FR Review 9 - Hyperlipidemia, Antihistamines, Steroids, Chemo

Question 1

In summary, what is the major effect of each class of the hyperlipidemia medications?

Answer 1

Statins: decrease LDL
Bile Acid Sequestering Agents: decrease LDL
Niacin: increases HDL with some decrease in triglycerides
Fibrates: decrease triglycerides
Omega-3 Fatty Acids: decrease triglycerides
Cholesterol Absorption Inhibitors: as an adjunct only to help decrease LDL

Question 2

What drug class is the most effective at lowering LDL?

Answer 2

Statin drugs

Question 3

What effect do statin drugs have on LDL, HDL, and triglycerides?

Answer 3

LDL: decrease
HDL: slight increase
Triglycerides: decrease

Question 4

What is the benefit of increasing HDL?

Answer 4

HDL is responsible for transporting other cholesterols back to the liver to be recycled

Question 5

Why is it theorized that statin drugs may reduce inflammation?

Answer 5

Statins cause a reduction in CRP. CRP is a marker of inflammation.

Question 6

Differentiate older statins from newer statins in terms of how they are administered?

Answer 6

Older: should be taken at night because they have a short half-life and cholesterol is mostly made during sleep
Newer: can be taken at any time because they have a longer half life

Question 7

Describe the AEs of statin drugs

Answer 7

Few AEs –> they are generally well tolerated
Statins can cause myalgias and cause rhabdomyolysis –> less common than most people believe
GI complaints: dyspepsia, heartburn, abdominal pain –> most frequent AE
AST and ALT can rise depending on dose

Question 8

What is the mechanism of action of Bile Acid Sequestering Agents?

Answer 8

They bind to and sequester bile acids in the colon so they are not absorbed. The subsequent decrease in bile acids causes the liver to attempt to make more bile acids. In this process, the liver consumes more cholesterol and LDL decreases.

Question 9

In what way do bile acid sequestering agents negatively impact lipids?

Answer 9

They increase triglycerides –> Triglycerides cannot be processed without bile acids.

Question 10

What two drugs do bile acid sequestering agents interact with and how is this managed?

Answer 10

• Warfarin and Levothyroxine –> they stick to the bile acid sequestering agents and are not absorbed.
• Space administration of bile acid sequestering agents from drugs they interact with.

Question 11

How is niacin used?

Answer 11

As an adjunct with another lipid lowering agent to raise HDL.

Question 12

What side effects might patients complain of after taking niacin and why and how might this be mitigated?

Answer 12

Facial flushing and headaches because niacin causes release of prostaglandins.
Take an NSAID with niacin to lessen release of prostaglandins

Question 13

What three conditions can be exacerbated by taking niacin?

Answer 13

Hepatotoxicity, Hyperglycemia, Peptic Ulcer Disease

Question 14

Describe the use of cholesterol absorption inhibitors?

Answer 14

Always used as an adjunct with another lipid agent to decrease LDL

Question 15

Name the only cholesterol absorption inhibitor available.

Answer 15

Ezetimibe

Question 16

What are the AEs of cholesterol absorption inhibitors?

Answer 16

Not well tolerated –> GI distress, abdominal pain, diarrhea, steatorrhea

Question 17

Describe the mechanism of action of PSK9 inhibitors.

Answer 17

PSK9 is an enzyme that metabolizes LDL receptors in the liver. By inhibiting the enzyme, LDL receptors in the liver increase and more LDL is pulled into the liver for recycling and elimination.

Question 18

What are the disadvantages of PSK9 inhibitors?

Answer 18

They are expensive and must be injected sub-Q

Question 19

Differentiate allergic rhinitis from non-allergic rhinitis?

Answer 19

Allergic rhinitis is caused by an increase in histamine (HST)
Colds cause rhinitis due to an increase in Ach

Question 20

If someone has a cold, would a sedating or non-sedating antihistamine be more effective?

