Therapeutics - Dyslipidemia Part 2 Flashcards

1
Q

patient on a statin is not reaching LDL goal

what do we do next

A

1st - assess adherence!

if they are adherent, add ezetimibe. could add bile acid sequesterant, but prolly not

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2
Q

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?

A

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

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3
Q

true or false

zetia cannot be combined with bempedoic acid

A

FALSE - it can

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4
Q

true or false

ezetimibe is not recommended to be used alone

A

TRUE

it’s well tolerated, but not very effective by itself

typically added to statin therapy

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5
Q

true or false

ezetimibe must be taken with food

A

false - doesnt matter

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6
Q

counseling point if patient is on ezetimibe and a bile acid sequesterant

A

take the zetia either 2 hours before or 4 hours after

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7
Q

3 available bile acid sequestrants

which comes as a tab in which the patient has to take 3 tabs BID (VERY INCONVENIENT)

A

colesevelam (lot of tabs)
cholestyramine
colestipol

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8
Q

should cholestyramine be taken with food

A

yes

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9
Q

true or false

bile acid sequestrants are not recommended to be used alone

A

TRUE - dont do too much alone

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10
Q

can bile acid sequestrants be combined with statins

A

yes - just cant take at same time

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11
Q

why are bile acid sequestrants not really used

A

no CV outcome trials, and there’s a lot of AE

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12
Q

if patient can’t take zetia for some reason, would a PCKS9 inhibitor or a bile acid sequestrant make more sense

A

typically PCKS9 inhibitor, unless cost is an issue

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13
Q

name some AE of bile acid sequestrants in general

A

constipation, nausea, dyspepsia

increased triglycerides!

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14
Q

true or false

bile acid sequestrants increase triglycerides

A

true

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15
Q

name 3 DDI of colesevelam with other drugs

A

-decreased phenytoin levels (increased seizures)

-decreased INR for warfarin (bleed)

-increased TSH in patients getting thyroid HRT

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16
Q

name 2 PCSK9 inhibitors

both can be given Q2 weeks

which can be given only Q month?

A

alirocumab ( praluent)
evolocumab (repatha)

repatha

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17
Q

name some AE of the PCSK9 inhibitors

A

not many - just miled injection site reactions, myalgia

however, no long term safety data - potential cognitive effects

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18
Q

repatha + efgartigimod interaction

A

decreased repatha levels

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19
Q

MOA bempedoic acid (nexletol)

how is the MOA an advantage?

A

ATP citrate lyase inhibitor

may be used in patients who get myalgia from statins

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20
Q

true or false

nexletol does not have significant LDL reduction on its own

A

TRUE

like ezetimibe, really only useful with statin, or all 3 can even be used together

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21
Q

true or false

nexletol is not as good as statins and PCSK9 inhibitors at reducing CV outcomes

A

TRUE

PCKS9 inhibitors are definitely a better option if the patient is statin intolerant

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22
Q

name some AE of bempedoic acid (nexletol) and who we definitely do not wawnt to give this drug to

A

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

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23
Q

true or false

bempedoic acid should not be considered 1st line, but is a possible option in shared decision making

A

true

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24
Q

molecular wise, what is Inclisiran (Leqvio)

A

a siRNA (small interfering ribonucleic agent)

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25
Q

how is inclisiran adminsitered

A

subQ injection given by HC provider

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26
Q

true or false

there is no long term safety data available yet for inclisiran (leqvio)

27
Q

only indication for evinacumab (Evkeeza)

A

familial hypercholesteremia (decreases LDL by 47%)

28
Q

why is Evkeeza (evinacumab) considered very last line

A

its very expensive, and is an IV hour long infusion every 4 weeks

29
Q

general MOA of evkeeza

A

angiopoietin-like 3 inhibitor

30
Q

2 potential natural alternative therapies for LDL lowering

A

red yeast rice
garlic

31
Q

counseling points if a patient wants to use red yeast rice to lower their cholesterol

