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Dyslipidemia meds Flashcards

1
Q

What synthesizes cholesterol?

A

The liver

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2
Q

Where do we get additional cholesterol?

A

From our diets

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3
Q

Give two features about cholesterol

A

It has a membrane structure

It is a precursor to steroid hormones

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4
Q

What is the formula for total cholesterol (endogenous and dietary)?

A

Total-C = (LDL + HDL + VLDL)

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5
Q

What is your bad cholesterol? What is the shorthand for this?

A

Low density lipoproteins

LDL

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6
Q

What is your good cholesterol? What is the shorthand for this?

A

High density lipoproteins

HDL

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7
Q

What is the shorthand for triglycerides?

A

VLDL

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8
Q

What is the optimal LDL measurement?

A

< 100 mg/dL

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9
Q

What LDL measure is classified as high?

A

160-180 mg/dL

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10
Q

What are the 2018 ACC/AHA adult recommendations

A

See slide 10

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11
Q

What are some causes of secondary dyslipidemia?

A 
Diabetes
Hypothyroidism
Obstructive liver disease
Chronic renal failure
Drugs
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12
Q

List some lifestyle changes that can lower LDL

A

TLC diet (reduced intake of cholesterol-raising nutrients and LDL lowering therapeutic options)
Weight reduction
Increased physical activity

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13
Q

Choice of lipid lowering drugs

A

See slide 17

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14
Q

What are the most commonly prescribed drugs for increased cholesterol?

A

HMG CoA Reductase Inhibitors

AKA statins

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15
Q

By what % do statins tend to reduce LDL and TG by?

A

18-55% (LDL)

7-30% (TG)

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16
Q

By what % do statins increase HDL?

A

5-15%

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17
Q

What are some major side effects of statins?

A

Myopathy (increased CK)

Increased liver enzymes (increased AST/ALT)

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18
Q

What are some contraindications for statins?

A

Absolute: liver disease
Relative: use with certain drugs

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19
Q

Give some examples of things that statins have demonstrated therapeutic benefits for.

A

Reduced major coronary events
Reduce CHD mortality
Reduce stroke

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20
Q

What is the MOA of statins?

A

Block rate -> limiting step in cholesterol synthesis

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21
Q

When do we see statin induced myopathy?

A

Serum CK >10x ULN with unexplained muscle pain

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22
Q

When do we see statin induced rhabdomyalysis?

A

Serum CK > 40x ULN with unexplained muscle pain or weakness

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23
Q

When do pts at risk of statin induced myopathy tend to present?

A

In the first 12 months

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24
Q

Which statin poses the highest risk for induced myopathy?

