Dyslipidemia highlights Flashcards
Which is good cholesterol? Which is bad?
1) High-density lipoproteins (HDL) = “Good cholesterol”
2) Low-density lipoproteins (LDL) = “Bad cholesterol”
Lipid abnormalities increase the risk of ________, __________ , and __________ vascular arterial disease collectively known as atherosclerotic cardiovascular disease (ASCVD)
coronary; cerebrovascular; peripheral
When patients who are at risk but who have not yet experienced initial cardiovascular (e.g., myocardial infarction [MI]) or cerebrovascular (e.g., ischemic stroke) events are treated, it is termed __________ prevention
primary
Treatment for those with manifest ASCVD is termed _______________ prevention
secondary
Only empty _______ and _________ are made in the liver
HDL; VLDL
Most patients are ______________ for years before they develop ASCVD
asymptomatic
Memorize these lab values:
1) Borderline high cholesterol
2) Near or above normal LDL
3) Borderline high LDL
4) High LDL
5) Very high LDL
1) 200-239mg/dL
2) 100-129 mg/dL
3) 130-159 mg/dL
4) 160-189 mg/dL
5) >/= 190 mg/ dL
Memorize these lab values:
1) HDL low value for men
2) HDL low value for women
3) Normal triglycerides
4) Borderline high triglycerides
1) <40 mg/dL
2) <50 mg/ dL
3) <150 mg/dL
4) 150-199 mg/ dL
Memorize these lab values:
1) High triglycerides
2) Very high triglycerides
1) 200-499 mg/ dL
2) >/= 500 mg/ dL
Therapeutic lifestyle change is the first-line therapy for any dyslipidemia without prior _______ or _______
ASCVD; DM
For patients between _____ and ______ years of age and no history of ASCVD, the ASCVD Risk Estimator Plus should be used, esp. in pts whose 10-year risk is _____% or greater
40 and 79; 7.5%
1) Nonstatin lipid-lowering therapies (such as ezetimibe, bempedoic acid, and PCSK9 inhibitors) play a supportive role in the management of dyslipidemia and are primarily used in combination with what?
2) When are they used as monotherapy?
1) Statins
2) In patients unable to tolerate the recommended dose of a statin
Goal for secondary prevention is to have LDL less than _____, for primary you want it less than ________.
70; 100
A _______________________ is generally recommended before considering lipid-lowering therapy in patients without evidence of ASCVD, diabetes, or other high-risk features
12-week trial of lifestyle modification
You should avoid concurrent use of what supplement with prescription statins?
Red yeast rice
Hypertriglyceridemia
What are generally considered first-line? [given they can reduce TG levels by up to 30% at higher doses and help achieve desired levels of LDL-C if fasting TGs are 150 – 499 mg/dL]
Statins
Hypertriglyceridemia:
Lipid-lowering therapies that primarily lower TG levels, such as what 3 things, are recommended as first-line agents?
Fibrates, omega-3 PUFA, and niacin
Low HDL cholesterol:
What has the potential for the greatest increase in HDL-C compared to other lipid-lowering therapies and the effect is more pronounced with regular or immediate-release forms than with sustained-release forms?
Niacin
HMG-CoA reductase inhibitors (Statins):
1) Significantly reduce ___________ (20%-60%), modestly ____________ (6%-12%) and decrease _______ levels (10%-29%)
2) What is the main takeaway of this group’s MOA?
1) LDL-C levels; increase HDL; TG
2) inhibiting HMG-CoA reductase
HMG-CoA reductase inhibitors (Statins):
1) What 2 drugs have very long half-lives compared to other statins & can be dosed any time of the day?
2) All other statins should be ______ because cholesterol synthesis primarily occurs at ________.
1) Atorvastatin and rosuvastatin
2) QPM; rest
What is the difference between QPM and QHS?
QPM = at night
QHS = bedtime
List 2 high intensity statins (lower LDL by >50%) and their high intensity doses
know these doses
1) Atorvastatin: 40-80 mg
2) Rosuvastatin: 20-40 mg
List 2 moderate intensity statins (lower LDL by 30-50%) and their moderate intensity doses
know these doses
1) Atorvastatin: 10-20 mg
2) Rosuvastatin: 5-10 mg
1) Besides Atorvastatin and Rosuvastatin, what is another statin that can be moderate-intensity?
2) What other intensity class can this statin be?
