Exam 1 - Lipids Flashcards
What is Primary Prevention?
Treatment of a patient before they have had an MI or stroke.
What is Secondary Prevention?
Treatment of a PT after they have had an MI or stroke.
What is the MOA of Omega-3 Fatty Acids?
Unknown. Reduces Triglyceride synthesis vs Reduces hepatic circulation of triglycerides
What is the clinical application for Omega 3 Fatty Acids?
Very high Triglycerides, over 500. Can reduce TG by 60%. Not first line.
What percent can Omega 3 Fatty Acids reduce TGs by?
60%
At what TG level do you use Omega 3 Fatty Acids?
500 or above
What is the name of an Omega 3 Fatty Acid medication/supplement?
Lovaza
What are three possible adverse effects of Omega 3 Fatty Acids?
Fishy burps, indigestion, altered taste
What is the MOA of Cholesterol Absorption Inhibitors?
Blocks absorption of biliary and dietary cholesterol from GI tract
What is a drug name of a Cholesterol Absorption Inhibitor?
Ezetimibe (only one)
What are three adverse reactions from Cholesterol Absorption Inhibitors?
Diarrhea, Musculoskeletal pain, Sinusitis
What is the pathway/active metabolite of the Cholesterol Absorption Inhibitor Ezetimibe?
Glucuronidation
Is the cholesterol absorption inhibitor Ezetimibe taken in combination with a moderate dose statin?
Yes. Vytorin=Simvastatin + Ezetimibe
statin + cholesterol absoprtion inhibitor
What is the MOA of Fibrates?
Activates PPAR-alpha which modulates metabolism and increases catabolism of lipids. Modulates genetic transcription to increase lipid metabolism.
What is the clinical application for Fibrates?
TG over 500. Used as a second line for select patients.
What is the TG required to be for initiating Fibrates?
500 or above. Second line treatment in select patients.
Where in line for treatment of high TGs are Fibrates?
Second line treatment in select patients.
What are three treatments for TGs over 500?
Omega 3 Fatty Acids, Fibrates, Niacin
What can TGs over 1000 cause? Treatment?
Acute pancreatitis. Fibrates are first line, Niacin & Omega-3 can be considered.
What are two examples of Fibrates?
Gemfibrozil, Fenofibrate
What are five possible adverse reactions to Fibrates?
Nausea, abdominal pain, myopathy, increased Serum Cr, increased Transaminases
What does the hepatic system to do Fibrates?
Metabolizes
Which system/where are Fibrates secreted?
Renal system
What is the MOA for Nicotinic Acid class medications?
Decreases TG synthesis. Unclear in adipose.
What are three drugs in the Nicotinic Acid class?
Niacin, Nicotinic Acid, Niacinamide
What are five adverse effects of the Nicotinic Acid drugs?
Nausea, vomiting, flushing, myopathy, increased transaminases
What happens to Nicotinic Acid class medications in the Hepatic system/pathway?
Conjugated
Where/how are Niacin-class drugs excreted?
Renal system
Where does flushing occur in patients on Niacin-class drugs?
Neck
How do you treat/prevent the flushing associated with Niacin-class drugs?
Give 325 ASA 15-20 minutes before Niacin
What is the MOA for Bile Acid Sequestrants?
Anion exchange resins that bind bile acids
What is the biggest adverse reaction in Bile Acid Sequestrants?
Flatulence. (Others are abd pain, constipation, nausea, vomiting. Bile=Bum=Fart)
What does the liver and kidneys do to Bile Acid Sequestrants?
Nothing. Not metabolized or absorbed.
What can Bile Acid Sequestrants do to vitamins? How do manage this?
Can inhibit vitamins absorption. Can interaction with many drugs. Take resin 1-2 hours after other meds OR take other meds 4-6 hours after resin.
What are three examples of Bile Acid Sequestrants?
Cholestyramin (P), Colestipol (P,T), Colesevelam (P,T)
P=powder
T=tablet
Bile Acid Sequestrants are where in line for treatment of XXX (she didn’t say, ask her and come back)
Second line in selected patients for XXX (she didn’t say, elevated TGs?, ask her and come back)
What is the MOA for statins?
Inhibiting HMH-CoA, rate limiting step of HMG CoA to Mevalonate (KNOW THIS!)
What do statins end in?
“-statin”
What are some adverse reactions of statins?
