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xPharm Exam 2 > Hyperlipidemia > Flashcards

Hyperlipidemia Flashcards

1
Q

Bile Acid Sequestrants (3 drugs)

A
  • Cholestyramine
  • Colesevalam
  • Colestipol
    ###
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2
Q

HMG CoA Reductace Inhibitors (4 drugs)

A

(statins)

  • Lovastatin
  • Simvastatin
  • Atorvastatin
  • Rosuvastatin
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3
Q

Fibrates (3 drugs)

A
  • Gemfibrozil
  • Fenofibrate
  • Clofibrate
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4
Q

Cholesterol Absorption Inhibitors (1 drug)

A
  • Ezetimibe
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5
Q

Bile Acid Sequestrants

  • Drugs:
  • Uses:
  • MOA:
  • Effectiveness:
  • Dosing:
  • ADRs:
  • Contraindications:
  • Monitoring:
A
  • Drugs: cholestryramine [TQ], colesevalam, colestipol
  • Uses: reduce major coronary events, reduce CHD mortality, decrease itching associated with cholestasis
  • MOA: increase LDL catabolism
  • Effectiveness:
    • Lowers LDL and TC 15-25%
    • Raises VLDL
    • NO effect on HDL
  • Dosing: give 1 hour before or 4-6 hours after meds
  • ADRs: GI distress, constipation, decreased absorption of drugs, vitamin K and folate affected
  • Contraindications: dysbetalipoproteinemia, raised TG (especially >400mg/dL) [TQ]
  • Slow titration and/or increased intake of fiber may decrease ADRs
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6
Q

Niacin

  • Drugs:
  • Uses:
  • MOA:
  • Effectiveness:
  • Dosing:
  • ADRs:
  • Monitoring:
A
  • Nicotinic acid (NOT nicotinamide)
  • Uses: reduces major coronary events and mortality
  • MOA: decreases LDL and VLDL synthesis
  • Effectiveness:
    • Lowers LDL 15-25%
    • Lowers TG 30-40%
    • Raises HDL 15-35% [TQ]
  • Dosing: slowly increase dose, administer with aspirin or NSAIDs to offset vasodilatory effects
  • ADRs: flushing/headache (prostaglandin-mediated vasodilation) [TQ], hyperglycemia, hyperuricemia, GI distress, hepatotoxicity
  • Monitoring: monitor uric acid, LFT and blood glucose
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7
Q

HMG CoA Reductase Inhibitors

  • Drugs:
  • Uses:
  • MOA:
  • Effectiveness:
  • Dosing:
  • ADRs:
  • Contraindications:
  • Monitoring:
  • Other:
A
  • Drugs: lovastatin, simvastatin, atovarstatin, rosuvastatin
  • Uses: reduce coronary events and procedures, reduce CHD mortality, reduce stroke, reduce total mortality
  • MOA: increases LDL catabolism [TQ]
  • Effectiveness:
    • Lowers TC and TG 15-20%
    • Raises HDL 5-15%
    • Lowers LDL (dose dependent)
  • Dosing: absorbed with food, LDL lowering is dependent on dose
  • ADRs: GI, rash, headache, muscle pain (must check CPK) [TQ], increased LFTs
  • Contraindications: avoid erythromycin, niacin and gemfibrozil, monitor PT with warfarin, digoxin concentrations increased, avoid grapefruit juice
  • Monitoring: monitor LFTs 6-12 weeks [TQ], monitor creatinine kinase
  • TG reduction is dependent predominantly on treatment of baseline TGs, discontinue if liver enzymes >3x upper limit
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8
Q

Lovastatin

A
  • HMG CoA Reductase Inhibitor
  • Prodrug
  • Recommended starting dose to lower cholesterol 20%
  • Must be taken at night
  • Patients on immunosuppressants need to adjust
  • Avoid combo with fibrates and other statins
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9
Q

Simvastatin

A
  • HMG CoA Reductase Inhibitor
  • Prodrug
  • Must be taken at night
  • ADRs: severe renal insufficiency
  • Interacts with cyclosporine, niacin and fibrates
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10
Q

Atorvastatin

A
  • HMG CoA Reductase Inhibitor
  • Active as given, not a prodrug
  • Used for renal patients (?)
  • Adjust doses every 4 weeks
    • Not required in renal impairment
  • Avoid with active liver disease, check liver status [TQ]
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11
Q

Rosuvastatin

A
  • HMG CoA Reductase Inhibitor
  • Adjust doses every 4 weeks
  • Avoid in liver impairment
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12
Q

