Hyperlipidemia Therapeutics Flashcards
what are the friedewald equations for cholesterol?
LDL=total ch -(HDL+TG/5)
VLDL=TG/5
Non-HDL=total ch - HDL
what are the ASCVD risk categories?
low <5%
borderline 5-7.5%
intermediate 7.5-19.9%
high >20%
ASCVD risk is calculated for what criteria of pts?
adults 40-75
non-diabetic
LDL 70-189
AHA/ACC LDL guidelines?
LDL <100 in primary prevention
LDL <70 with ASCVD
ESC/EAS LDL guidelines?
<100 in moderate risk
<70 in high risk
<55 w/ ASCVD or very high risk
<40 w/ recurrent events
what lvl of LDL do we consider adding on to statin therapy?
> 70
List the four ASCVD statin benefit groups (criteria of who would benefit from a statin)
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
steps to treating pts 40-75 LDL between 70-190?
calculate ASCVD risk
<5%: lifestyle factors
5-7.5%: risk discussion
7.5-20%= may benefit from statin
20 or more: start statin
statin initiation recommendation according tp USPSTF?
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
high-intensity statin treatment (lower LDL by 50%):
atorvastatin 40-80mg
rosuvastatin 20-40mg
moderate intensity statin treatment (lower LDL by 30-49%):
atorv 10-20mg
rosuv 5-10mg
fluva 40mg bid
low intensity statin treatment (lower LDL by 30%):
simvastatin 10mg
pravastatin 10-20mg
what did the IDEAL trial tell us?
determining benefit of high intensity statin use vs moderate intensity. showed moderate intensity is fairly similar in outcome to high intensity
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
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
to classify a pt w/ statin intolerance, a minimum of ____ statins should’ve been attempted
two
statin SEs:
myalgia (w/o CK elevation)
myopathy (w/ CK elevations)
rhabdo
what are non-drug causes of muscle symptoms?
low Vit D
high/new exercise
hypothyroidism
statin-drug interactions that increase risk of myalgia (ACAMP For Vincent)
Amiodarone
Cyclosporine
Azole antifungals
macrolide antibiotics
Fibrates (gemfibrozil)
Verapamil
which statins are 3A4?
drug interactions? (G PACMAN)
atorv
lova
simva
Grapefruit
Protease inhibitors
Azoles
Cyclosporine
Macrolides
Amiodarone
Non-dihydro CCBs
which statins are 2C9?
fluvastatin
rosuvastatin
UGT interacts w/ all statins and has an interaction with gemfibrozil and cyclosporine.
avoid combining gemfibrozil and statin, use fenofibrate if needed
we check pts liver function tests w/ statins if?
pt has chronic liver disease or concerns for hepatotoxicity
if pt has SEs to statin, consider combo therapy with ezetimibe
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
C, we want more LDL lowering
if pt is on max statin w/ very high-risk ASCVD with LDL over 70, what is a reasonable course of action?
adding ezetimibe and use ezetimibe before adding PCSK9-I
if pt is on max statin under 75 y/o with LDL over 70, what is a reasonable course of action?
adding ezetimibe
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
A
high-risk conditions for clinical ASCVD:
Age over 65
HeFH (familial hypercholesteremia)
CABG or PCI
diabetes
HPT
CKD
smoker
elevated LDL >100 with statin + ezetimibe
HF
PCSK9-Is can be used for what indications?
administration directions?
familial hypercholesterolemia and clinical ASCVD
SubQ every 2 weeks
when are we concerned with hypertriglyceridemia?
what makes TG levels worse?
when it is >500
insulin resistance/hyperglycemia, alcohol intake, high fat diet, obesity, hypothyroidism, and medications: estrogen, prednisone, thiazides, retinoic acid,
treatment for hyperTG?
lifestyle modifications, fibrate therapy to prevent acute pancreatitis, and omega-3s
fibrates are contraindicated for pts with?
fenofibrate should not be used if CrCl is?
severe renal or hepatic disease
less than 30
Omega-3s: dosing?
adverse effect?
2-4g/day
Afib risk and prolongation of bleeding time
what is icosapent ethyl?
an omega-3 which reduces CV risk in pts with hyperTG that contains EPA and does not contain DHA
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?
would benefit from icosapent ethyl, or a different omega-3
