Hyperlipidemia Flashcards
.
STATINS
Class:
Indications:
Mechanism of Action:
Effects of mechanism of Action:
Dosing:
Adverse Effects:
Absolute Contraindications:
Pregnancy:
Warning/ Precautions:
Drug-Drug Interactions (DDIs):
Monitoring Parameters:
STATINS
Class: HMG-CoA reductase Inhibitors
Indications:
Mechanism of Action: inhibit HMG-CoA reductase enzyme. This enzyme is a part of the rate limiting step in cholesterol synthesis. Prevents the synthesis of cholesterol.
Effects of mechanism of Action: LOWER cholesterol synthesis, increase LDL receptor expression in the liver, decrease LDL levels, decrease total cholesterol levels, decrease triglycerides, increase HDL levels, and decrease C- reactive protein (inflammatory marker).
Dosing: Split up into 3 categories
High Intensity (>50%)
Atorvastatin (40-80 mg)
Rosuvastatin (20-40 mg)
Moderate intensity
Low intensity
Rosuvastatin (5-10 mg)
Simvastatin (20-40 mg) Simvastatin (10 mg)
Pravastatin (40-80 mg) Pravastatin (10-20 mg)
Fluvastatin (80 mg) Fluvastatin (20-40 mg)
Pitavastatin (2-4 mg) Pitavastatin (1 mg)
Adverse Effects:
>10%:Diarrhea, Arthralgia, nasopharyngitis
2-10%: insomnia, new onset diabetes, nausea, dyspepsia, UTI, myalgia/musculoskeletal pain/ spasm
***note on myalgia-symmetrical muscle pain that involves large proximal muscle groups. typically take 4-6 weeks but not always. 2 diff approaches to dealing with myalgia from statins.
Mild to moderate pain Unexplained Severe Pain
hold statin for 2-4 weeks and see if pain goes away D/C statin and evaluate for rhabdomyolysis
if pain goes away- rechallange with same statin at lower Once resolved, do not reinitiate statin therapy unless discussed w. specialist
dose. if muscle pain starts again, give
non lipophyllic statin i.e Pravastatin or
Rosuvastatin
if pain doesn’t go away- consider other causes of muscle
symptoms
muscle related symptoms that stop after d/c of statin occur, with re challenge, and occur with at least 2-3 statins, may mean that the patient is statin intolerant*
Rare but Serious: hepatotoxicity, cognitive dysfunction/ confusion, skin reaction (steven-johnson syndrome), Rhabdomyolysis
Absolute Contraindications: Active liver disease, unexplained elevated transaminases, PREGNANT WOMEN, Major DDIs
Pregnancy: DO NOT USE
Warning/ Precautions: Caution in patients who drink a lot of alcohol, history of liver disease, significant DDIs,
Drug-Drug Interactions (DDIs): Atorvastatin, Lovastatin, and Simvastatin all metabolized by CYP3A4, so can have interactions with drugs that affect these enzymes.
Monitoring Parameters:
Fasting lipid panel- 4-12 weeks after initiation of therapy. then q 3-12 mo. as clinically indicated
Transaminases (ALT, AST)- get their baseline, and then measure in patients w. symptoms suggesting hepatotoxicity
Monitor for new onset diabetes
EZETIMIBE (Zetia)
Class:
Indication:
Mechanism of Action:
Effects of mechanism of Action:
Dosing:
Adverse Effects:
Absolute Contraindications:
Pregnancy: –
Warning/ Precautions: –
Drug-Drug Interactions (DDIs): —
Monitoring Parameters:
EZETIMIBE (Zetia)
Class: Antilipemic agent
Indication: Primary Hyperlipidemia: As adjunctive therapy to diet and HMG-CoA reductase inhibitor (statin) for patients who do not meet cholesterol treatment goals with therapy dietary modification plus maximally tolerated statin therapy (AHA/ACC 2018 guidelines) or as mono therapy if a statin is not tolerated for the reduction of total-C, LDL-C, apolipoprotein B and non high density lipoprotein cholesterol
Mechanism of Action: Inhibits absorption of cholesterol at the brush border of the small intestine.
Effects of mechanism of Action: Lower LDL (when used with statins, up to 25% LDL lowering capacity), Lower total Cholesterol, lower triglycerides, increase HDL.
Dosing: 10 mg PO daily with or without food
Adverse Effects: Upper Respiratory Tract infection, arthralgia, sinisitis, pain in extremities. When used with statins, can cause myalgia
Absolute Contraindications: Hypersensitivity, concaminant use with patients on statin with liver disease or unexplained elevated transaminases (AST and ALT ) pregnancy and breastfeeding(when used together with a statin)
Pregnancy–
Warning/ Precautions:–
Drug-Drug Interactions (DDIs):–
Monitoring Parameters:
Fasting lipid panel- 4-12 weeks after initiation of therapy. then q 3-12 mo. as clinically indicated
Transaminases (ALT, AST)- get their baseline, and then measure in patients w. symptoms suggesting hepatotoxicity
Bempedoic Acid (Nexletol)
Class:
Indication:
Mechanism of Action:
Effects of mechanism of Action:
Dosing:
Adverse Effects:
Absolute Contraindications:–
Pregnancy:
Warning/ Precautions: –
Drug-Drug Interactions (DDIs): –
Monitoring Parameters:
Bempedoic Acid (Nexletol)
Class: Antilipemic agent. Adenosine Triphosphate-citrate lyase (ACL) inhibitor.
