Exam 5 - Dyslipidemia Chaudhry Flashcards by Rehman Hameed

what values are included in a FLP? (4 of them)

TC
TG
HDL-C
LDL-C (using Friedewald Eq)

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what is the Friedewald equation and what is it used for?

LDL = TC - HDL -TG/5

Used to estimate LDL from FLP

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lifestyle management: how much sodium intake should pts get daily?

< 1500 mg

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what does DASH diet stand for?

dietary approach to stop HTN

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what is Olestra? (from internet)

-A fat substitute made from sucrose and vegetable oil.
-Used to reduce intake of saturated fats and cholesterol
-Not available in USA anymore

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which is not a soluble fiber used to decrease LDL?

a. oat bran
b. pectins or gums
c. Olestra
d. Psyllium products

c. Olestra

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lifestyle changes: ___-___ grams daily of sterols can dec LDL 6-15%

2-3

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how much physical activity should patients get?

40 mins 3-4 times a week

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if overweight, ___% weight loss is recommended

10%

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what are the two omega-3 fatty acid prescription products?

Lovaza
Vascepa

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what is the only triglyceride risk-based nonstatin therapy FDA approved for ASCVD risk reduction?

icosapent ethyl (IPE)

(brand name Vascepa)

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statins, BARs, ezetimibe, PCSK9 mAB, Inclisiran, and bempedoic acid mainly decrease serum

a. LDL
b. HDL
c. TG

a. LDL

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fibrates, omega 3 FA, and niacin mainly decrease serum

a. LDL
b. HDL
c. TG

c. TG

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which two statins are preferred in renal impairment?

fluvastatin, atorvastatin

(no dosing adjustments needed)

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four low intensity statins:

simvastatin ___ mg
pravastatin ___-___ mg
lovastatin ___ mg
fluvastatin ___-___ mg

simvastatin 10 mg
pravastatin 10-20 mg
lovastatin 20 mg
fluvastatin 20-40 mg

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two high intensity statins:

atorvastatin ___-___ mg
rosuvastatin ___-___ mg

atorvastatin 40-80 mg
rosuvastatin 20-40 mg

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what are the TWO hydrophilic statins?

a. fluvastatin
b. pitavastatin
c. pravastatin
d. lovastatin
e. simvastatin
f. atorvastatin
g. rosuvastatin

c. pravastatin
g. rosuvastatin

(the others are lipophilic)

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statin contraindications (4; slide 46)

-acute liver disease
-unexplained, persistent elevations of serum transaminases
-pregnancy
-breastfeeding

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if a pt is on statins and experiences muscle injury, what changes can we make to their therapy? (3)

-d/c statin to see if pain resolves
-switch to lower risk statin (hydrophilic)
-consider alternative dosing strategies (every other day, once weekly, etc)

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simvastatin considerations: do not exceed ___ mg daily with verapamil or diltiazem

10 mg

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simvastatin considerations: do not exceed ___ mg daily with amiodarone, amlodipine, or ranolazine

20 mg

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3 bile acid resins (BAR) drugs

-cholestyramine
-colestipol
-colesevelam

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one DISADVANTAGE of bile acid resins is that they may inc

a. LDL
b. TC
c. TG

c. TG

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for BARs, other meds should be taken ___ hour(s) before or ___ hour(s) after

1 hour before; 4 hours after

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cholestyramine contraindication

complete biliary obstruction

colesevelam contraindications (3)

-history of bowel obstruction -history of hypertriglyceridemia-induced pancreatitis -serum TG > 500 mg/dL

we are worried about pancreatitis when TG > ___ mg/dL

500 mg/dL

what causes Niacin flushing?

caused by interaction with skin causing prostaglandins to be released and dilation of vessels

administer ASA 325 mg ___ minutes before taking Niacin for flusing and/or itching

30 min

Niacin contraindications (4)

-active hepatic disease -significant or unexplained persistent liver transaminase elevations -active peptic ulcer -arterial hemorrhage

what drug is a cholesterol absorption inhibitor?

ezetimibe (Zetia)

what drug is ezetimibe + simvastatin?

