Hyperlipidemia Flashcards
What are the 5 major risk factors for CVD?
smoking hypertension (>140/90 or on meds) low HDL (45, women >55) Fam hx of early CHD Age (men >45, women >55)
LDL goal - “high risk” (CHD)
<70)
LDL goal - “moderately high risk” (2+ risk factors)
<130
LDL goal - “moderate risk” (2 risk factors)
<130
LDL goal - “lower risk” (0-1 risk factors)
<160
Risks factors for metabolic syndrome
3 or more: abdominal obesity (men >40, women >35) tg >150 low HDL (men 130/>85) fasting glucose >110
What is the treatment approach for hyperlipidemia?
- initiate TLCs
- Treat secondary causes (DM, meds, etc.)
- Treat LDL to goal
- When LDL is to goal, treat high tg (>200)
- Attempt to increase HDL if <40
What are the TLCs (therapeutic lifestyle changes) for LDL lowering?
- TLC diet (low fat, low cholesterol), plant stanols/sterols, fiber
- weight reduction
- increased physical activity
*What part of the cholesterol panel do statins mostly act on?
LDL reduction
*What part of the cholesterol panel do bile-acid resins mostly act on?
LDL reduction
*What part of the cholesterol panel do fibric acid derivatives mostly act on?
decrease triglycerides
*What part of the cholesterol panel do omega-3 fatty acids mostly work on?
decrease triglycerides
*Statins - MOA
inhibit HMG CoA reductase –> decrease in cholesterol production (up regulation of LDL receptors and enhanced clearance)
*only works if receptors are not defective
Statins - time of day to administer
usually at night so it peaks when cholesterol synthesis is the highest (2-4am)
Side effects are low with statins but include:
elevated liver enzymes
myopathy
rabdomyolysis
DDI - Statins (because of CYP450)
gembibrozil
Protease inhibitors
itraconazole/ketoconazole/voriconazole
emycin/clarithromycin
Which 2 statins reduce LDL the most?
Atorvastatin (Lipitor) 60%
Rosuvastatin (Crestor) 60+%
What level are we getting under control first in drug therapy for high cholesterol?
LDL
What level do we treat next after lowering LDL?
Triglycerides
What drug can reduce total cholesterol/LDL, Apo B, non-HDL or TG and increase HDL in patients where mono therapy is not adequate?
Niacin extended release/Simvastatin (Simcor)
As you increase the dose of statin, you increase the risk of _______.
Myopathy
What level is considered very high LDL?
> 190mg/dl
What can be added to statins for very high LDL?
ezetimibe +/- nicotinic acid
bile acid sequestrates +/- nicotinic acid
What class are: cholestyramine (Questran), colestipol (Colestid) and Colesevelam (Welchol)?
bile acid binding resins
What time of day are bile acid binding resins given?
with meals (acts on bile acid that is present during digestion)
*Bile acid binding resins - side effects
GI (bloating, constipation, gas), increase in liver enzymes, increase in TG
hard to tolerate
Bile acid binding resins - DDI
fat soluble vitamins (binds)
give 1 hr before or 4 hrs after meal
What is the selective cholesterol absorption inhibitor?
Ezetimibe (Zetia)
combo agent simvastatin + ezetimibe (Vytorin)
What is the nicotinic acid derivative used for hyperlipidemia?
ER Niacin (Niaspan) IR Niacin (available OTC)
Nicotinic acid derivative dosing considerations
start out low and titrate b/c of side effects effective range 1500-2000 mg/day take at night (b/c of flushing) take ASA or NSAID 30 min before avoid ETOH
*Nicotinic acid - side effects
flushing hepatotoxicity (esp. at higher doses) glucose homeostasis/insulin resistance blurry vision gout
Classification of serum TG
normal <150
borderline high 150-199
high 200-499
very high 500+
What is the secondary target of therapy for hyperlipidemia?
non-HDL (VLDL + LDL)
At what level do you treat TG?
> 200
Treatment of triglycerides
- treat underlying factors
- niacin
- fibric acid derivative “fibrates”
- fish oil
- therapeutic phlebotomy
What are the underlying factors for elevated triglycerides?
diet, ETOH, DM, hypothyroidism, antiretrovirals, steroids,
What is the treatment goal for very high triglycerides (>500)?
prevent acute pancreatitis
*What are the two formulations for fibrates?
Fenofibrates and Gemfibrozil
*Fenofibrates are favored b/c of dosing (no restriction with food timing)
*Fibrates - clinical issues
gall stones
Gemfibrozil can increase LDL and fenofibrates can decrease LDL
Fibrates - DDI
protein bound so can displace other meds: warfarin, ASA, glyburide, statins, niacin
Fibrates - ADE
contraindication: hepatic or renal dysfunction and preexisting gall bladder disease
How much fish oil is needed/day to reduce TG?
2-4 grams
Fish oils should be discontinued if what occurs?
acute bleeding episode such as hemorrhagic stroke
Causes of low HDL (<40 mg/d)
physical inactivity
type 2 diabetes
smoking
genetic
What med is the DOC for low HDL treatment?
Niacin
Red yeast rice - active ingredient
Monacolin K (comparable to Lovastatin) can lower cholesterol
Red yeast rice - dosage
600 mg po bid
Risk factors for statin induced myopathy
female
65+
kidney disease
hypothyroidism
Red yeast rice - effects on levels
lowers TC, TG and LDL
increases HDL
Ezetimibe (Zetia) - MOA
(selective cholesterol absorption inhibitor)
blocks niemann Pick C1 like 1 peptide (NPC1L1) in the small intestine
At what level should triglycerides be treated before LDL?
> 500
