Therapeutics - Dyslipidemia Part 2 Flashcards
patient on a statin is not reaching LDL goal
what do we do next
1st - assess adherence!
if they are adherent, add ezetimibe. could add bile acid sequesterant, but prolly not
if patient is still not at LDL goal with statin + zetia (or bile acid resin)
what do we do next? what if this doesnt work?
could add PCSK9 inhibitor, bempedoic acid (nexletol), or inclisiran (leqvio)
if this doesnt work – refer to lipid specialist – may need MAB (Evkeeza/evinacumab) - HOWEVER, this is very expensive and very last line
true or false
zetia cannot be combined with bempedoic acid
FALSE - it can
true or false
ezetimibe is not recommended to be used alone
TRUE
it’s well tolerated, but not very effective by itself
typically added to statin therapy
true or false
ezetimibe must be taken with food
false - doesnt matter
counseling point if patient is on ezetimibe and a bile acid sequesterant
take the zetia either 2 hours before or 4 hours after
3 available bile acid sequestrants
which comes as a tab in which the patient has to take 3 tabs BID (VERY INCONVENIENT)
colesevelam (lot of tabs)
cholestyramine
colestipol
should cholestyramine be taken with food
yes
true or false
bile acid sequestrants are not recommended to be used alone
TRUE - dont do too much alone
can bile acid sequestrants be combined with statins
yes - just cant take at same time
why are bile acid sequestrants not really used
no CV outcome trials, and there’s a lot of AE
if patient can’t take zetia for some reason, would a PCKS9 inhibitor or a bile acid sequestrant make more sense
typically PCKS9 inhibitor, unless cost is an issue
name some AE of bile acid sequestrants in general
constipation, nausea, dyspepsia
increased triglycerides!
true or false
bile acid sequestrants increase triglycerides
true
name 3 DDI of colesevelam with other drugs
-decreased phenytoin levels (increased seizures)
-decreased INR for warfarin (bleed)
-increased TSH in patients getting thyroid HRT
name 2 PCSK9 inhibitors
both can be given Q2 weeks
which can be given only Q month?
alirocumab ( praluent)
evolocumab (repatha)
repatha
name some AE of the PCSK9 inhibitors
not many - just miled injection site reactions, myalgia
however, no long term safety data - potential cognitive effects
repatha + efgartigimod interaction
decreased repatha levels
MOA bempedoic acid (nexletol)
how is the MOA an advantage?
ATP citrate lyase inhibitor
may be used in patients who get myalgia from statins
true or false
nexletol does not have significant LDL reduction on its own
TRUE
like ezetimibe, really only useful with statin, or all 3 can even be used together
true or false
nexletol is not as good as statins and PCSK9 inhibitors at reducing CV outcomes
TRUE
PCKS9 inhibitors are definitely a better option if the patient is statin intolerant
name some AE of bempedoic acid (nexletol) and who we definitely do not wawnt to give this drug to
increases uric acid - (by inhib OAT 2) so definitely dont give to gout patients!!!!
also risk of gallstones
increased SCr and LFT
tendon rupture
lot of SE
true or false
bempedoic acid should not be considered 1st line, but is a possible option in shared decision making
true
molecular wise, what is Inclisiran (Leqvio)
a siRNA (small interfering ribonucleic agent)
how is inclisiran adminsitered
subQ injection given by HC provider
true or false
there is no long term safety data available yet for inclisiran (leqvio)
true
only indication for evinacumab (Evkeeza)
familial hypercholesteremia (decreases LDL by 47%)
why is Evkeeza (evinacumab) considered very last line
its very expensive, and is an IV hour long infusion every 4 weeks
general MOA of evkeeza
angiopoietin-like 3 inhibitor
2 potential natural alternative therapies for LDL lowering
red yeast rice
garlic
counseling points if a patient wants to use red yeast rice to lower their cholesterol
no known effects on CV outcomes
also, if not fermented right, can cause kidney failure by containing citrinin
(also - would need so much of it. structurally similar to lovastatin, but need 1800mg of rice to equal effect of 5mg lovastatin)
counseling points if a patient wants to use garlic to lower LDL
conflicting data
can potentiall decrease LDL and increase HDL, but no effect on TG
also, formulation may be important to potentially see outcomes
bad breath and might smell bad
hypertriglyceridemia is most common in which gender and ethnicity
mexican male americans
what kind of diet/lifestyle can cause hypertriglyceridemia
lot of alcogol, high saturated fats, sugars, sedentary lifestyle
true or false
TPN with lipid emulsions can lead to high triglycerides
true
concerns with high triglycerides ALONE
alone, really no CV effect
biggest concern is pancreatitis
patient has TG over 500
what to do?
