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Week 11 Dyslipidemia Flashcards

1
Q

Where does cholesterol come from?

A

synthesized by the liver
additional from diet
membrane structure

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2
Q

What is the precursor to steroid hormones?

A

cholesterol

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3
Q

What is included in total cholesterol?

A

LDL-C
HDL-C
VLDL-C

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4
Q

What is the “bad” cholesterol? why?

A

LDL-C (low density lipoproteins)

promotes plaque development

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5
Q

What is the “good” cholesterol? why?

A

HDL-C (high density lipoproteins)

protective against plaque development

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6
Q

What the the category of triglycerides?

A

VLDL-C

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7
Q

What is the optimal level of LDL-C?

A

<100 mg/dL

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8
Q

What is “high” LDL-C?

A

160-189

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9
Q

What is the ACC/AHA recombination for pts with LDL-C >190?

A

high intensity statin to the goal of <100

+ or - ezetimibe and PCSK9 inhibitor

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10
Q

What are common causes of secondary dyslipidemia? (5)

A 
diabetes
hypothyroidism
obstructive liver disease
chronic renal failure
drugs that raise LDL and lower HDL (progestins, anabolic steroids and corticosteroids)
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11
Q

What are the therapeutic lifestyle changes in LDL-C lowering therapy? (3)

A

TLC diet
weight reduction
increased physical activity

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12
Q

What are the 2 criteria of TLC diet?

A

restrict intake of cholesterol raising nutrients (sat fats <7% of total) and dietary cholesterol
LDL lowering therapeutic options (plant stannous/sterols 2g daily) and viscous fiber (10-25g/day)

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13
Q

What is the lipid lowering drug of choice for tc of hyperlipidemia and for prevention in most pts?

A

statins

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14
Q

Why are statins the #1 for hyperlipidemia?

A

reduced the risk of first cardiovascular event and death in pts at increased risk for atherosclerotic cardiovascular disease (ACSVD)
decrease the risk of major coronary events and death in pts with ACSVD

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15
Q

Addition of what can reduce the risk of secondary cardiovascular events?

A

ezetimibe

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16
Q

What can be added to a statin to reduce LDL-C levels much more than a statin alone and can reduce the risk of CV events?

A

PCSK9 inhibitor

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17
Q

What else besides ezetimibe and PCSK9 shows limited evidence that it may reduce the risk of CV events when added to a statin?

A

bile acid sequestrants

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18
Q

What is the only fibrate has demonstrated beneficial events on CV outcomes but its use with statins can increase the risk of myopathy and NOT recommended?

A

gembribrozil

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19
Q

Is there convincing evidence that adding an extended-release niacin to a statin to increase CV outcomes?

A

NO

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20
Q

What reduced the risk of ischemic CV event in patients with hypertiglyceridemia and CV risk factors in one random controlled trial?

A

Icosapent ethyl, an omega 3 polyunsaturated fatty acid

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21
Q

What are statins?

A

HMG CoA Reductase Inhibitors

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22
Q

How much do statins lower LDL-C?

A

18-55%

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23
Q

How much do statins lower TG levels?

A

7-30%

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24
Q

How much do statins raise HDL-C levels?

