefit groups?

Answer 15

Clinical ASCVD - High intensity
LDL >190 - High intensity
Diabetes and 40-75 with LDL 70-189 - moderate/high
40-75 with LDL 70-189 - moderate (ASCVD risk 7.5-19.9%) or high (ASCVD risk >20%)

Question 16

Which cholesterol lowering medications should not be used if AST/ALT are >3 times ULN?

Answer 16

niacin, fibrates, statins and ezetimibe

Question 17

Statin MOA

Answer 17

inhibit HMG-CoA reductase, preventing conversion of HMG-CoA to mevalonate (rate limiting step for cholesterol synthesis)

Question 18

What are the moderate intensity statin doses?

Answer 18

Pharmacists Rock AT Saving Lives and PReventing Fatty-deposits

Pitava 2
Rosuva 5
Atorva 10
Simva 20
Lova 40
Prava 40
Fluva 80

Question 19

When can you see muscle pain from statins?

Answer 19

Any time but usually within 6 weeks

Question 20

Myalgias vs myopathy vs myositis vs rhabdo?

Answer 20

Myalgias: soreness and tenderness
Myopathy: weakness +/- CPK elevations
Myositis: inflammation
Rhabdo: CPK >10,000 + muscle protein in the urine (myoglobinuria) which can lead to acute renal failure

Question 21

What simvastatin dose is associated with myalgias?

Answer 21

Simva 80mg/d

Question 22

What cholesterol lowering medication interacts with statins and causes myalgias?

Answer 22

Gemfibrozil

Question 23

Statin contrindications

Answer 23

Pregancy
Use with strong CYP3A4 inhibitors (simva and lova)
Liver disease

Question 24

What factors increase risk of myopathy with statins?

Answer 24

higher dose, advanced age (>65), niacin, CYP3A4 inhibitors, hypothyroidism (uncontrolled), renal impairment

Question 25

When to check lipid panel after starting statin

Answer 25

4-12 weeks then every 3-12 months

Question 26

What statins MUST be taken at night?

Answer 26

Lovastatin, fluvastatin and simvastatin

Question 27

What statins have less drug interactions than other statins?

Answer 27

Rosuva and prava

Question 28

Significant drug interactions with statins

Answer 28

``` G-PACMAN Grapefruit Protease inhibitors Azole antifungals Cyclosporine/cobicistat Macrolides (except azithromycin) Amiodarone Non-DHP CCBs ```

Question 29

What should you add on if a patient is on a statin max dose and their LDL is still > 70?

Answer 29

Ezetimibe (preferred) or PCSK9 inhibitor

Question 30

What should you add on if a patient is on a statin max dose and has primary hypercholesterolemia (LDL >190) and their LDL remains >100?

Answer 30

Ezetimibe (preferred) or PCSK9 inhibitor

Question 31

What do fish oils and fibrates target?

Answer 31

high TG

Question 32

Ezetimibe drug interactions

Answer 32

Cyclosporine: increases concentration of both statin and cyclosporine Bile acid sequestrants: decrease ezetimibe concentration, separate 2 hours before or 4 hours after bile acid sequestrants Increased risk of gallstones with fenofibrate and gemfibrozil (do NOT use with gemfibrozil)

Question 33

Proprotein Convertase Subtilisin Kexin Type 9 (PCSK9) inhibitors MOA

Answer 33

LDL receptors clear the circulating LDL PCSK9 enzyme increases LDL receptor degredation PCSK9 inhibitors prevent the degradation of LDL receptors resulting in dramatic reduction in LDL (60%)

Question 34

PCSK9 inhibitor medications and biggest downfall

Answer 34

Alirocumab (Praluent) Evolocumab (Repatha) EXPENSIVE (~$14,000 per year)

Question 35

How are PCKS9 inhibitors administered and what are the most common side effects?

Answer 35

SQ every 2 weeks or monthly | SE: injection site reactions

Question 36

Bile acid sequestrant/binding resins MOA

Answer 36

binds to bile acid and forms a complex that is not reabsorbed by enterohepatic circulation and is excreted in the feces

Question 37

What drugs are bile acid sequestrants/binding resins?

Answer 37

Cholestyramine Colesevelam (Welchol) Colestipol

Question 38

Contraindications for bile acid binding resins

Answer 38

Cholestyramine: biliary obstruction Colesevelam: bowel obstruction, TG > 500, hx of hypertriglyceridemia induced pancreatitis

Question 39

Bile acid binding resin side effects and clinical pearls

Answer 39

SE: constipation, abdominal pain, cramping, bloating, gas, INCREASED TG Not recommended if TG > 300 Colesevelam can be used in pregnancy

Question 40

Bile acid sequestrant drug interactions

Answer 40

Colesevelam - fewest drug interactions For cholestyramine or colestipol - take all other drugs 1-4 hours before or 4-6 hours after Warfarin: can affect INR Decrease absorption of fat soluble vitamins (ADEK), folate, and iron

Question 41

Fibrates MOA

Answer 41

peroxisome proliferator receptor apha activators which upregulate expression of apolipoprotein C2 and A1. ApoC-II increases lipoprotein lipase activity leading to catabolism fo VLDL particles (decreases TG)

Question 42

Fibrate contraindications

Answer 42

severe liver disease CrCl <30 Gallbladder disease concurrent use of repaglinide or simvastatin (gemfibrozil only)

Question 43

Fibrate warnings, SE

Answer 43

Myopathy (esp when given with statin), cholelithiasis, reversible increase in SCr SE: dyspepsia (gemfibrozil), increased LFTs, increased LDL when TG are high

Question 44

What medications are fibrates?

Answer 44

fenofibrate, gemfibrozil

Question 45

Fibrate drug interactions

Answer 45

Gemfibrozil should not be given with ezetimibe or statins - myopathy and rhabdo Colchicine - increase risk of myopathy Repaglinide - contraindicated d/t hypoglycemic effects Sulfonylureas and warfarin - increased effects when administered with fibrates

Question 46

Niacin contrindications

Answer 46

Active liver disease | PUD o arterial bleeding

Question 47

Niacin Warnings SE, clinical pearls

Answer 47

Warnings: rhabdo, hepatotoxicity, increased BG, increased uric acid SE: flushing, pruritus, vomiting, diarrhea, increased BG, hyperuricemia IR niacin - flushing/itching CR/SR - more hepatotoxicity

Question 48

How to reduce flushing/itching with niacin

Answer 48

ASA 325 mg (or ibuprofen 200mg) 30-60 minutes before the dose With food Avoid spicy food, alcohol, and hot beverages

Question 49

When are fish oils indicated?

Answer 49

in addition to diet changes when TG > 500

Question 50

Lomitapide MOA and indication

Answer 50

decreases apoB by binding to and inhibiting microsomal triglyceride transfer protein Indication: homozygous familial hypercholesterolemia

Question 51

Bempedoic acid MOA adn indication

Answer 51

inhibits cholesterol synthesis by inhibiting adenosine triphosphate-citrate lyase (ACL) Indication: heterozygous familial hypercholesterolemia and in ASCVD requiring additional LDL lowering

Question 52

Lomitapide boxed warning and contraindications

Answer 52

BBW: hepatotoxicity Contraindication: active liver disease, pregnancy