Dyslipidemia (Guest Dr. LeVay) Flashcards
What are the two types of dyslipidemia?
Familial
Acquired
What are the lipid lowering medications? 6
—statins (4 benefit groups)
—Ezetimibe
—PCSK9
—Bile acid sequestrants
—Bempedoic acid
—Inclisaran
—Referral
What are triglyceride-lowering medications - 3
—fibrates
—niacin
—omega 3 fatty acids
When is HMG-CoA reductase (Statins) more active?
At night because statins have a short half life
What are the 4 main benefit groups for statins?
—secondary prevention in patients w/ clinical ASCVD
—primary severe hypercholesterolemia >190mg/dL LDL
—diabetes
—primary prevention over the lifespan
First statin benefit group: clinical ASCVD
what are high risk factors
what are high risk conditions
very high risk
— > major ASCVD event or (acute coronary syndrome, MI, Ischemic stroke, PAD w/ symptoms)
— 1 major ASCVD event and > 1 high risk condition
high-risk conditions
—>65 y/o
—genetic high cholesterol
—prior history of coronary bypass surgery
—DM
—HTN
—CKD
—smoking
—CHF
Second statin benefit group
Criteria:
—age range
—when do you add ezetimibe
—what about if TG >300 ? What would you add then?
—what about if pt was heterozygous FH, what would you add?
—what about if pt had baseline LDL >220
LDL >190
—20-75 y/o
—if. <50% reduction or LDL >100 consider ezetimibe
—if still <50% LDL reduction and TG >300-500, consider adding bile acid sequestrant
—if 30-75y/o and heterozygous FH and LDL >100 consider PCSK9 inhibitor
—40-75y/o w/ baseline LDL >220 who achieve LDL >130, also consider PCSK9 inhibitor
Third stain benefit group:
diabetes mellitus
—treatment if multiple ASCVD risk factors
—what are you considering for age 20-39, 40-75 and >75 y/o?
—multiple ASCVD risk factors ➡️ high intensity statin to achieve >50% reduction
—10 year ASCVD risk of >20% ➡️ + ezetimibe
—20-39y/o consider statins if presence of diabetes specific risk enhancers
—40-75y/o at least mod intensity
—>75y/o, if already on statin, continue, if not consider starting
What are the diabetes specific risk enhancers? 6
—long duration >10 years for type II, >20 years for type 1
—albuminuria >30mcg/creatinine
—eGFR <60
—retinopathy
—neuropathy
—ABI <0.9
4th statin benefit group
Primary prevention
Treatment?
—start on moderate intensity statin if ASCVD risk is 7.5 - 20%
What are the high, moderate and low intensity statins — learn this (my table)
Which statin medications are short acting?
Which are long acting?
Which do you take in the evening?
Which must you take with food?
Short
Sim, Lova, Flu and Prava
take all in the evening except Prava
Long (RAP)
Rosuva
Atorva
Pitava
Lova loves food
What are the contraindications for statins?
What are the statin associated side effects?
CI
—active liver disease (makes sense, cholesterol is made in the liver)
—pregnancy & lactation
—hypersensitivity
—caution w/ heavy EtOH use
side effects
—myalgias & myopathy (most common)
—inc liver enzymes
—altered condition
—inc glucose
Statins — DD & food interactions
Which is most common interaction and for which med?
—CYP3A4
Simvastatin > Lovastatin > atorvastatin
statins are SUBSTRATES of CYP 3A4 do you’ll get fluctuating statin levels
—grapefruit juice increases risk of myopathy
—red yeast rice — acts like statin so have an additive effect
Statins — what are you monitoring after you’ve prescribed them?
—lipid panel 4-12 weeks after initial dose
—reassess every 3-12 months
—AST/ALT if liver toxicity suspected
—CPK if muscle aches/weakness
—Rosuvastatin: kidney fxn
Ezetimibe
MOA
Benefits
Dose
Contraindications
S/E
Place in therapy — when is it used
—ABSORPTION inhibitor
—adjunct to statins if unable to achieve desired response
—mono therapy for HeFHLD (like PCSK9 and B.A.S)
—do not give if severe liver disease and taken with statins
PCSK9 (2 names)
MOA
Benefits
Administration
Contraindications
S/E
Place in therapy — when is it used
—evolocumab
—alirocumab
—increases LDL receptors therefore increasing LDL uptake from blood
—adjunct to statins after ezetimibe
—costly
—injection rxn / diarrhea / flu like symptoms
Bile-Acid Sequestrants
MOA
Benefits
Dose
Contraindications
S/E
Place in therapy — when is it used
—meds that start with Chole/Cole
—adjunct to statins — when TG >300
—but ❌ NOT TGs >500
—GI upset 🤮, constipation💩, bloating
—safe in pregnancy 🤰
Bempedoic Acid
MOA
Benefits
Dose
Contraindications
S/E
Place in therapy — when is it used
Inclisaran
MOA 2
Benefits
Administration PO/SC?
Contraindications
S/E
Place in therapy — when is it used
—like bempedoic acid
—FDA approved for pts w/ ASCVD of HeFH as adjunct to diet and max tolerated statin
—ADRs: injection site rxn / joint pain / UTI / diarrhea
Triglyceride-lowering medications:
Fibrates — names of 2
MOA
Benefits
Administration
Contraindications
S/E
Place in therapy — when is it used
—fenofibrate, gemfibrazil
—lowers TGs by up regulating LPL > clears VLDL > clears TGs
—pts w/ >500 TGs
—do not use gemfibrazil w/ statins = myopathy
—ADR: dyspepsia, gallstones
—PO
Triglyceride-lowering medications:
Niacin, aka which vitamin
MOA
Benefits
Dose
Contraindications
S/E
Place in therapy — when is it used
—B3
—bioconverted to coenzymes which are essential to lipid metabolism
—inhibits lipolysis in adipose tissue
—pts w/ >500 TGs
—c/i in pts with severe liver disease, like fibrates
—ADR: flushing, hyperglycaemia & uricemia, upper GI distress
Triglyceride-lowering medications:
Omega-3 Fatty Acids
MOA
Benefits
Dose
Contraindications
S/E
Place in therapy — when is it used
—decrease TG synthesising enzymes
—reduce TG in high doses
—PO
—c/i in pts w/ seafood/fish allergy
—indigestion, burping, fishy tast
Icosapent Ethyl
Make sure you know these take home points