A

High dose simvastatin

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25
What internal element causes simvastatin to pose the risk for induced cardiomyopathy?
CYP3A4
26
What should you do if pts experiences SEs on a statin?
Try a different one
27
Give two examples of statins?
Atorvastatin | Rosuvastatin
28
What is an issue with pitavastatin?
Its very expensive and not generically available as of 2/11/19
29
By what percent does rosuvastatin lower LDL??
63%
30
By what percent does atorvastatin lower LDL?
57%
31
By what percent does simvastatin lower LDL?
46%
32
How many high dose pts developed myopathy while on simvastatin?
52
33
How many low dose pts developed myopathy while on simvastatin?
22
34
How many high dose pts developed rhabdo while on simvastatin?
22
35
How many low dose pts developed rhabdo while on simvastatin?
0
36
What is the FDA simvastatin black-box warning?
Restricting dosing of 80 mg of simvastain
37
When can pts be put on 80 mg of simvastatin?
When they have been taking it for >12 months
38
What should pts on an 80 mg dose w/o adverse effects do when they need to take a contraindicated drug?
They should switch to another statin
39
What should pts who's LDL goal cannot be reached on the 40 mg dose of simvastatin?
They should be switched to a statin w/ less risk of cardiomyopathy
40
List some drugs that are contraindicated with simvastatin
``` Itraconazole Eythromycin HIV protease inhbitors Nefazodone Gemfibrozil Cyclosporin Danazol ```
41
With what drugs should we not exceed 10 mg simvastatin with?
Amiodarone Verapamil Diltiazem
42
With what drugs should we not exceed 20 mg simvastatin daily?
Amlodipine | Ranolazine
43
What is an odd contradiction with simvastatin?
Not ingesting > 1 quart of grapefruit juice daily
44
Are elevated transaminases on statins a reason to dc?
No
45
Are statin side effects agent specific or class specific?
Agent specific
46
What should you do with unexplained myalgias w/o CK elevation?
Try a different statin
47
How many pts receive new scripts for simvastatin?
Very few
48
What is the MOA of bile acid sequestrants?
Bind dietary cholesterol
49
What are the major actions of bile acid sequestrants (BAS)?
Reduce LDL 20-25% Raise HDL 3-5% May increase TG
50
What are some SEs of BAS?
GI distress/constipation, diarrhea, bloating | Decreased absorption of other drugs
51
When are BAS agents contraindicated?
``` Severe hepatic impairment Raise TG (esp > 400 mg/dL) ```
52
Give some examples of BAS
Cholestyramine Colestipol Colesevelam
53
What is an issue with colesevelam?
Its very exepnsive ($561)
54
When do we usually give BAS?
As add on therapy to max dose statins
55
What are the major actions if Niacin?
Lowers LDL by 5-25% Raises HDL by 15-35% Lowers TG by 10-50%
56
What is a major SE of niacin?
Flushing
57
How do we minimize flushing with Niacin?
Pretreatment with NSAIDS 30-60 minutes prior to ingestion
58
When is niacin usually used?
As add on therapy Not monotherapy Not often used
59
What was needed to prove the efficacy of niacin?
A new large trial
60
What did the niacin trial show?
Niacin did not reduce incidence of primary composite endpoint (??)
61
What happened with the niacin trial?
Trial was stopped early
62
What was an unexpected increase in the niacin trial?
Strokes increased
63
What was the basic conclusion of the niacin trial?
Niacin doesnt reduce CVA risk but does increase risk CVA risk so its little used
64
How much do fibric acids decrease TG and VDL by?
25-50%
65
How much do fibric acids lower LDL?
5-20%
66
Might fibric acids raise LDL?
Yes, with high TG
67
How much might fibric acids raise HDL by?
10-20%
68
What are two fibric acids?
Gemfibrozil | Fenofibrate
69
What class is ezetimibe a part of?
A drug of a new class that inhibits intestinal absorption of cholesterol
70
How much does ezetimibe lower LDL?
2-25%
71
What is the effect of ezetimibe with statins?
Increases effects of statin by 10-15% w/o side effects
72
When is ezetimibe well tolerated?
At 10 mg/d
73
What is vytorin?
Exetimibe + simvastatin
74
What are PCSK9 inhibitors?
New class of monoclonal antibodies
75
What do PCSK9 inhibitors do when they are added to statins?
Reduce LDL by 50-60%
76
How do you administer PCSK9 inhibitors?
SC injection q2-4 weeks
77
What place do PCSK9 inhbitors have in therapy?
Add on to max dose statins
78
What is a new class of drug not yet FDA approved?
Bempedoic acid | FDA labeling requested in Feb 2019
79
How often do you give bempedoic acid?
Daily
80
What is the MOA of bempedoic acid?
Inhibits ATP citrate lyase (key enzyme in chol synthesis)
81
What is the PO dose of bempedoic acid?
180 mg once daily
82
Did bempedoic acid show a decrease in LDL?
Yes
83
Did bempedoic acid decrease non-HDL?
Yes
84
Did TC decrease on bempedoic acid?
Yes
85
What are two other things that bempedoic acid decrease?
Apolipoprotein B | High-sensitivity CRP
86
Fixed dose statin therapies
See slide 46

Pharm (32 decks)

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