A

5-15%

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25
What are the major side effects of statins?
myopathy (increased CK) | Increased liver enzymes (AST/ALT)
26
What are contraindications to statins?
absolute: liver disease relative: certain drugs
27
What are the demonstrated therapeutic benefits of statins? (5)
``` reduce major coronary events reduce CHD mortality reduce procedures (PCTA/CABG) reduce stroke reduce total mortality ```
28
What is the MOA of statins?
block rate-limiting step in cholesterol synthesis (HMG-CoA to Mevalonic acid Blocked) decreases hepatic cholesterol
29
What indicates statin induced myopathy?
Serum CK >10 x the upper limit of normal with UNEXPLAINED muscle pain or weakness
30
What indicates statin induced rhabdomyolysis?
Serum CK >40 times the upper limit with UNEXPLAINED muscle pain or weakness
31
What statin has the highest risk of stain-induced myopathy?
high dose simvastatin (Zocor)
32
What causes the statin induced myopathy?
metabolism of CYP3A4
33
What should be done if pts experience SE of statin medication?
try a different statin
34
What are 2 examples of HMG CoA Reductase Inhibitors (Statins)?
atorvastatin (Lipitor) | Rosuvastatin (Crestor)
35
What statin is not available generically as of 2/11/19?
Pitavastatin (Livalo)
36
What 3 statins have the highest efficacy by percentage of LDL lowering?
Rosuvastatin (Crestor) 63% Atorvastatin (Lipitor) 57% Simvastatin 46%
37
What is the black box warning of simvastatin (zocor)?
restricting dose of simvastatin 80mg dose
38
An 80mg dose of simvastatin should be restricted to what pts?
patients who have been taking it for >12 months without s/s of toxic effects on muscle
39
According to simvastatin new labeling what should be done with pts that are on 80mg dose without adverse effects but take a contraindicated drug?
switch to another statin
40
According to new simvastatin label what should be done with pts whose LDL-C goal cannot be reached on the 40mg dose?
switch to a statin with less risk of myopathy
41
What medication is contraindicated with simvastatin?
gemfibrozil
42
What is the max dose of simvastatin if someone taking amino, verapamil or diltiazem?
do not exceed 10mg simvastatin daily
43
What is the max dose of simvastatin if someone is taking amlodipine or ranolazine?
do not exceed 20mg of simvastatin daily
44
What are the limitations of grapefruit juice if taking simvastatin?
do not ingest more than 1 quart daily
45
What is the statin pearl on elevated transaminases on statins?
not a reason to stop unless 3x normal
46
Statin side effects are often ____specific, not always ____specific
agent;class
47
What is the MOA of bile acid sequestrants?
bind dietary cholesterol
48
What are the major actions of bile acid sequestrants? (3)
reduce LDL-C 20-30% Raise HDL 3-5% May increase TG
49
What are side effects of bile acid sequestrants? (2)
GI distress/constipation, diarrhea and bloating | decreased absorption of other drugs
50
What are the contraindications of bile acid sequestrants? (2)
``` severe hepatic impariment raised TG (>400 mg/dL) ```
51
What are examples of bile acid sequestrants? (3)
cholestyramine (Questran) Colestipol (Colestid) Colesevelam (Welchol)
52
When are bile acid sequestrants usually given?
typically add on therapy to max dose statins
53
What are the major actions of Niacin (Nicotinic acid; Vitamin B3)?
lowers LDL 5-25% Raises HDL 15-35% Lowers TG 10-15%
54
What is a side effect of Niacin?
flushing
55
How can flushing be minimized when taking Niacin?
pretreatment with aspirin or NSADIS 30-60 minutes prior to ingestion
56
When is Niacin used?
as an add on therapy NOT mono therapy (if used at all)
57
According to study did niacin reduce incidence of primary composite endpoint?
NO
58
Why was the Niacin trial stopped early?
unexpected increase in stroke
59
What are the major actions of fibric acids?
decrease TG & VLDL by 25-50% lower LDL 5-20% (with normal TG) may raise LDL with high TG may raise HDL 10-20%
60
What are examples of fibric acids?
Gemfibrozil (Lopid) | Fenofibrate (Tricor)
61
What are cholesterol absorption inhibitors?
ezetimibe (Zetia) | Vytorin (ezetimibe + simvastatin)
62
How does ezetimibe affect LDL?
lowers LDL by 20-25%
63
What is the result of combining ezetimibe with a statin?
increases effects of statin by 10-15% without side effects
64
What dose of ezetimibe is well tolerated?
10mg daily
65
What is a new class of agents for cholesterol- monoclonal antibodies?
PCSK9 inhibitors
66
What is the MOA of PCSK9 inhibitors?
bind to proprotein converts subtilisin/kexin (PCSK9) receptors prevents it from binding to LDL thereby increase the number of hepatic LDL receptors Increasing clearance of LDL
67
How do PCSK9 medications affect LDL levels?
addition to statins reduce LDLs by 50-60%
68
How are PCSK9 medications given?
SC injection every 2-4 weeks *add on to max dose statins*
69
What is the newest lipid lowing agent that is not FDA approved?
Bempedoic Acid (BPDA)
70
What is the MOA of Bempedoic Acid (BPDA)?
inhibits ATP citrate lyase (key enzyme in cholesterol synthesis)
71
What is the PO dose of Bempedoic Acid (BPDA)?
180mg daily
72
According to trials, what is the effect of Bempedoic Acid (BPDA)?
``` LDL decrease by 12.6% Non HDL decrease by 10% TC decrease Apolipoprotein B decrease High sensitivity CRP decrease ```

Pharmacology (17 decks)

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