A

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)

32
Q

counseling points if a patient wants to use garlic to lower LDL

A

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

33
Q

hypertriglyceridemia is most common in which gender and ethnicity

A

mexican male americans

34
Q

what kind of diet/lifestyle can cause hypertriglyceridemia

A

lot of alcogol, high saturated fats, sugars, sedentary lifestyle

35
Q

true or false

TPN with lipid emulsions can lead to high triglycerides

36
Q

concerns with high triglycerides ALONE

A

alone, really no CV effect

biggest concern is pancreatitis

37
Q

patient has TG over 500

what to do?

A

need both lifestyle modification AND statin

38
Q

a low ___ and high ___ diet is best for lowering triglycerides

A

low carbs and high protein

39
Q

if TG is between 150 and 500, what to do?

A

change diet, increase activity, stop smoking

give fish oil! (omega 3)

40
Q

what 2 PARTICULAR foods are good to eat to lower TG

A

salmon, tuna

41
Q

if patients TG is over 1000, what meds to give?

A

either fibrate therapy or omega 3

42
Q

patient’s TG is 544. already on atorvastatin

what to do?

A

emphasize lifestyle modification and give fibrate therapy or omega-3

43
Q

true or false

weight loss cannot reduce TG significantly

A

FALSE - it can (up to 70% reduction!)

44
Q

foods that have omega-3 fatty acids

who should they be recommended to?

A

fish (salmon, tuna, herring, sardines, mackerel, anchovies)

seeds, cod liver oil, avacado, walnuts, soybeans
recommend to patients with high TG

45
Q

is OTC omega-3 supplementation recommended?

A

not really

efficacy isnt verifies, may have inconsistent contents.

also AE of burping, fishy taste, dyspepsia

46
Q

what is the prescription fish oil?

can it be combined with a statin

A

vascepa/icosapent ethyl

yes - better effects when combined with statin

47
Q

vascepa has shown a reduction in CV events and death when added to a statin

however, what is a big concern with vascepa

A

can cause afib

48
Q

true or false

gemfibrozil should be taken with a meal

A

true - 30 mins before meal

49
Q

which fibrate is preferred and why - fenofibrate or gemfibrozil

A

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

50
Q

ADR of gemfibrozil

A

dyspepsia
abdominal pain
gallstones

51
Q

true or false

fenofibrate must be taken with food

A

false - doesnt matter

52
Q

if a statin is needed with fenofibrate, what statin dose should be used?

A

low-moderate intensity

(bc myopathy risk)

53
Q

true or false

both fibrates need dose adjustment in renal insufficiency

54
Q

true or false

fenofibrate can be dicontinued after 2-3 months of therapy if the pt isnt responding

55
Q

3 CI to fenofibrate

A

pregnant/breastfeeding
gallbladder disease
active liver disease

56
Q

name some ADR of fenofibrate

A

increased LFT (with statin)
myopathy (with statin)
gallstones
pancreatitis (only if TG continues to be high)
increased BUN/SCr

57
Q

true or false

niacin is highly recommended to be given with a statin to decrease TG

A

FALSE - no benefit, and actually potential increase in ischemic stroke

58
Q

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)

A

supplementation - IR

ER - for cholesterol/TG but not rec

SR is not used

59
Q

AE of niacin

A

flushing, hives, hyperglycemia, hyperuricemia (gout)

NOT RECOMMENDED

60
Q

in terms of pregnancy, at what time point should lipid lowering agents be discontinued?

A

1-3 months before attempting conception

61
Q

which class of lipid lowering agents is pregnancy category C, meaning that there are no studies in pregnant women, but may be safe

A

bile acid sequestrants

may potentially be safe bc not systemically absorbed - but still not really recommended

62
Q

if a patient has been on a statin and stops bc they want to get pregnant, when can they restart the statin again?

A

only after they’re done breastfeeding