1) Simvastatin
2) Low intensity
HMG-CoA reductase inhibitors (Statins):
1) _________ is the most commonly reported muscle-related adverse effect with statin therapy and refers to bilateral muscle achiness, weakness, or cramps affecting larger muscle groups (such as thighs and back).
2) The most concerning of SAMS is _____________, which is a rapid breakdown of skeletal muscle resulting in ___________________ elevations greater than 10 times the upper limit of normal
1) Myalgia
2) rhabdomyolysis
3) creatine kinase (CK)
1) _____________ is not recommended to be initiated at 80mg/ day due to increased risk of myopathy (and rarely rhabdomyolysis)
2) Rhabdomyolysis in statin-treated patients is exceedingly rare occurring in only _______% of patients in RCT compared to 0.04% of patients receiving placebo
1) Simvastatin
2) .1%
HMG-CoA reductase inhibitors (Statins):
Patients presenting with rhabdomyolysis will often describe their urine as _________________ and present with nausea, vomiting, confusion, coma, cardiac arrhythmias, electrolyte disturbances, and even death
dark or “tea-colored”
HMG-CoA reductase inhibitors (Statins):
1) If intolerable symptoms resolve, what should you do?
2) Hydrophilic statins (such as ___________ or ________) may be better tolerated than lipophilic statins (such as _________)
1) Initiate a different statin at a lower dose
2) atorvastatin and rosuvastatin; simvastatin
Statins may be initiated in patients with chronic liver disease, compensated cirrhosis, and nonalcoholic fatty liver disease; however, statins are contraindicated in patients with what? (2 things)
Decompensated cirrhosis or acute liver failure
Statin use is also associated with a small increased risk of new-onset ___________ (abs. risk increase is <1%) and brain fog
diabetes
Cholesterol absorption inhibitors
1) The primary lipid-lowering effect of _______________ is a modest reduction in LDL-C of 15% to 24%.
2) What is the MOA?
1) ezetimibe (Zetia)
2) Reduces LDL-C by inhibiting the NPC1L1 protein
Cholesterol absorption inhibitors
1) The bile acid sequestrants (BAS), such as colesevelam, modestly ____________ and reduce cardiovascular events.
2) BAS are considered first line during pregnancy since they are not ______________________ and pose no risk to the fetus (but don’t usually Tx pregnant pts with it)
1) reduce LDL-C (13%-20%)
2) systemically absorbed
Cholesterol absorption inhibitors:
BAS may aggravate ______________ and should be avoided in those with ______ levels exceeding 300 mg/d
hypertriglyceridemia; TG
Cholesterol absorption inhibitors:
Potential adverse effects include impaired absorption of fat-soluble vitamins _____,____,____,____; gastrointestinal obstruction; and reduced bioavailability of other drugs such as what 3 things?
1) A, D, E, and K; warfarin, levothyroxine, and phenytoin
Cholesterol absorption inhibitors:
1) Drug–drug interactions may be avoided by taking other medications ____________ hour(s) before or ___________ hour(s) after the BAS.
2) Colesevelam is not only approved as a lipid-lowering agent but also as an ____________________ that modestly lowers glucose levels in patients with type 2 diabetes mellitus
1) 1 hour before or 4
2) antihyperglycemic
Proprotein convertase subtilisin/kexin type 9 (PCSK9) inhibitors
1) The PCSK9 inhibitors (e.g., alirocumab) reduce ________ by as much as ____% when added to background statin therapy.
2) What is this group’s MOA?
1) LDL-C; 60%
2) Inhibiting PCSK9 promotes LDL-R recycling to the cell surface
Adenosine triphosphate-citrate lyase (ACL) inhibitors
1) What is their MOA?
2) List one of these drugs
1) Prevent cholesterol production upstream from HMG CoA reductase inhibitors
2) Bempedoic acid (Nexletol)
Adenosine triphosphate-citrate lyase (ACL) inhibitors
1) Bempedoic acid (Nexletol): modest reductions in ________________ when combined with statin therapy or used as monotherapy in patients who are unable to tolerate statins
2) List 2 adverse effects of this drug
3) What 2 things should you avoid with Bempedoic acid due to increased risk of myopathy?
1) LDL-C (15-20%)
2) Hyperuricemia and tendon rupture
3) Simvastatin >20 mg/day or pravastatin >40 mg/day
Fibric acid derivatives (Fibrates):
1) May lower TG by _____%; HDL-C may rise by _____%.
2) What is the MOA of Gemfibrozil?