need both lifestyle modification AND statin
a low ___ and high ___ diet is best for lowering triglycerides
low carbs and high protein
if TG is between 150 and 500, what to do?
change diet, increase activity, stop smoking
give fish oil! (omega 3)
what 2 PARTICULAR foods are good to eat to lower TG
salmon, tuna
if patients TG is over 1000, what meds to give?
either fibrate therapy or omega 3
patient’s TG is 544. already on atorvastatin
what to do?
emphasize lifestyle modification and give fibrate therapy or omega-3
true or false
weight loss cannot reduce TG significantly
FALSE - it can (up to 70% reduction!)
foods that have omega-3 fatty acids
who should they be recommended to?
fish (salmon, tuna, herring, sardines, mackerel, anchovies)
seeds, cod liver oil, avacado, walnuts, soybeans
recommend to patients with high TG
is OTC omega-3 supplementation recommended?
not really
efficacy isnt verifies, may have inconsistent contents.
also AE of burping, fishy taste, dyspepsia
what is the prescription fish oil?
can it be combined with a statin
vascepa/icosapent ethyl
yes - better effects when combined with statin
vascepa has shown a reduction in CV events and death when added to a statin
however, what is a big concern with vascepa
can cause afib
true or false
gemfibrozil should be taken with a meal
true - 30 mins before meal
which fibrate is preferred and why - fenofibrate or gemfibrozil
fenofibrate bc it’s shown to have somehwat better outcomes, better tolerated, and has less DDI
gemfibrozil has a higher risk of myopathy with statins
also, fenofibrate is QD and gemfibrozil is BID
ADR of gemfibrozil
dyspepsia
abdominal pain
gallstones
true or false
fenofibrate must be taken with food
false - doesnt matter
if a statin is needed with fenofibrate, what statin dose should be used?
low-moderate intensity
(bc myopathy risk)
true or false
both fibrates need dose adjustment in renal insufficiency
true
true or false
fenofibrate can be dicontinued after 2-3 months of therapy if the pt isnt responding
true
3 CI to fenofibrate
pregnant/breastfeeding
gallbladder disease
active liver disease
name some ADR of fenofibrate
increased LFT (with statin)
myopathy (with statin)
gallstones
pancreatitis (only if TG continues to be high)
increased BUN/SCr
true or false
niacin is highly recommended to be given with a statin to decrease TG
FALSE - no benefit, and actually potential increase in ischemic stroke
Which form of niacin is really only used for supplementation in cases of deficiency, and which formulation is used to lower cholesterol/TG (BUT NOT RECOMMENDED)
supplementation - IR
ER - for cholesterol/TG but not rec
SR is not used
AE of niacin
flushing, hives, hyperglycemia, hyperuricemia (gout)
NOT RECOMMENDED
in terms of pregnancy, at what time point should lipid lowering agents be discontinued?
1-3 months before attempting conception
which class of lipid lowering agents is pregnancy category C, meaning that there are no studies in pregnant women, but may be safe
bile acid sequestrants
may potentially be safe bc not systemically absorbed - but still not really recommended
if a patient has been on a statin and stops bc they want to get pregnant, when can they restart the statin again?
only after they’re done breastfeeding