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NAPLEX Review > Dyslipidemia > Flashcards

Dyslipidemia Flashcards

1
Q

Triglycerides > _____ can cause pancreatitis

A

500

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2
Q

How to calculate non-HDL cholesterol

A

Non-HDL = Total - HDL

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3
Q

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

A

LDL = TC - HDL - TG/5

Do NOT use this if TG > 400

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4
Q

What drugs can increase LDL and TG?

A

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

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5
Q

What drugs can increase LDL

A

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

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6
Q

What drugs can increase TG

A

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

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7
Q

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

A

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

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8
Q

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

A

TG

Can cause incorrect LDL calculation

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9
Q

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

A

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

<7.5% is low

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10
Q

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

A

> 100

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11
Q

What 3 patient populations should always have a statin initiated

A

Clinical ASCVD
Diabetes
LDL > 190

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12
Q

OTC fish oils can reduce ____ but raise ____

A

lower TG

Increase LDL

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13
Q

Statins are the drug of choice in treating what?

A

High non-HDL and LDL

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14
Q

What are second line therapies if statins cannot be used?

A

ezetimibe and PCSK9 inhibitors

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15
Q

What are the statin benefit groups?

A

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%)

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16
Q

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

A

niacin, fibrates, statins and ezetimibe

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17
Q

Statin MOA

A

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

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18
Q

What are the moderate intensity statin doses?

A

Pharmacists Rock AT Saving Lives and PReventing Fatty-deposits

Pitava 2
Rosuva 5
Atorva 10
Simva 20
Lova 40
Prava 40
Fluva 80
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19
Q

When can you see muscle pain from statins?

A

Any time but usually within 6 weeks

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20
Q

Myalgias vs myopathy vs myositis vs rhabdo?

A

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

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21
Q

What simvastatin dose is associated with myalgias?

A

Simva 80mg/d

22
Q

What cholesterol lowering medication interacts with statins and causes myalgias?

A

Gemfibrozil

23
Q

Statin contrindications

A

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

24
Q

What factors increase risk of myopathy with statins?

A

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

25
Q

When to check lipid panel after starting statin

A

4-12 weeks then every 3-12 months

26
Q

What statins MUST be taken at night?

A

Lovastatin, fluvastatin and simvastatin

27
Q

What statins have less drug interactions than other statins?

A

Rosuva and prava

28
Q

Significant drug interactions with statins

A 
G-PACMAN
Grapefruit
Protease inhibitors
Azole antifungals
Cyclosporine/cobicistat
Macrolides (except azithromycin)
Amiodarone
Non-DHP CCBs
29
Q

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

A

Ezetimibe (preferred) or PCSK9 inhibitor

30
Q

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?

A

Ezetimibe (preferred) or PCSK9 inhibitor

31
Q

What do fish oils and fibrates target?

A

high TG

32
Q

Ezetimibe drug interactions

A

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)

33
Q

Proprotein Convertase Subtilisin Kexin Type 9 (PCSK9) inhibitors MOA

A

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%)

34
Q

PCSK9 inhibitor medications and biggest downfall

A

Alirocumab (Praluent)
Evolocumab (Repatha)

EXPENSIVE (~$14,000 per year)

35
Q

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

A

SQ every 2 weeks or monthly

SE: injection site reactions

36
Q

Bile acid sequestrant/binding resins MOA

A

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

37
Q

What drugs are bile acid sequestrants/binding resins?

A

Cholestyramine
Colesevelam (Welchol)
Colestipol

38
Q

Contraindications for bile acid binding resins

A

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

39
Q

Bile acid binding resin side effects and clinical pearls

A

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

40
Q

Bile acid sequestrant drug interactions

A

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

41
Q

Fibrates MOA

A

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)

42
Q

Fibrate contraindications

A

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

43
Q

Fibrate warnings, SE

A

Myopathy (esp when given with statin), cholelithiasis, reversible increase in SCr

SE: dyspepsia (gemfibrozil), increased LFTs, increased LDL when TG are high

44
Q

What medications are fibrates?

A

fenofibrate, gemfibrozil

45
Q

Fibrate drug interactions

A

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

46
Q

Niacin contrindications

A

Active liver disease

PUD o arterial bleeding

47
Q

Niacin Warnings SE, clinical pearls

A

Warnings: rhabdo, hepatotoxicity, increased BG, increased uric acid

SE: flushing, pruritus, vomiting, diarrhea, increased BG, hyperuricemia

IR niacin - flushing/itching
CR/SR - more hepatotoxicity

48
Q

How to reduce flushing/itching with niacin

A

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

49
Q

When are fish oils indicated?

A

in addition to diet changes when TG > 500

50
Q

Lomitapide MOA and indication

A

decreases apoB by binding to and inhibiting microsomal triglyceride transfer protein

Indication: homozygous familial hypercholesterolemia

51
Q

Bempedoic acid MOA adn indication

A

inhibits cholesterol synthesis by inhibiting adenosine triphosphate-citrate lyase (ACL)

Indication: heterozygous familial hypercholesterolemia and in ASCVD requiring additional LDL lowering

52
Q

Lomitapide boxed warning and contraindications

A

BBW: hepatotoxicity
Contraindication: active liver disease, pregnancy

NAPLEX Review (79 decks)

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