Therapeutics - Dyslipidemia Part 1 Flashcards
true or false
white women are at the highest risk for hyperlipidemia
FALSE
rates are similar among race and gender
true or false
hypertension is classified as ASCVD (atherosclerotic cardiovascular disease)
FALSE - it’s not
name some examples of ASCVD
ACS
MI
stable or unstable angina
CVA (stroke)
TIA (transient ischemic attack)
PAD (peripheral artery disease)
revascularization
differentiate between primary and secondary prevention in terms of LDL lowering
primary prevention - patient is at risk of ASCVD (doesnt have yet but is at risk – ie - a patient with HTN)
secondary - patient already has ASCVD (heart disease)
true or false
the higher the LDL cholesterol, the higher the risk of ASCVD
true
true or false
nonpharmacologic management is not important to lower LDL. medication is really the only solution
FALSE - nonpharm management like diet and exercise is very important
are there symptoms that a patient can watch out for to see if they have high cholesterol?
NO - not generally
if the pt has familial hypercholesteromemia – may get xanthomas – like bumps on the skin that contain lipids
also, may get pancreatitis, but only if TG levels are over 500mg/dL
true or false
familial hypercholesterolemia is a very high risk factor for getting heart disease (ASCVD)
true
true or false
acute pancreatitis does not present with symptoms
FALSE - it does
pt will get abdominal pain – have to go to ER
according to the older guidelines, how often should adults be screened for high cholesterol?
are there any exceptions?
generally - every 4-6 years
but if the patient has a history of heart disease or diabetes, or if family history – want to check more frequently – starting at 20 years old
how often should children/teens be screened for high cholesterol?
once
then again at age 17-21
but again - if diabetic or obese - may need more frequent screening
true or false
LDL automatically shows up in the lipid panel
FALSE - needs to be calculated
as mentioned, LDL is actually a calculated value using a formula
when would this formula not work?
it wouldnt work if triglycerides are over 400mg/dL
in this case, a direct LDL would have to be ordered (expensive!)
total cholesterol, in general, should be less than….
200mg/dL
HDL, in general, should be over….
40mg/dL
triglycerides should be less than….
150mg/dL
but high triglycerides really arent high risk for ASCVD unless also paired with high LDL/low HDL
also, over 500 is pancreatitis concern
a patient’s triglyceride levels come back as 168.
is this a concern? would we ask any follow up questions?
really not a concern. normal is less than 150. generally only a concern if very high
also, ask if the patient had a fatty meal before bloodwork, bc this can cause the TG to spike – ask to follow up in a couple days if she did have fatty meal
if a patient’s lipid panel comes back with hyperlipidemia, what is VERY IMPORTANT TO ASSESS?
if there are any secondary (underlying) causes of the high cholesterol
ie - diabetes, diet, metabolic issues (hypothyroidism, obese, pregannt), or even drugs can cause
name 3 altered states of metabolism that can be a secondary cause of hyperlipidemia
hypothyroidism
obesity
diabetes
___ or ___ fat consumption can be a cause of elevated LDL
high intake of ___ can be a cause of high TG
trans or saturated fat - increased LDL
eating lot of refined carbs - increased TG
true or false
if a patient has hypothyroidism and we treat it, their LDL should go down in turn
true
dont treat LDL as a second issue if it is due to a cause that can be treated
3 diet factors that can cause high LDL
3 diet factors that can cause high TG
high LDL - anorexia, weight gain, saturated oor trans fat
high TG - alcohol, weight gain, lot of refined carbs
true or false
medications cannot be an underlying cause of high cholesterol
FALSE - they can!
there’s a lot
however, most meds increase triglycerides more than they do cholesterol
explain thiazide diuretics and their increase on cholesterol and triglycerides
they really only increase them at doses of 50mg and over a day – not at normal doses
true or false
atypical antipsychotics can increase cholesterol and TG
true
if pharmacotherapy is needed to lower LDL (lifestyle modifications alone is not enough), which drugs are 1st line and why?
