Hyperlipidemia

Question 1

What are the LDL-C goals?

Answer 1

Low risk: <160 mg/dL, moderate to moderately high risk: <130, high risk: <100

Question 2

What are the goals of other lipoprotein levels?

Answer 2

total C: 50, TG: <150, HDL-C: >50

Question 3

What are the dietary guidelines for treating hyperlipidemia?

Answer 3

Question 4

What is the non-HDL-C (VLDL-C + LDL-C) goal?

Answer 4

LDL-C goal + 30 mg/dl

Question 5

Which drug classes are effective in lowering LDL-C?

Answer 5

statins

bile acid resins

niacin

cholesterol absorption inhibitors

Question 6

What is the mechanism of action of statins (simvistatin)?

Answer 6

Partially inhibits HMG-CoA reductase, the rate-limiting step of cholesterol synthesis, lowering intracellular cholesterol. This induces LDL receptor formation and removal of LDL-C from the circulation

Question 7

What are the benefits of statins?

Answer 7

Lowers LDL-C 25-50%, raises HDL-C 10%, lowers TG 15-25%

Question 8

What are the side effects of statins?

Answer 8

abnormal LFTs (increased transaminase), myositis/myalgias

Question 9

Concomitant use of which drug class increases the risk of myalgia/myositis with simvistatin?

Answer 9

fibrates

Question 10

What is the MOA of bile acid resins?

Answer 10

interrupts bile acid reabsorption, requiring bile acid synthesis from cholesterol; this upregulates LDL receptor synthesis, resulting in removal of LDL and VLDL from the blood

Question 11

What is an example of a bile acid resin?

Answer 11

cholestyramine

Question 12

What are the benefits of cholestyramine?

Answer 12

lowers LDL-C 10-15%

Question 13

What are the side effects of cholestyramine (and other bile acid resins)?

Answer 13

GI: constipation, bloating, abdominal pain

Drug interactions (affects absorption): warfarin, beta-blockers, thyroid hormone

Question 14

What is the MOA of niacin?

Answer 14

reduces hepatic production of VLDL and apo B, which results in decreased catabolism to LDL

Question 15

What are the benefits of niacin?

Answer 15

best agent to raise HDL-C, lowers LDL-C and TG 10-30%

Question 16

What are the side effects of niacin?

Answer 16

flushing, hepatotoxicity, hyperuricemia (uric acid), hyperglycemia and reduced insulin sensitivity, activation of peptic ulcer

Question 17

What are the contraindications for niacin?

Answer 17

active liver disease, peptic ulcer disease

Question 18

What causes niacin-induced flushing?

Answer 18

release of PGD₂ from tissue macrophages in the skin (minimize with aspirin)

Question 19

What is the MOA of cholesterol absorption inhibitors?

Answer 19

blocks the uptake of micelles into the brush border of the duodenum and jejunum

Question 20

What is an example of a cholesterol absorption inhibitor?

Answer 20

ezetimibe

Question 21

What are the benefits of ezetimibe?

Answer 21

decreases delivery of intestinal cholesterol to the liver, reducing hepatic stores; increases clearance from the blood; reduces LDL-C by 18%

Question 22

What are the adverse effects of ezetimibe?

Answer 22

relatively well-tolerated with few side effects

Question 23

Which drug classes are effective in lowering TG?

Answer 23

fibrates

niacin

Omega-3 fatty acids

Question 24

In patients with very high TG, what is the primary aim of therapy?

Answer 24

reduce risk of pancreatitis by lowering TG

Question 25

What is an example of a fibrate?

Answer 25

gemfibrozil

Question 26

What are the benefits of fibrates?

Answer 26

best TG-lowering drugs: decreases 25-50%; increases HDL-C 15-25%

Question 27

What are the side effects of fibrates?

Answer 27

GI upset, cholelithiasis, myositis, abnormal LFTs

Question 28

What are the contraindications for fibrates?

Answer 28

hepatic or renal dysfunction, gallbladder disease

Question 29

What is the MOA of omega-3s?

Answer 29

inhibits hepatic TG synthesis, augments chylomicron TG clearance