hyperlipidemia Flashcards
hyperlipidemia
serum cholesterol > 200
hyperlipidemia: causes
genetic, dietary, lifestyle
hyperlipidemia: tx goals changed- ACC/AHA guidelines
- risk based
- updated in 2018
- statins remain the mainstay of therapy
high intestiny (>/50)
- atorvastatin
- rosuvastatin
moderate intensity (30-40%)
- atorvastatin
- rosuvastatin
- simvasatin
low intensity (<30%)
- simvastatin
statins/ HMG-CoA reductase inhibitors: MOA
prevent the production of mevalonate – the building block of cholesterol
o Reduced intrahepatic cholesterol synthesis
o Upregulates expression of LDL receptor gene = more LDL receptors on the liver = lower LDL/triglycerides and higher HDL
statins/ HMG-CoA reductase inhibitors: indications
o Hyperlipidemia
o ASCVD
statins/ HMG-CoA reductase inhibitors: common side effects
o Myalgia
o Myopathy (can lead to rhabdo)
o Headache
o GI symptoms
o Elevated LFTs (<1% of patients)
o Increased risk for DM/hyperglycemia
o ? Cognitive decline
when are statins administered?
at night
Statins/HMG-CoA reductase inhibitor: common interactions
o Gemfibrozil or niacin + statin = increased risk of rhabdo
Ezetimibe (Zetia): MOA
works by inhibiting the intestinal absorption of cholesterol
Ezetimibe (Zetia): contraindicated
with statins in pts with liver disease
Ezetimibe (Zetia)
- can be used as monotherapy
- well tolerated
ENHANCE study (2008)
reduced cholesterol by 15-20% but no reduction in atherosclerotic plaque
Bile Acid Sequestrants: drug examples
o Cholestyramine, colestipol, colesevelam
Bile Acid Sequestrants: MOA
- Sequester bile acids
- Liver increases production of bile acids using cholesterol
- Bile acids are excreted in the gut
Bile Acid Sequestrants: side effects
GI SE common–diarrhea, GI upset, gassiness
Bile acid sequestrants
unsure effect of CV morbidity/mortality
PCSK9 inhibitors: MOA
- PCSK9 is an enzyme that degrades LDL receptors on the liver
- Inhibitors bind to PCSK9 resulting in inhibition of receptor degradation more LDL receptors lower serum LDL
PCSK9 inhibitors: side effects
not too many SEs–> only nasal pharyngitis
PCSK9 inhibitors:
o Shown to decrease ASCVD morbidity and mortality
o Cost is going down but still expensive
o Reserved for lipid specialists
Fibrates: MOA
Increase lipoprotein lipase activity–> more rapid degredation of triglycerides and LDL
Fibrates: common agents
Fenofibrate, gemfibrozil
Fibrates: contraindications
- Gemfibrozil should be avoided with statins
- Increased serum statin levels = increased risk for rhabdo
fibrates: primary role is
hypertriglyceridemia
nitrates: indications
- Management of acute and chronic angina
- Anal fissure
- CHF/MI
- Peri/intraoperative BP management
nitrates: MOA: vasodilation
Peripheral arteries & veins
* Causes less blood return to the heart decreasing filling volume (preload)
* Decreases the workload of the heart
Coronary arteries
* Causes increased blood flow and oxygen supply to the myocardium
* Increases oxygenation of the heart muscle
common side effects nitrates
- Headaches -pts with migraine hx at higher risk
- Flushing
- Dizziness
- Hypotension
- Syncope
- Reflex tachycardia
nitrates: interactions
- Caution with anti-hypertensives or any med that may cause hypotension
- Contraindicated with PDE-5 Inhibitors
- Anticholinergic agents may decrease absorption of SL and buccal formulations (dry mouth)
nitrates: admin (all formulations)
- Start low and go slow”
- Avoid abrupt discontinuation (rebound angina)
- Avoid EtOH use
- Avoid abrupt position changes
nitrates: sublingual/buccal (rapid acting)
- Patient should be seated when using
- Dry mouth may affect absorption – use spray
nitrates: oral
- Take at prescribed intervals
- Store in tightly closed amber glass containers
- Replace q6months if bottle open
nitrates: transdermal
- Rotate application sites
- Still require nitrate free interval
- Exercise may increase speed of absorption
- Gloves!!!
rapid acting nitrates
- Use: acute angina, acute angina prophylaxis
- Sublingual/Buccal (avoids the first pass effect)
-Tablet (0.3mg, 0.4mg, 0.6mg)
-Spray (0.4mg) - Repeat q 5 minutes for up to 3 administrations – then call 911
- Refill yearly to ensure potency
long acting nitrates
- Use: chronic prophylaxis of angina
- Oral – significant hepatic first pass metabolism
-Isosorbide dinitrate
-Isosorbide mononitrate - Transdermal
-2% Ointment
-Patch
tolerance nitrates
- Loss of ability of the smooth muscle to vasodilate in response to nitrates
- Occurs with continuous exposure
- Must have a 10–12-hour nitrate free interval per day
cardiac glycoside: digoxin
MOA
Inhibits Na/K ATPase resulting in increased cardiac contractility and decreased AVE conduction/heart rate
cardiac glycoside: digoxin
indications
- Afib
- Treatment resistant heart failure
- SVT
cardiac glycoside: digoxin
o Narrow Therapeutic Index
o Many drug/drug interactions
cardiac glycoside: digoxin
digoxin toxicity
- Can lead to lethal arrhythmias, hyperkalemia
- S/S: N/V, diarrhea, blurry vision with yellow tint/halos, disorientation, weakness
digoxin toxicity tx
digibind