Answer 20

Sedating because they have anti-Ach properties and Ach is the cause of rhinitis in a cold.

Question 21

What are the two primary indications for hydroxyzine?

Answer 21

Anxiety and pruritis –> used a lot in the ED for poison ivy

Question 22

When an antihistamine product is followed by the letter D (Ex, Claritin D) what does this mean and what two drugs are added?

Answer 22

The antihistamine is coformulated with a decongestant.

The antihistamine is combined with either pseudoephedrine or phenylephrine.

Question 23

In what patients would you want to avoid use of antihistamine-D products and why?

Answer 23

Patients with HTN because decongestants are alpha-1 agonists that provide vasoconstriction.

Question 24

Describe 7 AEs of steroids administration.

Answer 24

Hyperglycemia from gluconeogenesis and decreased use of glucose in the periphery
Catabolism and reduced anabolism
Osteoporosis with increased calcium excretion
Delayed growth in children
Fat deposition in the shoulders, face, and abdomen
Reduced healing
Suppress allergic responses and Ab production

Question 25

What dose of steroids is required to suppress the HPA axis and decrease endogenous steroid production?

Answer 25

At least 20mg of prednisone or equivalent for at least 14 days

Question 26

If a patient is on enough steroids to suppress their HPA axis, what will result from rapid withdrawal of the drug?

Answer 26

Acute adrenocortical insufficiency

Question 27

In patients on enough steroids to suppress their HPA axis, when might a clinician need to increase their dose?

Answer 27

During the course of stressful events (surgery for ex) - aka stress dose steroids

Question 28

What is the typical dose for stress dose steroids and what would the dose be for a minor procedure?

Answer 28

Typical: 50-100mg hydrocortisone IV

Minor procedure: 20mg hydrocortisone PO

Question 29

What differentiates leukocytosis due to demargination from leukocytosis due to an infection?

Answer 29

Infection shows a left shift –> increase in immature WBCs called bands

Question 30

List the hydrophilic steroids and their uses.

Answer 30

Triamcinolone - joint injections and topical agents

Beclomethasone, budesonide, fluticasone, mometasone, ciclesonide –> inhaled

Question 31

What is the most lipophilic steroid?

Answer 31

Dexamethasone

Question 32

What is the overriding goal of cytotoxic chemotherapy?

Answer 32

Drugs kill healthy and cancerous cells - goal is to kill the cancer without killing the patient

Question 33

T/F: Cytotoxic agents kill healthy cells at the same rate they kill cancer cells.

Answer 33

False: They tend to kill cancer cells faster because cancer cells are replicating more quickly.

Question 34

Of healthy cells, which will be affected first by cytotoxic drugs.

Answer 34

Rapidly dividing cells –> bone marrow, GI, hair, etc.

Question 35

Describe how dosing of cytotoxic agents is different than most other drugs.

Answer 35

Typically, drugs are dosed to efficacy - we give as much as possible to have the most positive effect. Cytotoxic drugs are dosed to toxicity - we give the max amount we can give without the drug killing you.

Question 36

What is another name for targeted therapy agents and how is this clinically relevant?

Answer 36

Cytostatic agents because they mostly inhibit cancer cell growth signals.
They prevent tumor growth rather than destroying the tumors. Only cytotoxic agents destroy tumors.

Question 37

Describe how cytostatic drugs are administered?

Answer 37

They are usually given continuously rather than in on-off cycles like cytotoxic agents.

Question 38

Other than simply being targeted agents, state why cytostatic agents are less toxic than cytotoxic agents.

Answer 38

They are dosed based on efficacy as opposed to cytotoxic agents which are dosed to toxicity.

Question 39

What are the common AEs associated with cytostatic agents?

Answer 39

EGFR - receptor blocked by cytostatic agents that cause skin rashes and other effects (including conjunctivitis and dry eyes)
VEGF - receptor blocked by cytostatic agents that inhibits angiogenesis (CV effects)