Hyperlipidemia Therapeutics

Question 1

what are the friedewald equations for cholesterol?

Answer 1

LDL=total ch -(HDL+TG/5)
VLDL=TG/5
Non-HDL=total ch - HDL

Question 2

what are the ASCVD risk categories?

Answer 2

low <5%
borderline 5-7.5%
intermediate 7.5-19.9%
high >20%

Question 3

ASCVD risk is calculated for what criteria of pts?

Answer 3

adults 40-75
non-diabetic
LDL 70-189

Question 4

AHA/ACC LDL guidelines?

Answer 4

LDL <100 in primary prevention
LDL <70 with ASCVD

Question 5

ESC/EAS LDL guidelines?

Answer 5

<100 in moderate risk
<70 in high risk
<55 w/ ASCVD or very high risk
<40 w/ recurrent events

Question 6

what lvl of LDL do we consider adding on to statin therapy?

Answer 6

> 70

Question 7

List the four ASCVD statin benefit groups (criteria of who would benefit from a statin)

Answer 7

clinical ASCVD: high-intensity statin
severe hypercholesterolemia (LDL 190 or over): high-intensity statin
Diabetes 40-75 y/o: moderate-to-high intensity
Primary prevention ASCVD 7.5-10%: moderate intensity

Question 8

steps to treating pts 40-75 LDL between 70-190?

Answer 8

calculate ASCVD risk
<5%: lifestyle factors
5-7.5%: risk discussion
7.5-20%= may benefit from statin
20 or more: start statin

Question 9

statin initiation recommendation according tp USPSTF?

Answer 9

pts 40-75 w/ 1 or more CV risk factors and ASCVD over 10%= initiate statin

pts 40-75 w/ 1 or more CV risk factors and ASCVD b/w 7.5-10%= may start statin

pts 76 or older: insufficient evidence for or against starting statin

Question 10

high-intensity statin treatment (lower LDL by 50%):

Answer 10

atorvastatin 40-80mg
rosuvastatin 20-40mg

Question 11

moderate intensity statin treatment (lower LDL by 30-49%):

Answer 11

atorv 10-20mg
rosuv 5-10mg
fluva 40mg bid

Question 12

low intensity statin treatment (lower LDL by 30%):

Answer 12

simvastatin 10mg
pravastatin 10-20mg

Question 13

what did the IDEAL trial tell us?

Answer 13

determining benefit of high intensity statin use vs moderate intensity. showed moderate intensity is fairly similar in outcome to high intensity

Question 14

A 57-year-old Hispanic man is referred to your lipid clinic for assessment of ASCVD risk. He has a
medical history of hypertension, chronic kidney disease stage 3, major depressive disorder, and
chronic back pain. The patient also has a history of hypertriglyceridemia (HTG), but no history of
pancreatitis and no family history of premature ASCVD. The patient denies use of tobacco or
alcohol.
He reports full adherence to the following medications: chlorthalidone 25 mg/day, amlodipine 5
mg/day, fluoxetine 20 mg/day, tramadol 50 mg every 6 hours as needed for pain.
Today his BP is 136/78 mm Hg, heart rate 88 bpm, and BMI is 27.5 kg/m2. His most recent
fasting lipid panel is as follows: TC 219 mg/dL, TG 286 mg/dL, HDL-C 38 mg/dL, and LDL-C 124
mg/dL. His most recent eGFR calculated to be 58 mL/min/1.73m2. His calculated 10-year ASCVD
risk is 11.8%.
Which of the following is the most appropriate recommendation for initial lipid-lowering
therapy to lower his ASCVD risk?
A. Rosuvastatin 20 mg
B. Atorvastatin 10 mg
C. Fenofibrate 135 mg daily.
D. Ezetimibe 10 mg daily

Answer 14

low HDL, high LDL
B, patient has no primary ASCVD, does have CV risk factors, but starting as primary prevention of ASCVD-> moderate intensity statin

Question 15

to classify a pt w/ statin intolerance, a minimum of ____ statins should’ve been attempted

Answer 15

two

Question 16

statin SEs:

Answer 16

myalgia (w/o CK elevation)
myopathy (w/ CK elevations)
rhabdo

Question 17

what are non-drug causes of muscle symptoms?

Answer 17

low Vit D
high/new exercise
hypothyroidism

Question 18

statin-drug interactions that increase risk of myalgia (ACAMP For Vincent)

Answer 18

Amiodarone
Cyclosporine
Azole antifungals
macrolide antibiotics
Fibrates (gemfibrozil)
Verapamil

Question 19

which statins are 3A4?
drug interactions? (G PACMAN)

Answer 19

atorv
lova
simva

Grapefruit
Protease inhibitors
Azoles
Cyclosporine
Macrolides
Amiodarone
Non-dihydro CCBs

Question 20

which statins are 2C9?

