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NAPLEX Studying > Dyslipidemia - Cardiovascular > Flashcards

Dyslipidemia - Cardiovascular Flashcards

1
Q

What are different types of atherosclerotic cardiovascular diseases (ASCVD)?

A
  • myocardial infarction
  • stroke/transient ischemic attacks
  • angina
  • peripheral arterial disease
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2
Q

What does total cholesterol include?

A
  • low-density lipoprotein (LDL)
  • high-density lipoprotein (HDL)
  • very-low density lipoprotein (VLDL)
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3
Q

Which type of lipoprotein decreases an individual’s ASCVD risk?

A

high-density lipoprotein (LDL)

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4
Q

What is the role of HDL?

A

takes cholesterol from the blood and delivers it to the liver for removal from the body

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5
Q

What types of lipoproteins contribute to atherosclerosis?

A

Non-HDL lipoproteins such as:

  1. LDL
  2. intermediate-density lipoproteins (IDL)
  3. VLDL
  4. chylomicron remnants and lipoprotein (a genetic variant of LDL)
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6
Q

What level of triglycerides can cause acute pancreatitis?

A

TG >500 mg/dL

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7
Q

What is dyslipidemia?

A

abnormal lipoprotein levels

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8
Q

What is Friedwald’s equation?

A

how to calculate LDL

LDL = TC - HDL - (TG/5)

*equation cannot be used if TG >400 mg/dL

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9
Q

What key drugs can increase LDL and TG levels?

A
  1. protease inhibitors
  2. diuretics
  3. atypical antipsychotics
  4. immunosuppressants (tacrolimus, cyclosporine)
  5. efavirenz
  6. steroids
  7. retinoids
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10
Q

What key drugs increase LDL only?

A
  1. fish oils
  2. anabolic steroids
  3. fibrates
  4. progestins
  5. SGLT2 inhibitors

except VASCEPA

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11
Q

What key drug increase TG levels only?

A
  1. IV lipid emulsions
  2. propofol
  3. bile acid sequestrates
  4. estrogen
  5. tamoxifen
  6. clevidipine
  7. beta blockers
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12
Q

Conditions that can raise LDL and/or TG levels

A
  1. obesity
  2. poor diet
  3. hypothyroidism
  4. alcoholism
  5. smoking
  6. diabetes
  7. renal/liver disease
  8. nephrotic syndrome
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13
Q

What are the drugs of choice for treating high non-HDL and LDL?

A
  1. statins
  2. ezetimibe
  3. PCKS9 inhibitors
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14
Q

What cholesterol-lowering drugs can cause liver damage and when should they not be used?

A
  1. fibrates
  2. niacin
  3. potentially statins
  4. ezetimibe

*SHOULD NOT BE USED IF AST OR ALT IS >3 TIMES THE UPPER LIMIT OF NORMAL

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15
Q

What is the MOA of statins?

A

Inhibits HMG-CoA reductase to prevent the conversion of HMG-CoA to mevalonate –> this is the rate limiting step in cholesterol synthesis

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16
Q

High-dosed statins

A
  1. atorvastatin 40-80 mg

2. rosuvastatin 20-40 mg

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17
Q

Moderate-dosed statins

A
  1. atorvastatin 10-20 mg
  2. rosuvastatin 5-10 mg
  3. simvastatin 20-40 mg
  4. pravastatin 40-80 mg
  5. lovastatin 40 mg
  6. fluvastatin 40 mg BID or 80 mg
  7. pitavastatin 2-4 mg
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18
Q

Low-dosed statin

A
  1. simvastatin 10 mg
  2. pravastatin 10-20 mg
  3. lovastatin 20 mg
  4. fluvastatin 20-40 mg
  5. pitavastatin 1 mg
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19
Q

Statin equivalent doses

A

Pharmacists Rock At Saving Lives and Preventing Fatty-Deposits

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

How do you change from a moderate-dosed statin to a high-dosed statin?

A

increase lower dose by multiplying by 4

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21
Q

What is the most common adverse effect of statins, how do they present to the body, and when do they usually occur?

A

muscle damage and within 6 weeks of starting tx

  1. myalgias: muscle soreness and tenderness
  2. myopathy: muscle weakness and CPK elevations
  3. myositis: muscle inflammation
  4. rhabdomyolysis: muscle symptoms with very high CPK and muscle protein in the urine (myoglobinuria), which can lead to acute renal failure

muscle damage is symmetrical on both sides of the body

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22
Q

How to manage mayalgias caused by statins?