Nausea, vomiting, dizziness, abd pain, myopathy, elevated transaminases
What order are statins in for treatment of hyperlipidemia?
First
What is the mnemonic for remembering the six types of statins?
Fat People Love Subs And Ribs
Fluva, Prava, Lova, Simva, Atrova, Rosuva -statin
What are the only two statins to be high intensity and dose?
Atorvastatin 80mg, Rosuvastatin 20mg
What are the two low-intensity statins and dose?
Lovastatin 20mg, Pravastatin 10mg or 20mg
What are three special things unique to Parvastatin?
Parvastatin is not Lipophilic, does not use CYP450 system, has an inactive metabolite
Vyrotin is a combo of what two drugs?
Simvastatin and Ezetimibe
Which two statins have high intensity but no low intensity?
Atrovastatin and Rosuvastatin
Which two fats can elevate LDL?
Saturated and trans fats
What happens to LDL and TGs during pregnancy?
Rise
Which three lipid drugs are contraindicates during pregnancy and lactation
Statins,Niacin,andEzetimibearecontraindicatedduring pregnancyandlactation
Multiple or serious ______ may predispose one to adverse effects to statins
Comorbidities
A history of previous _____ _____ _____ may predispose one to adverse effects to statins
intolerance to statins
Unexplained ____ 3x normal upper limit may predispose one to adverse effects to statins
ALT
Drug interactions that _____ statin concentration may predispose one to adverse effects to statins
Increase
Age over ____ may predispose one to adverse effects to statins
75 years
What four things would cause you to start a PT on a lower statin dose than normal?
- Hx of hemorrhagic stroke
- hx of alcohol abuse
- Asian ancestry
- small body frame/frailty
Which four labs should be checked before starting statins?
Fasting Lipid panel, ALT level, CK, fasting BGL/A1c
Before starting Niacin for hyperlipidemia what blood test should be checked?
Uric Acid
Before starting Bile Acid Sequestrants for hyperlipidemia what blood test should be checked?
Triglycerides
Before starting Fibrates for hyperlipidemia what blood test should be checked?
Serum Creatinine/GFR
What are 7 important criteria used in calculating ASCVD in addition to gender and race (Pooled Risk)?
- Total cholesterol,
- HDL,
- HTN or HTN meds,
- Systolic BP
- DM,
- Smoker
- Age
What is the definition of “family hx of premature ASCVD”?
FamilyhistoryofprematureASCVDmeansaneventbeforethe ageof55inafirstdegreemalerelativeor65inafirstdegree femalerelative
In Primary Prevention, what is the proper intensity statin to use in a PT age 21+ with an LDL above 190?
High intensity statin
In Primary Prevention, what is the proper intensity statin to use in a PT with DM and age 40-75, but with ASCVD below 7.5?
Moderate intensity
In Primary Prevention, what is the proper intensity statin to use in a PT with DM and age 40-75, but with ASCVD above 7.5?
High intensity
In Primary Prevention, what is the proper intensity statin to use in a PT age 40-75 and ASCVD above 7.5?
Moderate to High intensity
When is a high intensity statin used in primary prevention? (Hint: 2 situations)
- Age 21+ and LDL above 190
2. Age 40-75 with DM and ASCVD above 7.5%
When do you use a moderate intensity statin in primary prevention?
Age 40-75 with DM and ASCVD below 7.5%
When do you use a moderate to high intensity statin in primary prevention
Age 40-75 and ASCVD above 7.5
In secondary prevention with clinical ASCVD what intensity statin is used?
High intensity
Which three groups automatically get high intensity statin?
Three groups get automatic high intensity stating
- LDL above 90
- ASCVD above 7.5%
- Previous MI (Secondary Prevention)
What time of day/night are statins dosed?
At night as liver makes cholesterol at night.
Ten year ASCVD can be calculated in what age range?
40-79
Which two statins not Lipophilic?
Pravastatin and Rosuvastatin (People and Ribs are not lipophilic)
Which statins are low intensity?
People Love
What is the intensity of the seven statins?
Fat People Love Steak And Ribs
from less to more intense
Which statin uses sulfation? (hint: does not use CYP450 system)
Pravastatin (people)
Lifetime ASCVD can be calculated for what age range?
20-59
Which cholesterol meds do and don’t interact with statins?
Omega-3s do not interact with statins. Fibrates and niacin do interact with statins.
If TGs are above 500 can the LDL be calculated?
