Exam 1: Hyperlipidemia

Question 1

What do chylomicrons do?

Answer 1

Carry dietary lipids from intestine to the liver, skeletal muscle, and adipose tissue

Question 2

What do VLDLs do?

Answer 2

Carry newly synthesized triglycerides from the liver to the adipose tissue

Question 3

What do IDLs do?

Answer 3

Intermediate between VLDL and LDL, not usually detectable in blood

Question 4

What do LDLs do?

Answer 4

Carry cholesterol from the liver to body’s cells

Question 5

What does HDL do?

Answer 5

Collects cholesterol from body’s tissues and returns it to the liver.

Question 6

What are the 3 pathways of lipid metabolism?

Answer 6

-exogenous, endogenous, and reverse cholesterol transport

Question 7

What are the two types of familial hypercholesterolemia and what does it mean for their LDL levels?

Answer 7

1) Heterozygotes: 2x normal value of LDL

2) Homozygotes: 8x normal value of LDL

Question 8

What type of inherited increased lipid disorder is present in 33-50% of patients with CHD?

Answer 8

Familial combined hyperlipidemia

Question 9

What is secondary hyperlipidemia?

Answer 9

HLD with non-lipid etiology (DM, alcohol, smoking, obesity, hypothyroid, liver disease, etc)
-Less common than inherited

Question 10

What is the desirable level for cholesterol?

Borderline?

High risk?

Answer 10

<200mg/dL

200-239

240

Question 11

What is the desirable level for triglycerides?

Borderline?

High risk?

Answer 11

<150mg/dL

150-199

200-499

Question 12

What is the desirable level for HDL?

Borderline?

High risk?

Answer 12

60

35-45

<35

Question 13

What is the desirable level for LDL?

Borderline?

High risk?

Answer 13

60-130

130-159

160-189

Question 14

What are plane xanthomas?

Answer 14

Cholesterol filled, soft yellow, plaques that appear in various places
-May indicates familial or secondary causes

Question 15

What are tuberous xanthomas?

Answer 15

Yellow-orange nodules often located over knees and elbows, but can also be seen over tendons.
-Associated with familial hypercholesterolemia

Question 16

What are eruptive xanthomas?

Answer 16

• Crops of small red-yellow papules with abrupt onset on the extensor surfaces and buttocks most commonly.
• Caused by elevated triglycerides over over 1500
• may indicate familial HLD

Question 17

What is corneal Arcus?

Answer 17

-White or grey ring around the cornea, common in patients over 40yo without elevated lipids

Question 18

What is the use of statins?

Answer 18

They decrease the incidence of major vascular events and coronary mortality and are believed to stabilize the vulnerable plaques and reduce the underlying inflammation 
-it is the only class of drug to demonstrate clear improvements inn overall mortality in primary and secondary prevention

Question 19

What is the MOA of statins?

Answer 19

They inhibit HMG-CoA reductase, part of the rate limiting step in the cholesterol synthesis in the liver. Less cholesterol is produced, so the liver enzymes increase production of LDL receptors. LDL and VLDL enter liver and are digested

Question 20

What are the absolute contraindications of statins and when should statins be used with caution?

Answer 20

Absolute contraindications: active liver disease, pregnancy

Use with caution: concomitant use with CYP3A4 inhibitors and various drugs, chronic kidney and liver disease

Question 21

How should you monitor statin therapy?

Answer 21

• a baseline lipid panel, LFTs, and creatine kinase should be obtained
• Assess adherence and % response to meds and lifestyle changes and repeat lipid panel every 4-12 weeks after initiation or dose adjustment
• repeat every 3-12 months PRN

Question 22

If a person is at high risk for ASCVD and receiving maximum tolerated statin with an insufficient response, what should you do?

Answer 22

Consider a non-statin LDL lowering agent

Question 23

What do bile acid sequestrants do?

Answer 23

Binds bile acids in the intestine and decreases LDL by up to 24%.

Acts synergistically with statins and safe during pregnancy

Question 24

What are the absolute and relative contraindications of bile acid sequestrants?

Answer 24

Absolute: TGs >400
Relative:TGs >200

Question 25

What does nicotinic acid do?

Answer 25

• reduces production of LDL
• Increases HDL
• May reduce TGs

Question 26

What are the absolute and relative contraindications of nicotinic acid?

Answer 26

Absolute: active liver disease
Relative: Hyperuricemia, Hyperglycemia, unstable angina
-Not used during pregnancy

Question 27

What are the adverse affects of nicotinic acid?

Answer 27

Flushing, itching, liver damage, and safety concerns when used with statins

Question 28

What do fibric acid derivatives do?

Answer 28

• lowers TGs up to 50%
• raises HDL up to 25%
• Primarily useful in those with high TGs
• generally not used in pregnancy

Question 29

What are the absolute and relative contraindications of fabric acid derivatives?

Answer 29

Absolute: Severe hepatic or renal disease, preexisting gallstones, or taking simvastatin
Relative: other statin use, concurrent warfarin use

Question 30

What does ezetimibe do?

Answer 30

• Used on conjunction with a statin, it blocked intestinal absorption of dietary and biliary cholesterol via a transporter.
• Can lower LDL up to 17%

Question 31

What are the contraindications of ezetimibe?

Answer 31

-Use with a statin in liver disease, pregnancy

Question 32

What do PCSK9 inhibitors do?

Answer 32

The inhibit a protease that causes increased LDL from being produced in the liver. This process can reduce LDL as much as 70% and reduce cardiovascular events and mortality

Question 33

What is the difference between primary and secondary prevention?

Answer 33

Secondary prevention in statin therapy in patients that already have ASCVD. in primary prevention, patients do not have ASCVD

Question 34

What are the 3 categories of primary prevention?

Answer 34

1) individuals with LDL > 190
2) individuals with DM aged 40-75 with LDL > 70
3) individuals w/o ASCVD or DM with LDL 70-189 and estimated 10 year ASCVD risk >7.5%