A

do not use simvastatin 80 mg/day

do not use gemfibrozil plus statin

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23
Q

Contraindications to statins

A
  1. do not use in pregnancy and breastfeeding
  2. do not use strong CYP3A4 inhibitors with simvastatin and lovastatin
  3. do not use with liver disease
  4. do not use cyclosporine with pitavastatin
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24
Q

Warnings to statins

A
  1. muscle damage –> higher risk with higher dose, advanced age, niacin, CYP3A4 inhibitors, uncontrolled hypothyroidism, renal impairment
  2. diabetes: increase in A1C –> make sure the benefits outweigh the risks
  3. hepatotoxicity
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25
Q

Warnings to rosuvastatin

A
  1. proteinuria

2. hematuria

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26
Q

Warnings to atorvastatin

A
  1. hemorrhagic stroke (if recent stroke or TIAs)
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27
Q

Side effects of statins

A

GENERALLY WELL-TOLERATED

1. myalgia/myopathy

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28
Q

How to monitor statins?

A
  1. lipid panel 4-12 weeks (1-3 months) after starting treatment and then every 3-12 months annually
  2. LFTs
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29
Q

If patients have symptoms to statins, what should you monitor?

A
  1. myalgia/myopathy: check creatine phosphokinase levels (CPK)
  2. little to no urine: check SCr/BUN for acute renal failure due to rhabdomyolysis
  3. abdominal pain/jaundice: check LFTs possibly for hepatotoxicity
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30
Q

Which statins can you take at anytime of the day?

A
  1. Rosuvastatin
  2. Atorvastatin
  3. Pitavastatin
  4. Fluvastatin ER
  5. Pravastatin
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31
Q

Which statin must be taken on an empty stomach?

A

Simvastatin

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32
Q

What statins do you start with if CrCl <30 mL/min?

A

START WITH LOW DOSES OF:

  1. lovastatin
  2. simvastatin
  3. rosuvastatin
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33
Q

What statin do you start with if eGFR <60 mL/min?

A

start with low dose of pitavastatin

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34
Q

When should normal Fluvastatin (Lescol) be taken?

A

in the evening

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35
Q

When should lovastatin IR be taken?

A

with the evening meal

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36
Q

When should lovastatin (Altoprev) be taken?

A

at bedtime

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37
Q

Which statins have less drug interactions compared to other statins?

A
  1. rosuvastatin

2. pravastatin

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38
Q

Significant DDIs with statins?

A

G-PACMAN

  1. grapefruit
  2. protease inhibitors
  3. azole antifungals
  4. cyclosporine, cobicistat
  5. macrolids
  6. amiodarone
  7. non-DHP calcium channel blockers
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39
Q

What non-statin is preferred as an add-on treatment if statins are at its maximum tolerated dose?

A

Ezetimibe

b/c PCSK9 inhibitors are more expensive

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40
Q

What is the MOA of ezetimibe?

A

to inhibit the absorption of cholesterol in the small intestines

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41
Q

Contraindications to ezetimibe?

A
  1. do not use in pregnancy and breastfeeding
  2. do not use strong CYP3A4 inhibitors
  3. do not use with liver disease
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42
Q

Warnings for ezetimibe?

A
  1. avoid use in moderate-or-severe hepatic impairment

2. skeletal muscle effects –> risk increased when combined with a statin

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43
Q

Side effects of ezetimibe?

A
  1. myalgia
  2. diarrhea
  3. upper respiratory tract infections
  4. arthralgia
  5. pain in extremities
  6. sinusitis
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44
Q

Drug interactions with ezetimibe?

A
  1. used in combination with cyclosporine –> want to monitor levels of cyclosporine b/c there is an increase in the concentration of both
  2. concurrent use with bile acid sequestrants will decrease ezetimibe –> separate the drugs for 2 hours before or 4 hours after bile acid sequestrants
  3. increase risk of cholelithiasis when used concurrently with fenofibrate and gemfibrozil –> do not use with gemfibrozil
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45
Q

PCSK9 inhibitors?

A
  1. alirocumab

2. evolocumab

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46
Q

How are PCSK9 inhibitors administered?

A

subcutaneously

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47
Q

What is the MOA of PCSK9 inhibitors?

A

by blocking the ability of PCSK9 enzyme to bind to the LDL receptor –> allows for lowering of LDL cholesterol and reducing the risk of cardiac events

48
Q

Side effects of PCSK9 inhibitors?

A
  1. injection site reactions
  2. nasopharyngitis
  3. influenza
  4. upper respiratory tract infections
  5. UTIs
  6. back pain with evolocumab
  7. increase in LFTs with alirocumab
49
Q

Storage rules for PCSK9 inhibitors

A
  1. store in refrigerator in the original carton and protect from light or
  2. can be kept at room temperature for up to 30 days and must be discarded after 30 days if stored at room temperature
50
Q

What is the MOA of bile acid sequestrants?

