Hyperlipidemia

Question 1

Lipoproteins values

Answer 1

TC <20
TG < 150
LDL <100 mg/dl
HDL < 40 mg/dl

Question 2

Risk factors of Hyperlipidemia

Answer 2

• Cigarette smoking
• HTN
• Diabetes
• Advanced age
• Lipid panel abnormalities
• CKD
• Family ASCVD history

Question 3

Meds for Hyperlipidemia

Answer 3

• HMG-Coenzyme A reductase inhibitors (“statins”)
• Bempedoic acid (Nexletol)
• Cholesterol absorption inhibitor (ezetimibe)
• PCSK9 inhibitors
• Bile acid sequestrants
• Niacin
• Omega-3 fatty acids (EPA, DHA)
• Fibric acid derivatives
• Mipomersen (Kynamro)*
• Lomitapide (Juxtapid)*

Question 4

Statins

Answer 4

•	MOA: Inhibit HMG-CoA reductase, the rate-limiting step in cholesterol synthesis
•	↓cholesterol synthesis
•	↑ expression of LDL receptors
•	↓LDL, ↓Total Chol, ↓TG, ↑HDL
•	↓CRP
•	Pleiotropic effects
o	Improve endothelial function
o	Atherosclerotic plaque stabilization
o	Decrease oxidative stress and inflammation
o	Inhibition thrombogenic response

Question 5

High intensity statin >50%

Answer 5

Atorvastatin 40-80mg

Rosuvastatin 20-40mg

Question 6

Moderate intensity 30-49%

Answer 6

Atorvastatin 10-20mg
Rosuvastatin 5-10mg
Simvastatin 20-40mg
Pravastatin 40-80mg
Lovastatin 40mg
Fluvastatin 80mg
Pitavastatin 2-4mg

Question 7

Low Intensity <30%

Answer 7

Simvastatin 10mg
Pravastatin 10-20mg
Lovastatin 20mg
Fluvastatin 20-40mg
Pitavastatin 1mg

Question 8

Liphobic Statins

Answer 8

Pravastatin

Rosuvastatin

Question 9

Statin AE:

Answer 9

•>10%: Diarrhea, arthralgia, nasopharyngitis
•2-10%: insomnia, new-onset diabetes, nausea,
•dyspepsia, UTI, myalgia/musculoskeletal pain/spasm
•Rare but serious
oHepatotoxicity
oCognitive dysfunction/confusion (reversible)
oDrug induced skin reactions (SJS/TEN)

•PREGNANCY CATEGORY X

Question 10

Nexletol

Answer 10

Bempedoic Acid
•Dose → 180mg PO daily with or without food
•Effects: ↓ LDL

Adverse effects
oGout with prior gout history/Hyperuricemia
oTendon rupture
oMyopathy w/ concomitant use of simvastatin or pravastatin

Question 11

Zetia

Answer 11

Exetimibe:
• Dose → 10mg PO daily with or without food
• MOA: Inhibits absorption of cholesterol at the brush border of the small intestine
• Effects: ↓ LDL, ↓Total Chol, ↓TG, ↑ HDL
o Up to 25% LDL lowering
• Adverse effects
o URTI, diarrhea, arthralgia, sinusitis, pain in extremities
o (+ statin = myalgia)

Question 12

PCSK9

Answer 12

increases # of LDL receptors

Alirocumab (Praluent)
Evolocumab (Repatha)

Question 13

Bile Acid Sequestrants (BAS

Answer 13

• Products:
o Cholestyramine and Colestipol– powder
o Colesevelam – tablets or powder

Effects: ↓ LDL; ↑ VLDL

•Adverse effects: constipation, dyspepsia, nausea
o ↑ seizure activity or ↓ phenytoin levels in patients taking phenytoin
o ↓ INR in patients taking warfarin
o ↑TSH in patients taking thyroid hormone replacement therapy
o Bowel obstruction, dysphagia, hypertriglyceridemia, pancreatitis, increased transaminases

Question 14

Niacin

Answer 14

• Effects:
o↓ LDL 5-25%
o↑HDL 15-35%
o↓TG 20-50%

AE:
Cutaneous flushing
Headache, diarrhea, dyspepsia, abdominal pain
↑blood glucose

Question 15

Omega 3 F.A.

Answer 15

• Effects:
o ↓TG an additional 25-45%
o ↑HDL by < 10%
o May ↑ LDL

AE: GI upset,
after taste/belching, bleeding risk

Question 16

Fibric Acid Derivatives

Answer 16

• Effects:
o↓ LDL 5-20%
o↓TG 20-50%
o↑ HDL 10-20

Avoid with Statins

AE: Abdominal pain, diarrhea, arthralgia, myalgia, myopathy

Question 17

Major ASCVD events

Answer 17

Recent ACS
History of MI
History of ischemic Stroke
Symptomatic peripheral artery disease

Question 18

Statin Contraindications

Answer 18

•Absolute Contraindications
o Active liver disease
o Unexplained elevated transaminases
o Pregnant or nursing women
o Major drug-drug interactions

•Warnings/precautions
o Caution in patients who consume substantial quantities of alcohol
o H/o liver disease
o Significant drug-drug interactions