Indication: Treatment of established atherosclerotic cardiovascular disease, as an adjunct to diet and maximally tolerated statin therapy, in an adult patient who requires additional lowering of LDL cholesterol
Mechanism of Action: Adenosine triphosphate-citrate lyase is an enzyme found early in the cholesterol synthesis pathway. inhibition of this enzyme prevents cholesterol synthesis.
Effects of mechanism of Action: decreases cholesterol synthesis and lowers LDL-C in blood via up regulation of LDL receptors.
Dosing: 180 mg PO daily with or without food
Adverse Effects: gout/hyperuricemia, tendon rupturen myopathy with contaminant use with statins
Absolute Contraindications:–
Pregnancy: DO NOT USE
Warning/ Precautions: –
Drug-Drug Interactions (DDIs): –
Monitoring Parameters:
Fasting lipid panel- 8-12 weeks after initiation of therapy. Monitor uric acid levels, and s/s of tendon rupture (i.e joint pain, swelling, inflammation.
Cholestyramine, Colestipol, Colesevelam
Class:
Indication:
Mechanism of Action:
Effects of mechanism of Action:
Dosing:
Adverse Effects:
Absolute Contraindications:
Pregnancy:
Warning/ Precautions:
Drug-Drug Interactions (DDIs):
Monitoring Parameters:
Cholestyramine, Colestipol, Colesevelam
Class: Antilipemic agent. Bile acid sequestrants (BAS)
Indication:Primary hyperlipidemia: management of elevated LDL cholesterol in adults with primary hyperlipidemia in conjunction with diet and exercise. May be considered in patients with fasting triglyceride level <300 mg/dL who do not meat cholesterol treatment goals with dietary modification, and other lipid lowering therapies (eg. maximally tolerated statin and ezetimibe). AHA/ ACC 2018 guidelines
Mechanism of Action:Bind with bile acids in the small intestine to form an insoluble complex that is eliminated in the feces to prevent reabsorption.
Effects of mechanism of Action: decreases LDL, increase VLDL (which increase triglyceride levels)
Dosing:
Cholestyramine (powder) Colestipol
initial 4g 1-2 x/day
over >1 month intervals
maintenance: 8-16 g/day
divided into 2 doses: max
24g/ day
Colesevelam (tablets or powder)
625 mg POdaily or 3 tabs PO BID
increase gradually
Adverse Effects: constipation, dyspepsia, nausea, bowel obstruction, dysphagia, hypertriglyceridemia, pancreatitis, increased transaminases
Absolute Contraindications: hypersensitivity, complete bile obstruction
Pregnancy: Category C
Warning/ Precautions: BAS can decrease absorptions of other drugs, administer other drugs 4 hours apart from BAS.
Drug-Drug Interactions (DDIs): Phenytoin: BAS increase seizure activity or decrease phenytoin levels in patients taking phenytoin
Warfarin: BAS increase elimination of warfarin, decreasing INR in patienststaking warfarin
thyroid hormone replacement therapy: BAS can increase TSH in patients taking thyroid hormone replacement therapy
Monitoring Parameters:
Fasting lipid panel- at initiation. recheck every 4-12 weeks after starting therapy and every 3-12 months thereafter.
Niacin (nicotinic acid, Vitamin b3)
Class:
Indication:
Mechanism of Action:
Effects of mechanism of Action:
Dosing:
Adverse Effects:
Absolute Contraindications:
Pregnancy: —-
Warning/ Precautions:—-
Drug-Drug Interactions (DDIs): —
Monitoring Parameters:
Niacin (nicotinic acid, Vitamin b3)
Class: Antilipemic agent. vitamin
Indication: treatment of dyslipidemias as mono or adjunctive therapy, to lower the risk of recurrent MI in patients with a history of MI and hyperlipidemia. ** NOTE: niacin is no longer considered primary or secondary agent for dyslipidemias. Although niacin consistency effects surrogate markers, especially LDL, it has not been shown to reduce CVD outcomes beyond that achieved with statins and may be associated with harm **
Can be used in specific clinical situations (high triglyceride levels [>500 mg/dL] if not able to achieve desired response.