A

to bind bile acids in the stomach and form a complex that is excreted in the feces –> results in the removal of bile acid from the enterohepatic circulation and prevents reabsorption

51
Q

What are the 3 bile acid sequestrant drugs?

A
  1. cholestyramine
  2. colesevelam
  3. colestipol
52
Q

What is the contraindication with cholestyramine?

A

complete biliary obstruction

53
Q

What are the contraindications with colesevelam?

A
  1. bowel obstruction
  2. TG >500 mg/dL
  3. history of hypertriglyceridemia-induced pancreatitis
54
Q

What is the warning with bile acid sequestrants?

A

increased bleeding tendency due to vitamin k deficiency

55
Q

What are the main side effects associated with bile acid sequestrants?

A
  1. constipation –> may need to reduce the dose or laxative
  2. abdominal pain
  3. cramping
  4. bloating
  5. gas
  6. increase in TG
  7. dyspepsia
  8. nausea
  9. esophageal obstruction
56
Q

When are bile acid sequestrants not recommended?

A

when TG is greater or equal to 300 mg/dL

57
Q

What is the most common bile acid sequestrant to use and why?

A

colesevelam because there are less drug interactions

58
Q

What are the 2 bile acid sequestrants that have higher DDIs when taking with other drugs and what is the administration rule?

A
  1. cholestyramine
  2. colestipol

want to take all other drugs at least 1-4 hours before or 4-6 hours after the bile acid sequestrants

59
Q

Which drugs should be taken 4 hours prior to colesevelam?

A
  1. cyclosporine
  2. glimepiride
  3. glipizide
  4. glyburide
  5. levothyroxine
  6. olmesartan
  7. phenytoin
  8. oral contraceptives containing ethinyl estradiol and norethindrone
60
Q

What drug can colesevelam increase the levels of if taken concurrently?

A

metformin ER

61
Q

What vitamins can bile acid sequestrants decrease the absorption of and what should be done?

A

decrease the absorption of fat-soluble vitamins –> A, D, E, K, folate, and iron

a multivitamin should be taken

want to separate the multivitamin and bile acid sequestrant administration time

62
Q

What is the MOA of fibrates?

A

are peroxisome proliferator receptor alpha (PPAR-alpha) activators, which upregulate the expression of apoC-II and apoA-I

since apoC-II increases lipoprotein lipase activity, this leads to increased catabolism of VLDL particles –> leads to decrease in TG

if there is too high of TG –> fibrates can lead to increase of LDL particles and increase LDL cholesterol

63
Q

What are the fibrates?

A
  1. fenofibrate or fenofibric acid

2. gemfibrozil

64
Q

When should gemfibrozil be administered?

A

30 min before breakfast and dinner

65
Q

Contraindications to fibrates?

A
  1. severe liver disease
  2. severe renal disease (CrCl <30 mL/min)
  3. gallbladder disease
  4. breastfeeding (only for fenofibrate derivatives)
66
Q

Warnings with fibrates?

A
  1. myopathy
  2. cholelithiasis
  3. reversible increase in SCr
67
Q

Common side effects of fibrates?

A
  1. dyspepsia (with gemfibrozil)
  2. increase in LFTs (dose-related)
  3. abdominal pain
  4. increase in CPK (creatinine phosphokinase)
  5. upper respiratory track infections
68
Q

How do you monitor fibrates?

A
  1. LFTs

2. renal function

69
Q

When do you want to reduce the dose of fenofibrates?

A

when the CrCl 31-80 mL/min

70
Q

What drugs should gemfibrozil not be given with and why?

A

increased risk of myopathies and rhabdomyolysis

  1. ezetimibe
  2. statins
71
Q

What drug should not be administered with fenofibrate and why?

A

colchicine b/c increased risk of myopathy

72
Q

What drugs are contraindicated with gemfibrozil only?

A
  1. repaglinide

2. simvastatin

73
Q

What drugs/class of drugs can fibrates increase the effect of?

A
  1. sulfonylureas

2. warfarin

74
Q

What is the MOA of niacin?

A

decreases the rate of hepatic synthesis of VLDL and LDL, and increases the rate of chylomicron TG removal from the plasma

75
Q

What is the brand name of Niacin IR

A

Niacor

76
Q

What is the brand name of Niacin ER

A

Niaspan

77
Q

What is the brand name of Niacin controlled release or sustained-release?

A

Slo-Niacin

78
Q

When do you want to take Niacin IR and CR/SR?

A

with food

79
Q

When do you want to take Niacin ER?

A

at bedtime after a low-fat snack

80
Q

Contraindications to niacin?

A
  1. active liver disease
  2. active PUD
  3. arterial bleeding
81
Q

Warnings with niacin?

