1. Hyperlipidemia

Question 1

What is the leading cause of death in America?

Answer 1

cardiovascular disease

Question 2

For every __mg/dL decrease in LDL, there is a ~__% reduction in risk of CV events over 5 years.

Answer 2

38

25%

Question 3

What is the cornerstone of therapy for hyperlipidemia?

Answer 3

Statins

Question 4

Statins should only be used in severe or symptomatic hyperlipidemia. (T/F)

Answer 4

False: Statins should be used in all patients who meet criteria for treatment of hyperlipidemia and do not have a contraindication.

Question 5

In patients with ASCVD, what intensity statin should be used?

Answer 5

high

Question 6

In patients with LDL ≥ 190 mg/dL, what intensity statin should be used?

Answer 6

high

Question 7

In patients aged 40-75 with diabetes and/or LDL 70-189 mg/dL, what intensity statin should be used?

Answer 7

moderate

Question 8

In patients with 10 year risk for CVD ≥ 7.5%, age 40-75, and LDL 70-189 mg/dL WITH diabetes, what intensity statin should be used?

Answer 8

high

Question 9

In patients with 10 year risk for CVD ≥ 7.5%, age 40-75, and LDL 70-189 mg/dL WITHOUT diabetes, what intensity statin should be used?

Answer 9

moderate to high

Question 10

What are high intensity statin regimens?

Answer 10

Atorvastatin 40-80 mg

Rosuvastatin 20-40 mg

Question 11

What are moderate intensity statin regimens?

Answer 11

Atorvastatin 10-20 mg
Rosuvastatin 5-10 mg
Simvastatin 20-40 mg
Pravastatin 40-80 mg
Lovastatin 40 mg

Question 12

What are low intensity statin regimens?

Answer 12

Simvastatin 10 mg
Pravastatin 10-20 mg
Lovastatin 20 mg

Question 13

What is the goal for NLA guidelines?

Answer 13

specific LDL levels

Question 14

According to the NLA guidelines, who are the high/very high risk patients?

Answer 14

diabetes
CKD
LDL > 190
ASCVD

Question 15

What is the goal for ACC/AHA guidelines?

Answer 15

% reduction

Question 16

What is the basis for the hypothesis of the ACC/AHA guidelines?

Answer 16

statin hypothesis

Question 17

In the ACC/AHA guidelines, LDL level specific goals are __________.

Answer 17

abandoned

Question 18

What is the basis for recommending statin regimens in the ACC/AHA guidelines?

Answer 18

statin intensity targets

Question 19

Which risk calculator is used in the ACC/AHA guidelines?

Answer 19

ASCVD risk calculator

Question 20

What is the basis for the hypothesis of the NLA guidelines?

Answer 20

LDL hypothesis

Question 21

According to the NLA guidelines, LDL levels are targeted with emphasis on using ________ to achieve the goals.

Answer 21

statins

Question 22

What risk calculator is used for the NLA guidelines?

Answer 22

Framingham risk calculator

Question 23

What should you do if patient is not getting to goal due to intolerance?

Answer 23

• Look for drug interactions
• Reduce dose by half and see if tolerated
• Alternative day regimen
• Try different statin
• Co-Q10 supplements
• Ensure muscle soreness is not confused with myalgia
• Attempt to re-start if symptoms resolve

Question 24

What is the MOA for Ezetimibe?

Answer 24

Inhibits NPC1L1 protein, which reduces cholesterol absorption in the small intestine.

Question 25

What is the dose for Ezetimibe?

Answer 25

- 10 mg PO daily | - Take either ≥ 2 hours before or ≥ 4 hours after BAS

Question 26

What are the ADRs with Ezetimibe when used with statin?

Answer 26

- nasopharyngitis, URI - myalgia, arthralgia - diarrhea

Question 27

What drugs does Ezetimibe interact with?

Answer 27

- cyclosporin - fibrates - BAS

Question 28

What is the mechanism of action for PCSK9 inhibitors?

Answer 28

Human monoclonal antibody to PCSK9. Binds to PCSK9 and increase the number of LDL receptors available to clear circulating LDL.

Question 29

What does PCSK9 do?

Answer 29

Removes LDL receptors

Question 30

What are the PCSK9 agents?

Answer 30

- Alirocumab | - Evolocumab

Question 31

How is Alirocumab dosed?

Answer 31

- initiate 75 mg SQ every 2 weeks | - if ineffective, may increase to 150 mg SQ every 2 weeks

Question 32

How is Evolocumab dosed?

Answer 32

- Primary hypercholesterolemia with clinical ASCVD or HeFH: 140 mg SQ every 2 weeks or 420 mg SQ monthly - In HoFH give 420 mg SQ monthly

Question 33

What are the ADRs of Alirocumab?

Answer 33

- nasopharyngitis - injection site reactions - influenza

Question 34

What are the ADRs of Evolocumab?

Answer 34

- nasopharyngitis, URI, influenza - back pain - injection site reactions

Question 35

What are the drug interactions with PCSK9 inhibitors?

Answer 35

There are no clinically significant drug interactions

Question 36

What is the mechanism of action of bile acid sequestrants?

Answer 36

- Non-absorbed, lipid lowering polymer binds bile acids in intestine and impedes their reabsorption. - Total bile acid ↓, hepatic enzyme cholesterol (7α-hydroxylase), is unregulated - ↑ conversion of cholesterol to bile acids.

Question 37

What are the BAS agents?

Answer 37

- Colesevelam - Cholestyramine - Colestipol

Question 38

What are the ADRs of BAS?

Answer 38

- constipation - dyspepsia - nausea

Question 39

What are the drug interactions with BAS?

Answer 39

- cyclosporin - glimepiride, glipizide - levothyroxine - olmesartan + medoxomil - OCs - phenytoin - warfarin

Question 40

How should drug interactions be handled with BAS?

Answer 40

Drugs with potential interactions should be taken at least 4 hours after BAS to avoid impeding absorption.

Question 41

What is the MOA for phytosteroids?

Answer 41

- not fully understood | - related ti displacement of cholesterol from micellar phase

Question 42

What are the ADRs of phytosteroids?

Answer 42

generally recognized as safe

Question 43

What are drug interactions with phytosteroids?

Answer 43

BAS administration should be separated from phytosteroids by 2-4 hours

Question 44

What are unmodifiable patient specific risk factors are considered in the ACC/AHA ASCVD risk estimator?

Answer 44

- gender - age - race

Question 45

What are patient specific (lab values and vitals that are risk factors considered in the ACC/AHA ASCVD risk estimator?

Answer 45

- total cholesterol - HDL cholesterol - systolic BP

Question 46

What are patient specific comorbidities that are risk factors considered in the ACC/AHA ASCVD risk estimator?

Answer 46

- treatment for HTN - history of diabetes - smoker

Question 47

What are patient specific risk factors that are outlined by the NLA?

Answer 47

- age - family history - current cigarette smoking - high BP - low HDL

Question 48

What are treatment goals?

Answer 48

The measurable endpoint to assist in determining the success of the plan.

Question 49

What are monitoring parameters?

Answer 49

The means and frequency you will measure and assess your treatment.

Question 50

How is Non-HDL-C calculated?

Answer 50

total cholesterol - HDL