statins
bc they are proven to significantly reduce morbidity and mortality in both primary (no ASCVD yet) and secondary (have ASCVD)prevention
as mentioned, eating healthy can help to decrease cholesterol
name some foods to recommend to a patient to do this
fruits, vegetables, whole grains
fish, poultry (no skin), low-fat dairy
legumes, non-tropical oils, nuts
name some foods to LIMIT if a patient has high cholesterol
saturated and trans fat
sweets and sugar-sweetened drinks
red meats
true or false
if a patient is trying to lower their LDL, they should try to eat a lot of red meat
FALSE - they should limit it
have poultry without the skin instead
name 2 foods to consider recommending to a patient to lower LDL
plant sterols/stanols (yogurt, protein bars)
viscous fibers (fruit, vegetables, supplements)
3 classes of lifestyle modifications to recommend to a patient to lower LDL cholesterol
physical activity
weight loss
stop smoking
true or false
quitting smoking cannot help to decrease LDL cholesterol
FALSE - it can – also significantly lowers risk of ASCVD
weight control can be recommended to a patient who has high cholesterol
how much should they lose?
for overweight and obese patients - even a 5% weight loss can really lower risk of ASCVD, even if they are still overweight after losing this amount
explain the exercise that should be recommended to a patient who has high LDL
aerobic activity 3-4x a week
40 mins at least of moderate-vigorous exercise – just walking isn’t enough
what BMI is a patient considered overweight/obese
overweight - over 25
obese - over 30
name 5 scenarios in which a statin is basically immediately initiated (as long as no contraindications)
-if 0-19 and has familial hypercholesterolemia
-if 40-75 with diabetes (even is LDL is good!) moderate intensity usually - but consider high intensity if risk factors
-if LDL 190 or more - automatic high intensity
-if ASCVD is 20% or more - auto statin (high intensity)
-if ASCVD is 7.5-19% (intermediate risk) - initiate mod intensity
name the 4 “risk” categories for the ASCVD score that are used to determine if statins should be started
less than 5% is low risk
5%-less than 7.5 is borderline risk
7.5%-19% is intermediate risk
20% or more is high risk
2 conditions SPECIFIC TO WOMEN that are an example of a risk enhancer when determining if a patient should be given a statin
preeclampsia or premature menopause
true or false
persistently high triglycerides over 175 is considered a risk enhancer for being on a statin
true – combo of high TG and high LDL is bad
patient’s ASCVD score is 3%
has a family history of early MI
LDL is 133
should a statin be started?
NO
LDL is not 190 or more
ASCVD is low risk
just emphasize lifestyle modifications
if she was in the borderline risk category, could potentially consider starting - but still not automatic
patient has diabetes and is 62 years old
LDL is 152
ASCVD is 31.9%
should he be started on a statin?
YES - just 40-74 and having diabetes is enough to be on a statin, not to mention that LDL is already high
high intensity statin should be given due to ASCVD score and other conditions
name the only 2 high intensity statins
atorvastatin 40-80mg
rosuvastatin 20-40mg
name the 4 low intensity statins (and their doses)
what is important to note about them?
simvastatin 10mg
pravastatin 10-20mg
lovastatin 20mg
fluvastatin 20-40mg
they really aren’t used anymore. dont lower LDL much and also not shown to affect morbidity and mortality outcomes
which statin is considered the “gentler statin” and why
pravastatin
bc it’s not metabolized by 3A4, and has less potential for adverse effects of myopathy
HIV regimen is important to consider when giving statins, because there are many drug-drug interactions
why else are HIV regimens a consideration?
because HIV drugs increase cholesterol
however, there’s really nothing we can do about the regimen bc patients need to be on it for life
_______ is the HIV drug that should be avoided with atorvastatin
atazanavir
What are the 3 statins that are RECOMMENDED with cobicistat or ritonavir boosted HIV therapy?
what doses and why?