Answer 20

fluvastatin
rosuvastatin

Question 21

UGT interacts w/ all statins and has an interaction with gemfibrozil and cyclosporine.

Question 22

avoid combining gemfibrozil and statin, use fenofibrate if needed

Question 23

we check pts liver function tests w/ statins if?

Answer 23

pt has chronic liver disease or concerns for hepatotoxicity

Question 24

if pt has SEs to statin, consider combo therapy with ezetimibe

Question 25

A.V. is a 48-year-old non-Hispanic man who presents for follow up of elevated LDL-C. He was referred to you for lipid management after a baseline LDL-C of 236 mg/dL and positive family history of premature ASCVD. A.V. is initiated on rosuvastatin 40 mg, but shortly afterward complains of severe and intolerable myalgias. These symptoms resolved once the rosuvastatin dose was reduced to 20 mg daily. After 6 weeks of recommended lifestyle therapies and rosuvastatin 20 mg daily, A.V.’s lipid panel shows TC 204 mg/dL TG 156 mg/dL; HDL-C 43 mg/dL and LDL-C 128 mg/dL. All other labs are within normal limits. which one of the following is best to recommend given A.V.’s most recent lipid results? A. No change necessary. B. Rechallenge with rosuvastatin 40 mg daily. C. Add ezetimibe 10 mg daily. D. Add colesevelam 3.75 g daily

Answer 25

C, we want more LDL lowering

Question 26

if pt is on max statin w/ very high-risk ASCVD with LDL over 70, what is a reasonable course of action?

Answer 26

adding ezetimibe and use ezetimibe before adding PCSK9-I

Question 27

if pt is on max statin under 75 y/o with LDL over 70, what is a reasonable course of action?

Answer 27

adding ezetimibe

Question 28

T.H., a 63-year-old African American man with a medical history of hypertension, dyslipidemia, type 2 diabetes, myocardial infarction, and obesity, presents for dyslipidemia management. His home drugs include metformin ER 500 mg – 2 tablets twice daily, linagliptin 5 mg daily, lisinopril 40 mg daily, chlorthalidone 12.5 mg daily, atorvastatin 80 mg daily, metoprolol succinate 50 mg daily, and aspirin 81 mg daily. T.H.’s most recent lipid panel shows TC 214 mg/dL; TG 186 mg/dL; HDL-C 41 mg/dL; and LDL-C 86 mg/dL; all other lab results are within normal limits. According to the 2018 ACC/AHA cholesterol guidelines, which of the following patient factors, in addition to history of ASCVD, most places T.H. at “very high” risk? A. Type 2 diabetes mellitus B. Age C. Race D. Elevated LDL

Answer 28

A

Question 29

high-risk conditions for clinical ASCVD:

Answer 29

Age over 65 HeFH (familial hypercholesteremia) CABG or PCI diabetes HPT CKD smoker elevated LDL >100 with statin + ezetimibe HF

Question 30

PCSK9-Is can be used for what indications? administration directions?

Answer 30

familial hypercholesterolemia and clinical ASCVD SubQ every 2 weeks

Question 31

when are we concerned with hypertriglyceridemia? what makes TG levels worse?

Answer 31

when it is >500 insulin resistance/hyperglycemia, alcohol intake, high fat diet, obesity, hypothyroidism, and medications: estrogen, prednisone, thiazides, retinoic acid,

Question 32

treatment for hyperTG?

Answer 32

lifestyle modifications, fibrate therapy to prevent acute pancreatitis, and omega-3s

Question 33

fibrates are contraindicated for pts with? fenofibrate should not be used if CrCl is?

Answer 33

severe renal or hepatic disease less than 30

Question 34

Omega-3s: dosing? adverse effect?

Answer 34

2-4g/day Afib risk and prolongation of bleeding time

Question 35

what is icosapent ethyl?

Answer 35

an omega-3 which reduces CV risk in pts with hyperTG that contains EPA and does not contain DHA

Question 36

RF is a 57 y.o. male with a history of HTN, DM, hypertriglyceridemia, peripheral neuropathy, seen in the cardiology clinic for increased dyspnea, chest pressure on exertion, and an abnormal stress test. The patient was diagnosed with angina and started on metoprolol 25 mg BID and nitroglycerin 0.4 mg PRN for chest pain. His chronic medications include gemfibrozil 600 mg BID, aspirin 81 mg, amlodipine 10 mg, metformin 1000 mg BID, basal/bolus insulin. He was on lovastatin and fenofibrate a couple of years ago but didn’t tolerate it so was switched to gemfibrozil. His most recent lipid profile (1 year ago) is: HDL 25 mg/dl, LDL 53 mg/dl, Triglycerides 670 mg/dl. He is following up in the cardiovascular risk reduction clinic with you to see how he is tolerating new medications. *What changes would you recommend in his therapy?

Answer 36

would benefit from icosapent ethyl, or a different omega-3