Vytorin

ezetimibe adverse effects (3)

-fatigue -diarrhea -GI upset

ezetimibe contraindications (3 of them)

-concomitant use with a statin and active hepatic disease or unexplained persistent serum transaminase elevations -pregnancy (when used w/ statin) -breastfeeding (when used w/statin)

gemfibrozil and fenofibrate are in which drug class?

fibrates

fibrates contraindications (3)

-history of gallbladder disease -ESRD or dialysis -persistent liver disease

what are the three PCSK9 mAb drugs we talked about?

alirocumab (Praluent) evolocumab (Repatha) inclisiran (Leqvio)

Indication for PCSK9 monoclonal antibodies, inclisiran (Leqvio), bempedoic acid

adjunct to diet and statin to reduce LDL in familial heterozygous hypercholesterolemia or ASCVD

MOA for Praluent and Repatha

-inhibits binding of PCSK9 to LDL receptors and upregulate the recycling of LDL receptors, causing dec in LDL-C (43-64%) (PCSK9 protein normally breaks down LDL receptors so we have less of them. An inhibitor will stop the protein from working so we have more LDL receptors on liver and less cholesterol in blood)

which is not a side effect of fibrates? a. GI disturbances b. rash c. myalgia d. influenza e. dizziness

d. influenza

inclisiran (Leqvio) MOA

-long-acting synthetic small interfering ribonucleic acid (siRNA) that inhibits translation of PCSK9 protein thus inhibiting PCSK9 production, prolonging activity of LDL receptors (basically siRNA inhibits PCSK9 production)

how is Leqvio dosed?

get initial dose, another at 3 months, then after every 6 months (it's an injection)

bempedoic acid may increase blood _____ _____ levels and lead to the development of _____

uric acid; gout

true or false: bempedoic acid should be avoided concomitant use with simvastatin > 20 mg and pravastatin > 40 mg

true (due to myopathy)

bempedoic acid is a prodrug activated in liver by what enzyme?

ACSVL1 (very-long-chain acyl-CoA synthetase-1)

what enzyme does bempedoic acid inhibit?

ACL (ATP-citrate lyase)

true or false: activated bempedoic acid is present in skeletal muscle

false

active ingredient in red yeast rice

lovastatin

boxed warning for lomitapide (Juxtapid)

risk of hepatotoxicity

what protein does lopitamide inhibit?

MTTP (microsomal triglyceride transfer protein) (prevents assembly of apoB containing lipoproteins in enterocytes and hepatocytes...there is more to the mechanism; slide 79)

lomitapide (Juxtapid) and evinacumab (Evkeeza) are used for what disease state?

homozygous familial hypercholesterolemia (HoFH)

what does evinacumab inhibit?

ANGPTL3 (angiopoietin-like protein 3) (rest of mech is on slide 81)

if LDL-C is 190 or greater, what intensity statin would we use?

high intensity

TG over what # is reasonable to initiate a statin?

> 500

therapy in severe hypertriglyceridemia: adults 40-75 with severe hypertriglyceridemia and especially those with TG of 1000 or more a. favors initiation or intensification of statin therapy to reduce ASCVD risk b. initiate statin treatment c. initiate statin treatment + fibrate OR omega3

c. initiate statin treatment + fibrate OR omega3

what are the two go-to pharmacological therapies to dec risk of acute pancreatitis?

fibrates or omega 3 FA's

evinacumab (Evkeeza) is an additional med that can be used in adjunct with other meds to lower LDL-C in pts with a. heterozygous familial hypercholesterolemia b. homozygous familial hypercholesterolemia

b. homozygous familial hypercholesterolemia

for primary prevention of pt with LDL-C of 190 or more, what strength statin should be used?

high intensity statin

for primary prevention of 40-75 year old pt with diabetes, what strength statin should be used?

moderate-high intensity statin

guidelines for < 20 year old pt with LDL-C 160+ and familial hypercholesterolemia

initiate statin

what age range do we start having to assess 10-year ASCVD risk?

40-75

risk discussion for low risk (< 5%) 10-year ASCVD risk pts

emphasize lifestyle to reduce risk factors

risk discussion for borderline risk (5 - < 7.5%) 10-year ASCVD risk pts

if risk enhancers present then discuss moderate-intensity statin

risk discussion for intermed risk (7.5 - < 20%) 10-year ASCVD risk pts

if risk estimate + risk enhancers favor statin, initiate moderate-intensity statin to reduce LDL-C by 30-49%

risk discussion for high risk (20% or more) 10-year ASCVD risk pts

initiate statin to reduce LDL-C by 50% or more

if risk discussion is uncertain, what test can we consider to determine initiation of statin?

coronary artery calcium (CAC) test (CT of chest to measure calcium buildup)

true or false: if coronary artery calcium (CAC) test comes up with CAC = 1-99, this favors statin therapy, especially age 55+

true

what treatment does a CAC of 100 or more indicate?

initiation of at least moderate-intensity statin

fasting TG > 150 following at least 4-12 weeks of lifestyle intervention, a stable dose of a max tolerated statin, and a secondary cause evaluation a. persistent hypertriglyceridemia b. moderate hypertriglyceridemia c. severe hypertriglyceridemia

a. persistent hypertriglyceridemia

TG of 150-499 a. persistent hypertriglyceridemia b. moderate hypertriglyceridemia c. severe hypertriglyceridemia

b. moderate hypertryglyceridemia

TG > ____ mg/dL is considered severe hypertriglyceridemia

> 500 mg/dL