A
  1. rhabdomyolysis if niacin doses are greater or equal to 1 g/day combined with statins
  2. hepatotoxicity
  3. lab abnormalities –> increase in BG, uric acid, phosphate
82
Q

Side effects of niacin?

A
  1. flushing
  2. pruritis (itching)
  3. vomiting
  4. diarrhea
  5. increase in BG
  6. hyperuricemia or gout
  7. nausea
  8. cough
  9. orthostatic hypotension
  10. hypophosphatemia
  11. decrease in platelets
83
Q

Monitoring for niacin?

A
  1. check LFTs at the start, every 6-12 weeks for the first year, and then every 6 months
  2. blood glucose if diabetic
  3. uric acid if gout history
  4. INR if on warfarin
  5. lipid profile
84
Q

What is the best clinical choice of niacin and why?

A

ER Niapsan b/c less flushing and hepatotoxicity

85
Q

How do you reduce flushing caused by niacin?

A
  1. aspirin 325 mg or ibuprofen 200 mg 30-60 min before the dose
  2. taking medication with food
  3. avoid spicy food, alcohol, and hot beverages
86
Q

Are the formulations of niacin interchangable?

A

No

87
Q

When should niacin be administered when concurrently being used with bile acid sequestrants?

A

4-6 hours after bile acid sequestrants

88
Q

When are fish oils used?

A

as an adjunct to diet when triglycerides are 500 mg/dL and more

89
Q

Fish oil is the same as?

A

omega-3 fatty acids

90
Q

What selected patients is Vascepa recommended for ASCVD risk reduction if triglycerides are 135-499 mg/dL despite maximum tolerated statin?

A
  1. age >45 years and presents with clinical ASCVD risk OR

2. age >50 years with type 2 diabetes and additional risk factors

91
Q

What patients should be cautioned for using omega-3?

A

patients with known hypersensitivity to fish and/or shellfish

92
Q

Can omega-3 increase levels of LDL?

A

yes- patients should monitor

93
Q

Should patients with hepatic impairment on omega-3 be monitored?

A

yes- monitor LFTs

94
Q

Common side effects associated with omega-3?

A
  1. burping
  2. dyspepsia (indigestion)
  3. taste perversions
  4. arthralgias
95
Q

What are the only brand name fish oils FDA approved for TG lowering?

A
  1. Vascepa

2. Lovaza

96
Q

Does fish oil affecting bleeding?

A

fish oil prolongs bleeding time - want to use caution with other medications that can increase bleeding risk

*want to monitor the patient’s INR if they are taking warfarin

97
Q

When should simvastatin and fluvastatin IR be taken during the day?

A

evening

98
Q

When should lovastatin IR be taken during the day?

A

with the evening meal

99
Q

When should majority of all statins be taken during the day?

A

any time of the day

100
Q

What kind of damage can statins typically cause?

A

muscle and liver damage

101
Q

What food should you avoid when taking statins?

A

grapefruit

102
Q

Are pregnant women safe to take statins?

A

no - considered teratogenic

103
Q

What kind of damage can ezetimbe cause?

A

muscle and liver damage

104
Q

What kind of injection are PCSK9 inhibitors and where are the optimal places to inject?

A

subcutaneous injections - want to inject into the thigh, abdomen, or upper arm

105
Q

What kind of reactions can a PCSK9 inhibitor cause after injection?

A
  1. allergy/anaphylaxis reaction

2. injection site reaction

106
Q

Storage rules for PCSK9 inhibitors?

A

should be stored in the refrigerator - before injecting, allow injection to warm to room temperature

*can be kept at room temperature for 30 days

107
Q

When should bile acid sequestrants be taken during the day?

A

during mealtimes with plenty of water or other liquids

108
Q

Can bile acid sequestrants cause constipation?

A

yes

109
Q

What does bile acid sequestrants reduce absorption of?

A

fat-soluble vitamins - ADEK

110
Q

When should the fibrates, Fenoglide and Lipfen be taken during the day?

A

taken with food

111
Q

When should the fibrate, Lopid be taken during the day?

A

twice daily, 30 min before breakfast and dinner

112
Q

What kind of damages can fibrates cause?

A
  1. muscle damage
  2. liver damage
  3. cholelithiasis (gallstones) - should contact prescribe r if experiencing abdominal pain, nausea, or vomiting
  4. pancreatitis
113
Q

When should Niaspan, a type of Niacin be taken during the day?

A

at bedtime after a low-fat snack

114
Q

What can Niacins cause?

A
  1. hyperglycemia
  2. liver damage
  3. flishing - may disappear after several weeks of use
115
Q

What can you do to reduce flushing caused by Niacins?

A
  1. take aspirin 325 mg 30-60 minutes before the dose
  2. take with food
  3. avoid alcohol or hot beverages or eating spicy foods around the time taking niacin

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