Module 7: (c) Special Population Considerations; Lipids Flashcards
Resistant HTN
-Considerations
- Sequentially combine agents w/ different MOA
- Meds are dosed at maximally tolerated doses
- Effective diuretic use almost always necessary
Resistant HTN
-Triple Combo option?
- ACEi or ARB PLUS long-acting Di-hydropyridine CCB (Amlodipine) PLUS long-acting thiazide diuretic (Consider Chlorthalidone)
Resistant HTN
-Adding a 4th medication?
- If HTN is still resistant to triple combo
- Add MRA such as Spironolactone - WATCH POTASSIUM**
Resistant HTN
-When a loop diuretic is better?
- Add a loop to a thiazide-diuretic for patient with PERSISTENT EDEMA
- Add Loop to thiazide or switch to loop for patients with eGFR < 30 (Watch potassium)
HTN in Older Adults
-
- Individualize goals and shared decision making***
HTN in Older Adults
-Orthostatic Hypotension consideration?
- Consider Orthostatic hypotension
- Potential limiting factor to the use of antihypertensive drugs in older adults
- Hip fracture is a risk
HTN in Older Adults
-Potential A/E’s
- Potential of impairment of mental function, such as confusion or sleepiness
- Think about cardiovascular risk in older adults prior to lowering diastolic pressures too low.
HTN in Older Adults
-Meds to consider?
- Consider starting with a low dose of:
- Thiazide-type diuretic
- Long-acting dihydropyridine CCB - In combo therapy, start with LOW DOSES
Non-Emergent Pediatric HTN
-Meds to consider?
- ACEi or ARB (AVOID in pregnancy risk)
- Long acting CCB (Amlodipine)
- Thiazide diuretics are not first choice with peds
Non-Emergent Pediatric HTN
-Drugs NOT to use in Peds
- Beta Blockers are NOT RECOMMENDED as initial therapy in children
- Impaired glucose tolerance
- interference in lipid metabolism
HTN in Pregnancy
-Severe Level of BP?
- SBP >/= 160 mmHg and/or diastolic BP >/= 110 mmHg
- PROMPT treatment is recommended to reduce risk of maternal stroke
- SEND TO ER for IV meds
HTN in Pregnancy
-Meds to Consider?
- Labetalol (alpha/beta blocker)
- Nifedipine, extended-release (Dihydropyridine CCB)
- Methyldopa (alpha agonist; milder agent; sedation)
- ALL HTN meds cross the placenta
- NO large scale study data is available
HTN in Pregnancy
-Meds to AVOID?
- ACEi, ARB’s
- Direct Renin inhibitors
- Mineralocorticoid receptor antagonists (MRA’s)
- Spironolactone
- Eplerenone
Conditions that Increase Total Cholesterol and LDL-C?
- Progestin
2. Protease inhibitors for treatment of HIV infection
Conditions that Increase Triglycerides and VLDL-C?
- Protease inhibitors for treatment of HIV infection
- Anti-hypertensive meds (Thiazide diuretics and beta blockers)
- Corticosteroid therapy
- Oral estrogen; oral contraceptives
- Hypothyroidism and Diabetes
HMG CoA Reductase Inhibitors “statins”
-Info
- Primarily used to LOWER LDL
2. AVOID in pregnancy or breastfeeding; Avoid in liver disease
HMG CoA Reductase Inhibitors “statins”
-High Intensity Statin Meds? Don’t Memorize
Lowers LDL by >/= 50%
- Atorvastatin 40-80 mg
- Rosuvastatin 20-40 mg
HMG CoA Reductase Inhibitors “statins”
-Moderate-Intensity Statins? Don’t memorize
Lowers LDL by 30-50%
- Atorvastatin 10-20 mg
- Rosuvastatin 5-10 mg
- Simvastatin 20-40 mg
- Pravastatin 40-80 mg
- Lovastatin 40 mg
MOST BENEFIT is in moderate-dose therapy
HMG CoA Reductase Inhibitors “statins”
-A/E’s
- Elevated LFT’s, myalgias, and glucose increase
- Rhabdomyolysis rare but possible
- Check baseline CK prior to starting medication
HMG CoA Reductase Inhibitors “statins”
-Monitoring?
- Monitor Baseline LFT’s then periodic monitoring
2. Monitor LDL and check 6-8 wks after starting for adherence
HMG CoA Reductase Inhibitors “statins”
-Common Drug interactions?
- Warfarin
- Non-dihydropyridine CCB’s
- Antibiotics, antifungals
Etc..
HMG CoA Reductase Inhibitors “statins”
-And Diabetes?
- First-line for individuals w/ DM and Dyslipidemia or high CV risk
- Can increase BG levels but benefit outweighs the risk
PCSK9 Inhibitors
-Info?
- Most POWERFUL LDL lowering meds
- Expensive and require subq injections
- Caution in pregnancy
Ezetimibe (Zetia)
- Alternative to Statin if a patient has statin intolerance
- Can also be added to a statin
- Monitor LFT’s
- Caution in pregnancy
Bile Acid Sequestrants
-Exemplars
Not used a lot:
- Colesevelam
- Colestipol
- Cholestyramine
Commonly associated w/ GI effects
Niacin
-Info?
- High rates of side effects and limited evidence of benefit
- Commonly causes FLUSHING
- ASPIRIN given 30 minutes prior to niacin dose can prevent or reduce flushing - Adverse events
- Impaired glucose control
- Increase uric acid concentrations
- hepatotoxicity
- Doesn’t mix well with other lipid therapies
Hypertriglyceridemia
-Reason to treat?
- Can lead to pancreatitis.
2. Controlling high blood sugar can also reduce triglyceride levels
Hypertriglyceridemia
-Statins that lower triglycerides
- Atorvastatin and rosuvastatin can lower triglycerides
Hypertriglyceridemia
-FIBRATES
- Fenofibrate (MOST USED)
2. Can reduce TG by as much as 50-70%
Hypertriglyceridemia
-Omega 3 fatty acids
- Idosapent ethyl (Vascepa)
- Reduces TG by approx 20-50% - Can cause GI symptoms
Hypertriglyceridemia
-Measuring and classifying?
- Moderate TG
- 150 to 499 mg/dL - Moderate to severe
- 500-999 mg/dL - Severe
>1000 mg/dL
Dyslipidemia in children and adolescents
-Info?
- Consider lifestyle + Pharm for those >10 years of age w/
- LDL >/= 130 and high-risk w/out response to lifestyle changes
- LDL >/= 160 and moderate or high risk
- LDL >/= 190 w/ no CV risk
Refer to lipid specialist