2) What is the MOA of Fenofibrate?
1) 20-50%; 10-15%
2) Increases the activity of LPL
3) Increases LPL activity and [reduces LDL inhibitor] activating peroxisome proliferator-activated receptor α (PPARα)
True or false: Fibrates require renal dose adjustments
True
Fibric acid derivatives (Fibrates):
1) Current guidelines do not recommend ____________ to be initiated in patients receiving statin therapy; fenofibrate is favored instead.
2) Drug interactions include what 2 things? Why?
1) gemfibrozil
2) statins and warfarin; respectively increases risk of rhabdomyolysis and can increase INR
Omega-3 polyunsaturated fatty acids (PUFA)
1) Significantly ___________________ with lesser effects on other lipoproteins.
2) Gastrointestinal complaints (such as abdominal pain and “_____________”) that can be mitigated by refrigerating them (not freezing).
1) reduce TG and VLDL cholesterol levels (20%-50%)
2) fishy burps
Omega-3 polyunsaturated fatty acids (PUFA):
1) Caution is advised in patients with known sensitivities or allergies to what 2 things?
2) Drug–drug interactions are minimal with omega-3 PUFA, although caution is advised when used concomitantly with antiplatelet agents or anticoagulants since omega-3 PUFA may ____________________.
1) Fish or shellfish
2) prolong bleeding time
Niacin (Vitamin B3):
1) Increases __________; lowers _____________ and ______________.
2) Adverse reactions: ________________ and itching appear to be prostaglandin mediated and can be reduced by administering aspirin 325 mg given shortly before niacin ingestion
1) HDL-C (5%-30%); TG (20%-50%) and LDL-C (5%-20%)
2) cutaneous flushing
Niacin (Vitamin B3):
1) What are the abnormal labs? (3)
2) Who is it contraindicated in? (2 conditions)
1) Elevated liver function tests, hyperuricemia, and hyperglycemia
2) Patients with active liver disease and active peptic ulcer disease
What are 2 key things to remember when treating older adults with HTN?
Primary prevention may not have a benefit for patients 75 years and older
Cataracts and adverse cognitive effects do not appear to be associated with statins
Statins are pregnancy category ____________ and contraindicated due to potential ___________ effects
category X; teratogenic
Short-term evaluation of therapy for dyslipidemia is based on a complete lipid panel obtained 4 to ________ weeks after initiation or following a dose adjustment of lipid-lowering therapy to evaluate therapeutic response
12
Diabetes x HTN:
1) _________________ appears to reduce the progression of diabetic retinopathy
2) The BAS colesevelam is FDA-approved to improve both __________ and ____________ control, but it can exacerbate hypertriglyceridemia.
1) Fenofibrate
2) glycemic and lipid
A nonfasting lipid panel is generally acceptable, except in patients with ______________________, where a fasting lipid panel is preferred [to minimize interference from chylomicrons]
hypertriglyceridemia
1) Patients taking niacin should have hepatic function tests performed at baseline, after each dosage increase, and every ____ months thereafter while taking a stable dose.
2) Periodic monitoring of A1c is warranted in persons with diabetes receiving _________ and patients treated with __________ who are at high risk for developing diabetes
1) 6 months
2) niacin; statins
For statins, you should AVOID _______________& caution use with cyclosporin or _____
Gemfibrozil; ART
What 3 statins are contraindicated with CYP3A4 inhibitors?
1) Atorvastatin (Lipitor)
2) Lovastatin (Mevacor)
3) Simvastatin (Zocor)
Lovastatin (Mevacor):
1) Do not exceed ______mg daily with amiodarone
2) Do not exceed ______mg daily with diltiazem, verapamil, danazol, dronedarone, or niacin >1000 mg/day
1) 40
2) 20
For which statin does this apply?: If CrCl <30 mL/min (but not on hemodialysis), starting dose is 5 mg daily, maximum 10 mg daily
Rosuvastatin (Crestor)
Simvastatin (Zocor)
1) Do not exceed _____mg daily with amiodarone, amlodipine, ranolazine, or lomitapide.
2) Do not exceed ________mg daily with diltiazem, verapamil, or dronedarone.
3) Do not exceed ____________mg daily with extended-release niacin (Niaspan), in Chinese patients taking >1 g/day niacin, or with lomitapide in patients who have previously tolerated simvastatin 80 mg.
1) 20 mg
2)10 mg
3) 40 mg