Fibrates

  • Drugs:
  • Uses:
  • MOA:
  • Effectiveness:
  • Dosing:
  • ADRs:
  • Contraindications:
  • Other:
A
  • Gemfibrozil, Fenofibrate, Clofibrate
  • Reduce coronary lesions and coronary events
  • MOA: increase VLDL clearance and decrease VLDL synthesis
  • Effectiveness:
    • Lowers TGs 20-50%
    • Lowers TC
    • Lowers VLDL
    • Lowers LDL 5-20%
    • Raises HDL 10-20%
  • Dosing: give before morning/evening meals (to prevent GI probs)
  • ADRs: GI, myalgias, rash, increased risk of gallstone formation due to increased cholesterol concentrations in bile [TQ]
  • Contraindications: avoid with lovastatin and use caution with other statins
  • Fenofibrate is a uricosuric agent in the treatment of gout
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13
Q

Cholesterol Absorption Inhibitors

  • Drugs:
  • Uses:
  • MOA:
  • Effectiveness:
  • Dosing:
  • ADRs:
  • Contraindications:
A
  • Ezetimibe
  • Uses: reduces TC, LDL, and Apo-B in primary hypercholesterolemia, can treat famililial hypercholesterolemia
  • MOA: inhibits absorption of cholesterol at brush border of SI via the sterol transporter NPC1L1 [TQ], active metabolite
  • Effectiveness:
    • Liver: decreases delivery of cholesterol, reduces cholesterol stones
    • Blood: increases clearance of cholesterol
  • Dosing: adjunctive to therapy to diet, can combine with a statin
  • ADRs: abdominal pain, anaphylaxis, angioedema, cholelithiasis
  • Contraindications: statins if active liver disease, may increase cyclosporine concentration
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14
Q

Red Yeast Rice

A
  • Yeast forms monocolons that inhibit HMG-CoA reductase
  • Varies in potency
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15
Q

Probucol

A
  • Treatment of high cholesterol with only a modest effect on LDL
  • Not proven to reduce CHD risks
  • Prolongs QT interval
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16
Q

Folate and Vitamin B12

A
  • Treat patients with increased homocysteine concentrations
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17
Q

Estrogens

A
  • Increase HDL by increasing Apo-A production and by inhibiting hepatic lipase activity
  • Does reduce LDL but should NOT be used instead of lipid lowering therapy (adjunct only)
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18
Q

Omega 3 Acid Ethyl Esters

  • Drugs:
  • Uses:
  • MOA:
  • Dosing:
  • Contraindications:
A
  • Drugs: Fish oil, Lovaza (from fish), Vascepa (icasapent ethyl ester)
  • Uses: for patients with TG > 500mg/dL, adjunctive to diet
  • MOA: decrease synthesis of VLDL and increase clearance of TG from VLDL, increase LPL
  • Dosing: take with food, do NOT crush
  • Contraindications: shellfish allergy [TQ], A fib (lovaza), monitor LFTs (vascepa)
19
Q

Major atherogenic lipoprotein

A

Low Density Lipoprotein (LDL)

20
Q

Elevations in _____ are associated with increased risk in patients with metabolic syndrome

A

Triglycerides

21
Q

A cholesterol-rich lipoprotein that transports cholesterol from tissues to the liver

A

High Density Lipoprotein

(High concentrations lower CDH risk)

22
Q

Proteins on the surface of lipoproteins that regulate metabolism of lipoproteins and are important to cellular uptake

A

Apolipoproteins

23
Q

HMG-CoA is AKA

A

3-Hydroxy-3-Methylglutaryl-Coenzyme A

24
Q

What is the Adult Treatment Panel III?

A
  • Guidelines from National Cholesterol Education Program (NCEP)
  • Management of hyperlipidemia in adults
  • Recommends early identification of risk, then lifestyle modification, and then medication
25
Q

Risk Factors for Primary Dyslipidemia

A
  • Modifiable (HD-PODS)
    • HTN
    • Obesity
    • Smoking
    • Physical inactivity
    • Diabetes
    • Drugs
  • Non-Modifiable (FAG.. you can’t change them to be straight)
    • Age
    • Gender
    • Family history
26
Q

Risk Factors for Secondary Dyslipidemia

A
  • Diabetes
  • Hypothyroidism
  • Obstructive liver disease
  • Chronic renal failure
  • Drugs that rase LDL and lower HDL
27
Q

Drugs that Affect Lipids

A
  • Beta Blockers
  • Anabolic Steroids
  • Progestational Agents
  • Corticosteroids
  • Protease Inhibitors for HIV
  • Estrogens
  • Thiazide Diuretics
  • Antipsychotics (Olanzepine and Clozapine)

(BEAT C-PAP)

28
Q

Diagnosis

A
  • Fasting lipid panel every 5 years after age 20
    • LDL
    • HDL
    • TG
  • NCEP: states there should be more frequent measurements in those with multiple risk factors
29
Q

Optimal LDL:

A

<100

30
Q
  • Low HDL:
  • High HDL:
A
  • Low: <40 (bad)
  • High: >60 (good)
31
Q

Optimal TC

A

<200

32
Q

What does the ATP III state about LDL goals for risk categories?

