Hyperlipidemia

Question 1

Desired LDL

Answer 1

< 130

Question 2

Desired HDL

Answer 2

> 60

Question 3

Desired Total Cholesterol

Answer 3

< 200

Question 4

Desired Triglycerides

Answer 4

< 150

Question 5

Desired LDL/HDL ratio

Answer 5

< 3.0

Question 6

Desired Total Cholesterol/HDL ratio

Answer 6

< 3.5

Question 7

Desired Apo B

Answer 7

< 80

Question 8

Four Major Statin Benefit Groups

Answer 8

1. Individuals with ASCVD
2. Individuals with LDL > 190 without ASCVD
3. Individuals with DM, 40-75yo, LDL 70-189, without ASCVD
4. Individuals without ASCVD or DM with LDL 70-189 and established 10 year ASCVD risk > 7.5%

Question 9

ASCVD

Answer 9

• acute coronary syndrome
• history of MI
• stable angina
• PCI or other revascularization
• stroke/TIA
• PAD

Question 10

1. Individuals with ASCVD

Answer 10

High Risk: HIGH INTENSITY STATIN

Very High Risk: (over 75) HIGH + EZETIMIBE or HIGH + EZETIMIBE and PCSK9 INHIBITOR

Question 11

2. Individuals with LDL > 190 without ASCVD

Answer 11

Over 21

HIGH INTENSITY STATIN

Question 12

3. Individuals with DM, 40-75yo, LDL > 70 and without ASCVD

Answer 12

MODERATE INTENSITY STATIN
or if
1) Multiple risk factors or 2) 50-75yo and want to decrease LDL by more than 50% then HIGH INTENSITY STATIN

Question 13

4. Individuals without DM or ASCVD but with LDL 70-189 and 40-75yo and 10 year ASCVD risk > 7.5%

Answer 13

MODERATE - HIGH INTENSITY STATIN

Question 14

Drug Interactions for Statins - What to use what not to use

Answer 14

• Most likely to interact are the CYP3A4 metabolizers (atorvastatin, lovastatin, simvastatin)
  
  • instead use fluvastatin, pravastain, pitavastatin,
    rosuvastatin
• Increases risk of myopathy + rhabdo
  
  • Antifungal agents (-conazoles)
  • HIV and HCV protease inhibitors
  • CCB: amlodipine, dilt, verapamil
  • Antiarrhythmic agents: amiodarone, dronedarone
  • Antibiotics: clarithromycin, erythromycin,
    telithromycin

Question 15

Drugs that decrease statin levels

Answer 15

ONLY CYP3A4 Metabolizers

- carbamazepine, oxcarbazepine, phenytoin, rifampin, st johns wort

Question 16

Drugs that interact with ALL statins that increase risk of Rhabdo/Myopathy

Answer 16

• colchicine
• *** gemfibrozil (rhabdo)
• cyclosporine
• niacin
• daptomycin
• red yeast rise
• fenofibrate

Question 17

Statins that increase AC effect of warfarin

Answer 17

fluvastatin, rosuvastin, lovastatin, simvastatin, pravastatin,
** consider using atorvastatin **

Question 18

Statin Therapy Monitoring (8)

Answer 18

1. Check ALT at baseline. Repeat only if symptoms of hepatotoxicity occur
2. Document any pre existing muscle symptoms before starting a statin to establish a baseline
3. Consider checking Cr Kinase at baseline in patients at increased risk of myopathy (ie drug interactions). Repeat only if symptomatic
4. If severe muscle symptoms or fatigue of unknown cause develop, hold the statin and check Cr and UA to rule out rhabdo
5. *** check fasting lipid panel 4-12 weeks after statin initiation then every 3 to 12 months after stabilized
6. Check adherence to statin and lifestyle interventions if LDL drop less than expected
7. Consider statin dose reduction if two consecutive LDL measurements are < 40
8. Monitor for new onset diabetes per diabetes screening guidelines

Question 19

Non Statin Therapy

Answer 19

Ezetimibe
Bile acid sequestrant
Fibrates (do not add gemfibrozil to statin therapy)
PCSK9 Inhibitor ( only 3yrs, bene uncertain in pts without ASCVD)
no proof adding non statin to a statin prevents events in patients without clinical ASCVD

Question 20

Who to use Non statin therapy on

Answer 20

• Pts at very high risk of ASCVD who do not reach LDL of 70 with statin
  
  • add ezetimibe
  • failing that, may add PCSK9
• Patients 20-75yo with LDL > 190 who cannot achieve a 50% LDL reduction and/or LDL < 100 with statin
  
  • Add ezetimibe
  • LDL threshold still not met and fasting triglycerides < 300
    = add on bile acid sequestrant
    = failing that, may add PCSK9
• Patients 30-75yo with genetic hypercholesterolemia and LDL 100 despite statin and ezetimibe
  
  • add PCSK9
• Primary prevention in adults 40-75yo with LDL 70-189 and estimated 10 year risk of ASCVD of 7.5% or higher and CKD
  
  • combine ezetimibe to statin
• Triglycerides 500-1000 despite lifestyle changes (ver low fat diet with increased ome3 consumption, cutting refined carbs and alcohol) and ruling out secondary causes
  
  • Fibrate

Question 21

HIGH INTENSITY DOSAGES

Answer 21

Atorvastatin 40-80mg

Rosuvastatin 20-40mg

Question 22

MODERATE INTENSITY DOSAGES

Answer 22

Atorvastatin 10-20mg
Rosuvastatin 5-10mg

Fluvastatin 40mg BID 
Fluvastatin XL 80mg
Lovastatin 40-80mg
Pravastatin 40-80mg
Simvastatin 20-40mg

Pitavastatin 1-4mg

Question 23

LOW INTENSITY DOSAGES

Answer 23

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