No
“I am prescribing this medication to you to reduce your risk of ____ and ____.”
Heart attack and stroke
“Some people experience ____, _____, and ____ ____ while taking this medicine.”
Dizziness, headache, and upset stomach
“If dizziness, headache, or upset stomach occur take it at _____. If it occurs it will lessen with _____.”
Night. With time.
“These side effects are not harmful as long as you can ____ _____. If you cannot then I can persribe a ____ ____.”
Tolerate them. Lower dose.
“Very rarely some people have _____ _____ _____. If this happens let me know and I can order tests to see if it is the medication causing this.”
Unexplained muscle pain
“STOP taking this medication and go to the ER immediately if you notice ____ ____.”
Dark urine (rhabdomyelitis)
Statins are prescribes for signs and symptoms of ____50
ASCVD
High intensity statins reduce cholesterol by what percent in what time frame?
50%, 6-8 weeks
Benefits of statins for are demonstrated after what range in years?
2-5 years
What type of measure is a fasting lipid panel after being in statins?
Surrogate. Used to make sure they are taking the statin.
Can you increase intensity of statin after confirming the current dose is tolerable?
Yes
Once reaching lipid target should you order repeat labs?
No
If LDL drops below 40 while on statins what should change?
Reduce intensity
Asymptomatic elevations of ____ occur in 0.5 - 2% of cases
Liver transaminases (specifically ALT)
If a PT begins to look jaundice (yellow) after starting statins what should be checked?
ALT
In what time frame does statin-induced liver transaminase elevation occur?
Within 3 months of starting
Mild to moderate myalgia without CK increase occurs in what percentage of cases?
5%
Severe myalgias with CK 10x UNL are rare but can progress into what two things?
- Rhabdomyelitis
2. Kidney failure
What most commonly causes severe myalgias while statins?
Drug interactions which increase statin concentration
Which cholesterol lowering medication can interact with statins and cause severe myalgias leading to rhabdomyelitis and kidney failure?
Fibrates
If PT has 10x UNL CK what to do?
Stop statins, go to ER for supportive care
If PT has 3-10 ULN CK with tolerable symptoms what do you do?
Closely monitor sx and CK
Which two statins are less likely to cause myopathy and why?
Pravastatin and Rosuvastatin. Not lipophilic.
What to do if PT cannot take recommended intensity of statin?
Take a reduced intensity and monitor closely. Might consider adding Zettia + moderate dose statin if they have CAD.
Men at risk for ASCVD who cannot take a statin should take what primary and secondary alternatives?
Primary=Colestipol 5g TID before meals
Secondary=Gemfibrozil 600mg BID
Men at high risk for ASCVD who cannot take a statin should take what alternative?
Cholestyramine 24g/day in 2-4 doses
Men and women with T2DM who cannot take statins should take what?
Micronized Fenofibrate 200mg QAM (every morning)
Men and women with established ASCVD who can’t take statins should take what as primary and secondary alternatives?
Primary: Gemofibrozil 1200mg QD or 600mg BID
Secondary: Colestipol TID before meals
Can you use the Pooled Cohort Equation for people already taking lipid lowering medications?
No. Not designed for it.
What to do if a PT is taking a statin but they should be on a higher intensity?
Counsel PT about possible side-effects, titrate up dose as tolerated
What to do if a PT is on combo statins and non-statins?
Discuss risks/benefits, can continue if low-risk and tolerating well, very reasonable to discontinue to reduce pill burden
Which class has an unknown MOA but perhaps decreased hepatic circulation vs TG synthesis?
Omega 3 FAs
Which drug class blocks absorptions of biliary and dietary cholesterol?
Cholesterol Absorption Inhibitors
Which drug class activates PPAR-alpha which genetically modifies catabolism of lipids?
Fibrates
Which drug class has an unknown effect on adipose tissue but can reduce TG synthesis?
Nicotonic acid
Which drug class has anion exchange resins which binds to bile acids?
Bile Acid Sequestrants
Which drug class inhibits HMG-CoA reductase rate limiting step to prevent Mevalonate conversion?
Statins
Which drug class works best when ASA is taken 15-20 minutes before the drug?
Nicotinic acid
Which drug class can inhibit vitamin absorption requiring to be taken 1-2 hours before or 4-6 hours after other drugs?
Bile Acid Sequestrants
Which statin used sulfation as it’s metabolism?
Parvastatin