A

As the risks get higher, the LDL goal gets lower.

Low risk: LDL goal is \<160mg/dl
High risk (CHD): LDL goal is \<100mg/dl
33
Q

NCEP Guidelines

A
  • Primary focus of therapy: LDL [TQ]
  • Treat elevated TGs with intensified weight management and increased physical activity
  • If TGs remain >200mg/dl after LDL goal is reached, secondary goal: non-HDL cholesterol of 30mg/dl high than LDL goal
  • Non-HDL = TC - HDL
34
Q

ATP III First Steps:
Non-Pharmacologic Therapy Recommendations

  • Saturated Fat:
  • Cholesterol:
  • Plant Stanols, Sterols:
  • Fiber
  • Total Calories
  • Physical Activity
A
  • Saturated Fat: <7% of total calories
  • Cholesterol: <200mg/day
  • Plant Stanols, Sterols: 2gm/day
  • Fiber: 10-25gm/day
  • Total Calories: adjust to maintain desirable weight
  • Physical Activity: ~200kcal/day
35
Q

Weight and HDLs

A
  • Inverse correlation between body weight and HDL
  • For every 3kg (7lb) of weight loss, HDL increases 1mg/dl
36
Q

Smoking and HDLs

A
  • Smokers have 15-20% lower HDLs
  • Cessation increases HDLs
    • Levels return to normal within 30-60 days
    • HDL may increase 12mg/dl in 60 days
    • If patients return to smoking, HDL decreases to baseline
  • 2 in 5 smoking deaths are from CV disease
  • 1 in 5 deaths from CV disease is due to smoke
  • Risk of dying following an MI is 40% greater for smokers
37
Q

Exercise and HDLs

A
  • Increasess HDL in a dose dependent manner
  • Encourage exercise
38
Q

ATP Recommendation
Drug Therapy for Primary Prevention

First Step:

A
  • Initiate LDL-lowering drug (after 3 months lifestyle therapies)
  • Options: statins, bile acid sequestrant, nicotinic acid
  • Continue therapeutic lifestyle changes as well
  • Return in 6 weeks
39
Q

ATP Recommendation
Drug Therapy for Primary Prevention

Second Step:

A
  • Intensify LDL-lowering therapy (if goal isn’t achieved)
  • Options: higher statins, statin + bile acid sequestrant, statin + nicotinic acid
  • Return in 6 weeks
40
Q

ATP Recommendation
Drug Therapy for Primary Prevention

Third Step:

A
  • Indensify LDL therapy or refer to lipid specialist (if goal still isn’t met)
  • Treat other lipid risk factors:
    • High TGs (>200mg/dl)
    • Low HDL (<40mg/dl)
  • Monitor response and adherance every 4-6 months
41
Q

ATP Recommendation
Drug Therapy for Secondary Prevention

For CHD and CHD Risk Equivalents

A

LDL goal: <100mg/dl

  • First: achivel LDL goal
  • Second: modify other lipid and non-lipid risk factors
  • Patients hospitalized for coronary events:
    • Measure LDL within 24 hours
    • Discharge on LDL-lowering drug if >130mg/dl
    • Consider LDL-lowering drug if 100-129mg/dl
    • Start lifestyle therapies as well
42
Q

Determining LDL Goal

A
  • If any of the following:
    • CAD
    • PVD
    • Abdominal aortic aneurysm
    • Symptomatic carotid disease
    • DM
  • Then: LDL should be <100mg/dl and medication should be started at >130mg/dl
  • If none of the above risks, count these factors:
    • HTN
    • Smoker
    • HDL <40mg/dl
    • Age (40 in men, 55 in women)
    • Family history (55 in male relative, 65 in female)
43
Q

Treatment Gap Causes:

A
  • Inadequate dose titration of existing treatment
  • Patient compliance
  • Lack of routine follow-up
  • Limited access to healthcare
44
Q

Improving Adherence

A
  • Simplify med regimens
  • Provide explicit patient instructions
  • Encourage use of prompts to help patients to remember
  • Use systems to reinfore adherence and maintain contact with the patient
  • Encourage family/friends to support
  • Reinforce and reward adherence
  • Increase visits for patients unable to achieve goals
  • Increase convenience and access to care
  • Involve patients

xPharm Exam 2 (8 decks)

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