pitavastatin 4mg
atorvastatin 20mg
rosuvastatin 10mg
“PAR”
even if the HIV patient, in theory, needs a high intensity statin, these moderate doses are still used because they will be “boosted” and act as high intensity
which 2 statins should definitely be AVOIDED in HIV boosted regiments (cobicistat or ritonavir)
simvastatin and lovastatin
true or false
rosuvastatin is less likely to have drug-drug interactions than atorvastatin
TRUE - not metabolized by CYP3A4
name 5 contraindications to statins
-pregnant or breastfeeding
-active liver disease
-excessive alc
-unexplained and persistent LFT 3x over ULN (upper normal limit)
-CPK over 3x ULN
how often do we check LFT (liver function tests) in a statin patient?
only get the baseline level, and only check again if the patient has symptoms
why is CPK over 3x the ULN a contraindication for statins?
because this is a clear sign of myopathy, and can progress to life threatening rhabdomyolysis
true or false
statins do not affect the liver
FALSE - they can cause hepatotoxicity
active liver disease is thus a contraindication! and LFT 3x over the ULN is also a CI
name 3 AE in statins
headache (only when 1st start - goes away)
increased LFT (rare)
myalgia (can progress to rhabdo)
true or false
when a patient is on a statin, routine checking for increased LFT is recommended
FALSE - baseline is gotten, and then only checked again if the patient is symptomatic
if LFT is over 3x ULN at this point, it is a contraindication and the statin needs to be discontinued
“SAMS”
who is most at risk?
statin-associated muscle symptoms
women, asians, and elderly are at increased risk
explain the outline of what to do if a patient experiences new or worsening muscle pain on a statin
-give the questionnaire, get CK level
-if the patient’s symptoms are intolerable, OR if CK level is over 3x over baseline, stop stain for 2-4 weeks/2 months
if their symptoms IMPROVE - review the meds and d/c any statin interactions. start a different statin at LOWEST RECOMMENDED DOSE. give same statin that is tolerated by other fam members if possible.
if the patient’s symptoms come back even on this new statin - try non daily dosing with ros. or atorv 1-2 times a week (after 2-4 weeks of witholding). if their symptoms STILL COME BACK - they can’t tolerate statin. give zetia or bile acid agent or both (after 2-4 week washout)
if their symptoms DO NOT IMPROVE when initial statin removed- see if other cause
do statins cause diabetes?
short answer - no
shown to increase the risk by around 9%, but these trialed patients were already on the brink of diabetes.
mechanism - statins increase insulin resistance
are statins used in patients over 75?
yes - benefits have been shown in both primary and secondary prevention
if the benefits outweigh risks, we can start moderate-high intensity statin.
important to note that statins really only start to show benefit after taking for 5 years – do we think the patient will even live that long?
2 safety concerns of giving statins to older patients over 75
more likely to get myopathies and rhabdo
some case reports show a concern of cognitive or dementia risk
true or false
it is not important to take statins every day
FALSE - it is
true or false
all statins must be taken at bedtime
false - all except atorvastatin and rosuvastatin (have long half life)
counseling about grapefruit/grapefruit juice with statins
patients can have 1-2 cups of juice per week on atorvastatin if they really want to
grapefruit itself is probably okay
explain how often to monitor LDL for a statin patient
baseline (obviously)
then 4-12 weeks after initiating the drug or increasing the dose
if the goal is achieved, only monitor every 3-12 months.
if not achieved after 4-12 weeks, consider increasing dose or adding on
true or false
the efficacy of statins is based on the LDL
true
name the LDL goal for:
-non-ASCVD patients
-ASCVD patients or VERY HIGH RISK
-ASCVD patients with diabetes
non-ASCVD - LDL less than 100
ASCVD or high risk - LDL less than 70
ASCVD + diabetes - LDL less than 55
true or false
diabetes is considered a “very high risk” for ASCVD and automatically puts a patient into the less than 70 LDL goal
true
if they have ASCVD on top of it, then goal is less than 55
true or false
we do not want LDL to go too low
FALSE – recent data shows there is no concern with hemorrhage, cancer risk, depression, diabetes, etc
