Exam 2 Lecture 3 Flashcards
Which one decreases LDL more PCSK9 or LDL
PCSK9, but more expensive.
Lovastatin generic
Pravachol
Pitavastatin generic
Livalo
Simvastatin (important) generic
Zocor
atorvastatin generic
lipitor
rosuvastatin generic
crestor
High intensity statins name and strength
atorvastatin 40-80
Rosuvastatin 20-40
Moderate intensity statins name and strength
Atorvastatin-10-20
Rosuvastatin 5-10
Simvastatin 20-40
pravastatin- 40-80
Lovastatin- 40-80
flovastatin- 40
Low intensity name and dosage
Simvastatin- 10
pravastatin- 10-20
CYP3A4 statins
Lovastatin, simvastatin, Atorvastatn
What are the two hydrophilic drugs
Pravastatin and rosuvastatin
Use of hydrophilic drugs
Patients prone to muscle toxicity/pain, consider picking hydrophilic drugs (pravastatin, rosuvastatin)
When to take statins
Once a day anytime. Simvastatin in evening.
When to dx statin
If LFT is 3X normal dx statin
When to check LFT for statin
if dark urine or yellow skin
What are some considerations when taking statins
Muscle toxicity
-myopathy
-rhabdomyolysis (more pain, causes kidney failure)
Major interaction with statins
Grapefruit juice
statins contraindicated in
pregnant/nursing
characteristics pre disposing individuals to adverse effects of statin
Impaired renal or hepatic function
prior statin intolerance or muscle disorder
unexplained ALT elevation of 3X
>75 yo
What happens when someone does experience symptoms of achy muscles from statins
Dx statins and evaluate for rhabdomylosis (creatine kinase)
If it is just myopathy it resolves on its own
restart same or lower dose statin once symptoms improve
contraindications to statins
Acute liver disease (ALT, AST levels high)
Pregnant/breastfeeding
What are some alternative dosing strategies for statins.
every other day dosing and once weekly dosing has been suggested to improve tolerability
double daily dosing for atorvastatin, fluvastatin and rosuvastatin for every other day dosing.
which drugs are contraindicated with simvastatin drugs
all of the -azole drugs
all of the-mycin drugs
Relation between statins and hyperglycemia
Statins may cause increased risk of diabetes
Monitoring for statins
When statin started, wait 4-12 weeks following initiation to get another lipid panel.
then lipid panel once a year.
What is another thing to monitor for statins
Monitor baseline CK while on statin therapy for rhabdomylosis
Name bile acid resin drugs (BAR)
Cholestyramine (questran)
Colestipol (colestid)
Colesevelam (welchol)
How do Bile acid resins (BAR) work
Work by trapping bile, liver uses cholesterol to create more bile, reducing cholesterol
disadvantage of bile acid resins
May increase TG
Take other meds 1 hour before or 4 hours after BAR
side effects of BAR
GI side effects
adverse effects of bile acid resins
Impaired fat soluble vitamin absorption (A,D,E,K)
contraindications of bile acid resins
cholestyramine- complex biliary obstructon
Colesevelam- Hx of bowel obstruction
serum TG>500
Hx HLD induced pancreatitis
Niancin side effects and how to counteract
Flushing, can be avoided if ASA 325 mg given before niacin
Niacin contraindications
Active hepatic disease (peptic ulcers, elevated ALT, AST)
cholesterol absorption inhibitor drug
Ezetimebe (zetia)
Ezetimebe combined with statin name? efficacy?
ezetimebe with simvastatin is called vytorin.
can reduce LDL 12-20%
side effects of zetia
fatigue, diarrhea, GI upset
contraindications of zetia
active hepatic disease
pregnancy/breast feeding
Fibrates use
elevated triglycerides
side effects of fibrates
GI disturbance, rash, dizziness
contraindication of fibrates
Hx of gallbladder disease
ESRD or dialysis
liver disease
Fibrates increase levels of
Statins, ezetimebe, warfarin
PCSK9 drug names with generic important
Alirocumab (praluent)
Evolocumab (repatha)
indication for PCSK9 drugs
reduced LDL in HeFH or ASCVD
Side effects of PCSK9 drugs
influenza, inj site rxn
myalgia
Inclisiran (lequivo) indication
Lowers LDL and cholesterol for HeFH and ASCVD pts
side effects of Inclisiran
UTI
Inj site rxn
Indication for bempedoic acid (Nexletol)
lowers LDL in HeFH and ASCVD pts
side effects of bempedoic acid (nexletol)
avoid use in
May cause gout
avoid in use in simvastatin>20
pravastatin>40
Red yeast rice use
Can lower LDL
Lomitapide (juxtapid) blackbox warning
Hepatotoxicity
what is a drug used for HoFH that can be used in pediatric pts
Evinakumab (evkeeza)
5 questions to ask ourselves to assess what category pt is in for dyslipidemia
- is this primary prevention
- Is this secondary orevention
- What is their LDL (is it over 190?)
- does patient have diabetes
- Age and ASCVD risk
If patient has not had previous ASCVD event and LDL>190 what instensity statin
High intensity
If patient has not had previous ASCVD event and patient had DM and aged 40-75 years.
moderate intensity
If patient has not had previous ASCVD event and If ASCVD risk>20%
high intensity
If patient has not had previous ASCVD event and if age>75
not high intensity
risks enhancing factors for primary orevention
FH of premature ASCVD
CKD
Elevated TG (>175)
Premature menopause
For secondary prevention, ASCVD events include
MI, stable/unstable angina, Revascularization, stroke, PAD (peripheral artery disease)
If patient has had an ascvd ebent, what intensity?
Strat on high intensity statin.
follow up and monitoring recommendation for statins
Initiate statin
follow up in 4-12 weeks
follow up 3-12 months
What is a CAC test
Coronary artery calcium test.
Tests how much calcium is built uo
CAC>100 initiate which type of statin
atleast moderate intensity
LDL requirements for primary prevention and no clinical ascvd vs secondary prevention
LDL<100
for secondary prevention LDL goal is <70
What to do if patient is on statin and is not meeting LDL requirements
Maximize dose of statin
If they still have not reached LDL requirements, add a secondary agent (zetia)
What are non-statin recommendations (after maximally tolerating statins)
1st line- Zetia (ezetimebe)
2nd- PCSK9 inhibitors (also used if pts can not tolerate statin and ezetimebe)
other- bile acid resin
What are the 3 different types of hypertriglyceridemia and define them
Persistent- fasting TG>150 following 4-12 weeks of SM and statin
moderate- 150-499
severe>500 (concerned about pancreatitis)
Secondary causes for elevated triglyceride
Obesity (Diabetes mellitus), alcohol , metabolic syndrome,
LSM to reduce TG
5-10% weight loss= 20% reduction in TG
low fat diet
moderate or high intensity physical activity (>150 min per week)
Pharmacologic treatment of TG >150
start statin and intensify it (maximize it)
recheck lipid panel in 4-12 weeks
add fibrates or fish oils as supplements
If LDL>100 and Tg between 150-499 how to treat
Maximize statin therapy and non-statin (fishoil and fibrate)
If LDL<70 and TG between 150-499, how to treat
LSM, consider fish oils
