MCP: Lipid Management and Anticoagulation

Question 1

Pravastatin

Answer 1

Pravachol

Question 2

Lovastatin

Answer 2

Mevacor

Question 3

Simvastatin

Answer 3

Zocor

Question 4

Atorvastatin

Answer 4

Lipitor

Question 5

Rosuvastatin

Answer 5

Crestor

Question 6

Pravachol

Answer 6

Pravastatin

Question 7

Mevacor

Answer 7

Lovastatin

Question 8

Zocor

Answer 8

Simvistatin

Question 9

Lipitor

Answer 9

Atorvastatin

Question 10

Crestor

Answer 10

Rosuvastatin

Question 11

Statin MOA

Answer 11

• Inhibit conversion of HMG-CoA to mevalonate
• Reduces hepatic cholesterol synthesis
• Lowers intracellular cholesterol
  
  • Stimulates the up-regulation of the LDL receptor
  • Increases the uptake of non-HDL particles from systemic circulation

Question 12

Statin Benefits

Answer 12

• Lipid Effects
  
  • Decrease LDL
  • Decrease TG
  • Increase HDLs
• Pleiotropic effects
  
  • Improve endothelial dysfunction
  • Inhibit platelet aggregation
  • Decrease LDL oxidation
  • Reduce vascular inflammatory responses
  • Stabilize atherosclerotic plaques

Question 13

Statin SE

Answer 13

• Common
  
  • GI upset
  • Headache
  • Elevated hepatic transaminases
  • Non-specific muscle and joint pain
• Rare
  
  • Rhabdomylysis (muscle weakness)
  • Cognitive impaiement
  • Hyperglycemia
  • Hyeptatoxicity

Question 14

Statins CI in what populations

Answer 14

• Pregnancy
• Lactation
• Liver disease

Question 15

Statin Interactions

Answer 15

• Cyp 450
  
  • Cyp 3A4
    
    • Lovastatin, Simvistatin, Atorvastatin
      
      • Grapefruit juice, amplodipine, diltiaxem, veramapil, azoles, macrolides
  • Minor CYP 2C9 metabolism
    
    • Rouvastatin
• Antacids
• Increase myopathy with fibrates and niacin

Question 16

Prodrug, Hydophilic and Potency of Statins

Answer 16

• Prodrug
  
  • Lovastatin
  • Simvistatin
• Hydrophilic
  
  • Pravstatin
  • Fluvastatin
  • Rouvastatin
• Potency (high to low)
  
  • Rouvastatin, atorvastatin, simvastatin, pravastatin, lovastatin, fluvastatin

Question 17

Niacin (Vitamin B3) MOA

Answer 17

• Lipid lower efffect is independent as role as vitamin
• Inhibits hepatic synthesis of LDL, VLDL
• Reduces plasma concentration of TG, VLDL
• Change LDL composition from small dense particles to large buoyant particles

Question 18

Niacin Benefits

Answer 18

• Decrease LDL
• Decrease TG
• Increase HDL
• Small dose to change HDL and TG, large doses to lower LDL

Question 19

Niacin SE

Answer 19

• Common
  
  • Flushing
    
    • due to prostaglandin release and vasodialation
    • more common in IR products
  • GI
• Rare
  
  • Hyperglycemia
  • Hyperuricema and gout
  • Hepatotoxiciyt
  • Myopathy

Question 20

Niacin Flushing Management

Answer 20

• Slow titration
• ASA 325mg or Ibuprofen 200mg 30-60 min before niacin
• Avoid spicy food, hot beverage, alcohol
• Do not skip doses

Question 21

Niacin Products (interchangability and SE association)

Answer 21

• Dosing is not interchangable
• Long-acting associated with hepatotoxicity
• Short acting associated with worse flushing

Question 22

Fibrates Benefits

Answer 22

• Primary Indication (TG over 400)
  
  • Decreases TG (Main benefit)
  • Increases HDL (Main benefit)
  • Decreases LDL
    
    • may increase when used in patients with high TG

Question 23

Fibrates MOA

Answer 23

• PPAR-alpha actiation
• Increases synthesis of apolipoproteins and enzymes of lipoprotein metabolism
• Increase expression of several genes involed in fibrinolysis and inflammation

Question 24

Fibrates: CI, Interaction, Precautions

Answer 24

• CI
  
  • Hepatic dysfunction
  • Severe renal dysfunction
  • Preexisiting gallbladder disease
• Statins increase risk of muscle weakness
• Anticoagulants increase risk of bleeding
• Gemfibrozil may interact with diabetes medications like pioglitazon, repglinide, SFU and result in hypoglycemia

Question 25

Fibrates SE

Answer 25

* Common * Well toleerated * GI * Rare * Elevated liver enzymes, creatinine * Myopathy * Gallstones

Question 26

Omega-3 Fatty Acids: MOA, Active Ingredients

Answer 26

* MOA: * Inhibit hepatic secretion TG * Promote TG metabolism * Active Ingredients * EPA * DHA

Question 27

Omega-3 Fatty Acid: Benefits, SE, Interactions

Answer 27

* Benefits * Reduce TG used as alternative to niacin or fibrates * Lower overall mortality * May reduce inflammation, inhibit atherosclerosis * SE * Fishy burn * Methylmercury toxicity * LDL can increase by 40% in patient with TG \>500 * Interaction * Anticoagulation (when \>3g)

Question 28

Which Statins have long half life? (can take them at anytime)

Answer 28

* Atorvastatin * Rouvastatin * All others are PM because cholesterol made at night

Question 29

Warfarin Indication

Answer 29

* Afib * Pulmonary embolism * Venous thromboembolism * Post MI * Prophylaxis in knee and hip replacement surgeries

Question 30

Warfarin MOA

Answer 30

* Inhibits synthesis of vitamin K dependent clotting factors II, VII, IX, X * Inhibits anticoagulatnt proteins C and S * Hlaf life 36-72 hours * Cyp2C9, 1A2, 3A4 * Highly protein bound

Question 31

Warfarin Monitoring

Answer 31

* Measure INR weekly to monthly * Target is 2-3 (normal=1) * Higher #= longer clotting time * INR=Pt PT/control PT

Question 32

Warfarin Education

Answer 32

* Tablets color coded * Daily dose may vary * Frequent changes by anticoag clinic * NEVER double up

Question 33

Signs of clotting and bleeding

Answer 33

* Bleeding * Significant bruising * Nosebleed * Coughing up blood * Blood in stool/urine * Clotting * Sever pain in calf * Cheft pain * One sided weakness * Severe HA * Sudden change in speech and vision

Question 34

Drugs that increase INR

Answer 34

* Fluroquinolones * Macrolides * TMP/Sulfa * Metornidazole * Azole * Amiodarone

Question 35

Drugs that decrease INR

Answer 35

* Diclozacillin * Nafcillin * Rifampin * Cabamazepine

Question 36

Effect of Warfarin Interaction

Answer 36

Effect seen in 3-14 days; need to adjust warfarin dose by 30-50%