Exam 2 Lecture 3 Flashcards by Matti Daniel

Which one decreases LDL more PCSK9 or LDL

PCSK9, but more expensive.

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Lovastatin generic

Pravachol

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Pitavastatin generic

Livalo

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Simvastatin (important) generic

Zocor

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atorvastatin generic

lipitor

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rosuvastatin generic

crestor

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High intensity statins name and strength

atorvastatin 40-80
Rosuvastatin 20-40

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Moderate intensity statins name and strength

Atorvastatin-10-20
Rosuvastatin 5-10
Simvastatin 20-40
pravastatin- 40-80
Lovastatin- 40-80
flovastatin- 40

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Low intensity name and dosage

Simvastatin- 10
pravastatin- 10-20

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CYP3A4 statins

Lovastatin, simvastatin, Atorvastatn

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What are the two hydrophilic drugs

Pravastatin and rosuvastatin

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Use of hydrophilic drugs

Patients prone to muscle toxicity/pain, consider picking hydrophilic drugs (pravastatin, rosuvastatin)

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When to take statins

Once a day anytime. Simvastatin in evening.

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When to dx statin

If LFT is 3X normal dx statin

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When to check LFT for statin

if dark urine or yellow skin

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What are some considerations when taking statins

Muscle toxicity
-myopathy
-rhabdomyolysis (more pain, causes kidney failure)

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Major interaction with statins

Grapefruit juice

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statins contraindicated in

pregnant/nursing

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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

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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

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contraindications to statins

Acute liver disease (ALT, AST levels high)
Pregnant/breastfeeding

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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.

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which drugs are contraindicated with simvastatin drugs

all of the -azole drugs
all of the-mycin drugs

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Relation between statins and hyperglycemia

Statins may cause increased risk of diabetes

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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

1. is this primary prevention 2. Is this secondary orevention 3. What is their LDL (is it over 190?) 4. does patient have diabetes 5. 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