Mechanism of Action: reduces hepatic synthesis of VLDL and LDL. inhibits diacyl-glycerol acetyltransferase-2 and inhibits hepatic catabolism of HDL
Effects of mechanism of Action: decreases triglycerides 20-50%, decrease LDL 5-25%, increase HDL 15-35%
Dosing: Niacin extended release (Niaspan): 500mg-2000mg PO at bedtime
Adverse Effects: Cutaneous flushing, (up to 88%of patients) -warmth, redness, itching, tingling (can pretreat with ASA 325 mg 30 min prior. take with food. titrate dose slowly). headache, diarrhea, dyspepsia, abdominal pain, increased blood glucose
Absolute Contraindications: hypersensitivity, active hepatic disease.
Pregnancy: —-
Warning/ Precautions:—-
Drug-Drug Interactions (DDIs): —
Monitoring Parameters:
monitor blood glucose if patient is diabetic.
is on statin, periodically check CPK and serum potassium,
Liver function test at baseline, every 6-12 weeks for first year, then periodically (q6mo)
Vascepa, Lovaza, Epanova, Omtryg
Class:
Indication:
Mechanism of Action:
Effects of mechanism of Action:
Adverse Effects:
Dosing:
Absolute Contraindications:
Pregnancy: —-
Warning/ Precautions:—-
Drug-Drug Interactions (DDIs): —
Monitoring Parameters:
Vascepa, Lovaza, Epanova, Omtryg
Class: Antilipemic agent. omega 3 fatty acids
Indication: Hypertriglyceridemia: as an adjunct to diet to reduce triglyceride levels in patients with severe (>500 mg/dL) hypertriglyceridemia
Mechanism of Action: hepatic inhibition of triglyceride synthesis, decrease ldl secretion, increased vldl METABOLISM
Effects of mechanism of Action: decrease triglyceride an additional 25-45%, increase HDL by <10%, may increase LDL (avoid formulations with DHA may help [Vascepa doesn’t have DHAs in it]
Adverse Effects:GI upset, aftertaste/ belching, bleeding risk
Dosing: OTC 1-3 g of EPA +DHA daily in divided doses.
Absolute Contraindications: hypersensitivity
Pregnancy: —-
Warning/ Precautions:—-
Drug-Drug Interactions (DDIs): —
Monitoring Parameters:
Triglycerides and other lipids (ldl-c) should be monitored at baseline and periodically.
Gemfibrozil, Fenofibrate
Class:
Indication:
Mechanism of Action:
Effects of mechanism of Action:
Adverse Effects:
Dosing:
Absolute Contraindications:
Pregnancy: —-
Warning/ Precautions:—-
Drug-Drug Interactions (DDIs):
Monitoring Parameters:
Gemfibrozil, Fenofibrate
Class: Antilipemic agent. Fibric acid derivates.
Indication: Hypertriglyceridemia: for patients who are at greater risk of pancreatitis and who have not responded to dietary intervention for patients with very high TG (>500) mg/ dl
Mechanism of Action: Peroxisome proliferator-activated receptor -alpha agonist. increases fatty acid oxidation of free fatty acids and triglycerides metabolism. increases affinity of LDL for LDL receptor. increase hepatocyte production of Apo-A (responsible for HDL formation)
Effects of mechanism of Action: decrease LDL mildly (5-20%), decrease TG 20-50%, increase HDL 10-20%
Adverse Effects:abdominal pain, diarrhea, arthralgia, myalgia, myopathy
Dosing: Gemfibrozil- 600 mg PO BID 30 minutes before breakfast and dinner
Absolute Contraindications: hypersensitivity, preexisting gall lbladder disease, primary biliary cirrhosis, concurrent use with statins
Pregnancy: —-
Warning/ Precautions:—-
Drug-Drug Interactions (DDIs): do not use with statins (especially gemfibrozil) fenofibrate considered safer)
Monitoring Parameters:
serum cholesterol, LFTs periodically.
Coronary Artery Calcium
What is it?
When is it indicated?
When is it not indicated?
When to recheck CAC?
CT scan that measures the amount of calcium in the walls of the artery.
Useful when the clinician and patient are uncertain whether to start a statin.
patients who are on statins
recheck after 5-10 years
Coronary Artery Calcium Score meanings
Zero:
> 100 agatson units:
Zero: indicates a low ASCVD risk score
EXCEPTIONS: cigarette smokers, diabetes mellitus, strong family history of ASCVD, chronic inflammatory conditions like HIV
> 100 agatson units: have a 10 year risk of ASCVD >7.5%
Aspirin for primary prevention
indication
specific population group indications
ASA has more established role for secondary prevention than primary prevention
adults age 50-59 with >10% 10 year CVD risk score: ppl who are not at increased risk for bleeding, have a life expectancy >10 years and are willing to take a low dose aspirin daily for at least 10 years. grade recommendation B
Aspirin doses at 75-100 mg can be considered
adults age 60-69 with a >10% 10 year CVD risk: its who are not at risk for bleeding and have a life expectancy >10% and willing to take a low dose aspirin daily for at least 10 years are more likely to benefit: Grade of recommendation C
Aspirin doses at 75-100 mg can be considered
