Dyslipidemia Flashcards
cholesterol is an important component of healthy cells and tissues including the brain. It is a component of cell walls and a precursor in hormone synthesis. Also is used in the production of bile acids. It is when cholesterol levels are in elevated states that put us at risk for ___________
cardiovascular and other disease
Bile acids are needed to __________. Bile acids are produced __________ and then travel through the bile ducts into __________. This is where bile acids are converted to __________ which are then recycled and returned to _______
absorb lipids, including fat-soluble vitamins.
in the liver.
the small intestine
bile salts
the liver
The process enterohepatic recycling involves the __________ and the __________
gut (enteric system)
liver (hepatic)
Atherosclerosis: is _____
the formation of plaque from the buildup of fats, cholesterol and other substances on the inner walls of arteries
Atherosclerosis although asymptomatic, leads to ______________, which includes ___________.
Different types of cholesterol either __________from or contribute to ASCVD risk
(ASCVD) atherosclerotic cardiovascular disease
myocardial infarction, stroke/transient ischemic attacks, angina and peripheral arterial disease.
protect
Cholesterol in the body can be decreased by:
1)
2)
3)
reducing the formation (like with statins)
blocking absorption (ezetimibe)
blocking enterohepatic recirculation of bile salts (bile acid sequestrants like colesevelam)
Lipids in the body are transported via _________. they are not transported by themselves. These types of lipoproteins are what we call are types of ________
lipid proteins
cholesterol or types of lipids
LDL
what level is desirable?
what level is very high?
In someone with diabetes or ASCVD we want to target a lower level. what level is desirable in this case?
Low-density lipoprotein “bad cholesterol”
we want low
- < 100mg/dL is desirable
- > or = 190mg/dL is very high
In someone with diabetes or ASCVD we want to target a lower level.
We want a level < 70 mg/dL
HDL
what level is normal in men?
what level is normal in women?
High density lipoprotein “good cholesterol”
we want high
> 40mg/dL is normal in men
50mg/dL is normal in women
VLDL
Very-low density lipoproteins
-these carry TG
Total cholesterol:
LDL + HDL + VLDL + TG
Non-HDL:
what level is desirable?
total cholesterol - HDL
< 130 mg/dL id desirable
elevations in cholesterol increase risk for _________________ due to fat accumulation in the arteries.
atherogenic disease (tending to promote the formation of fatty plaques in the arteries)
Dyslipidemia:
abnormality in lipoprotein levels
Primary (or familial) hypercholesterolemia:
inherited (genetic defect), severe cholesterol elevations
heterozygous familial hypercholesterolemia (HeFH)
homozygous familial hypercholesterolemia (HoFH)
Secondary (or acquired) dyslipidemia:
“what we normally are thinking of, things that can cause high levels of fat in the body”
happens from
-Diet
-Diseases like obesity, hypothyroidism, nephrotic syndrome, biliary obstruction
-Drugs
Key Drugs that increase cholesterol: they can raise LDL AND (TG)
triglycerides
diuretics
efavirenz
steroids
immunosuppressants (cyclosporine & tacrolimus)
atypical antipsychotics
protease inhibitors
retinoids
Key drugs that increase LDL only:
Fish Oils (except Vascepa)
fibric acids
SGLT2 inhibitors
thiazolidinediones
anabolic steroids
fibrates
progestins
Key drugs that increase TG only:
IV lipid emulsions
Propofol
Bile acid sequestrants
alcohol
estrogen
tamoxifen
clevidipine
beta-blockers
Lipid panels are taken after a _________. If the LDL isn’t reported, it can be calculated using _____________.
We cannot use this equation when _______________
9-12 hour fast
Friedewald equation: LDL = TC - HDL - (TG/5)
TGs > 400mg/dL
when should medications be considered when just looking at a patients LDL level?
if the LDL is > or equal to 190 mg/dL, then medications should be considered in a patient.
when triglyceride levels hit ____________, that is when we are worried about starting treatment for triglyceridemia and are worried about causing _____________
> or equal to 500 mg/dL this is very high
pancreatitis, if we do not get triglycerides down.
Non-drug treatment for dyslipidemia includes:
Diet: personalized diet to individual patient, to maintain a healthy weight (BMI 18.5-24.9 kg/m2)
-eating vegetables, fruits, whole grains, low fat dairy, poultry, fish, legumes, nuts
-limit sugared beverages, sweets
-Aim for 5-6% calories from saturated fat, limit trans fat
Exercise: moderate-to-vigorous physical exercise 3-4 x/week lasting 40 minutes/session
Avoid tobacco products and limit alcohol consumption.
What are natural products that may lower cholesterol levels?
Treatment Principles
*Reducing the risk of the patient
Statin Treatment: 4 groups that benefit most from statin therapy.
what are these groups?
1) Clinical ASCVD
2) Primary elevations of LDL > or equal to 190 mg/dL
3) Diabetes & age 40-75 years old with an LDL 70-189 mg/dL
4) Age 40-75 years old with LDL 70-189 mg/dL
what are the criteria for patients with clinical ASCVD and what statin treatment is recommended in this group?
patient criteria for clinical ASCVD: “already had an event” so at much greater risk of another.
- (CHD) coronary heart disease which includes: (ACS) Acute Coronary Syndromes - MI, stable or unstable angina, coronary or other arterial revascularization like a stent to open up an artery, stroke = (TIA) transient ischemic attack. (PAD) peripheral artery disease
(Secondary prevention)
statin treatment: High intensity
what are the criteria for patients with primary elevations of LDL > or = to 190 mg/dL and what statin treatment is recommended in this group?
patient criteria: any age
statin treatment: High intensity
what are the criteria for patients with diabetes & age 40-75 years old with an LDL between 70 - 189 mg/dL? What statin treatment is recommended in this group?
Regardless of ASCVD risk ———— moderate intensity statin
If multiple ASCVD risk factors ——— High intensity statin
what are the criteria for patients aged 40-75 years old with an LDL between 70-189 mg/dL? what statin treatment is recommended in this group?
IF —– 10-year ASCVD risk is > or = to 20% then High intensity statin
if —- 10-year ASCVD risk is 7.5-19.9% + patient has risk-enhancing factors then Moderate intensity statin
what are ASCVD risk factors?
they are the same things that go into an ASCVD risk score but we are not using the risk score in these patients.
gender
age
TC
HDL
systolic blood pressure, is antihypertensive treatment being used
is diabetes present
smoking status
what are the high intensity statins and doses?
what does it mean to be on a high intensity statin?
Atorvastatin 40mg - 80mg
Rosuvastatin 20mg - 40mg
A High intensity statin will decrease LDL on average 50% or greater
what are the moderate intensity statins and doses?
what dose it mean to be on a moderate intensity statin?
Pitavastatin 1-4mg
Rosuvastatin 5-10mg
Atorvastatin 10-20mg
Simvastatin 20mg - 40mg
Lovastatin 40mg
&
Pravastatin 40-80mg
Fluvastatin 80mg (either 40mg bid for IR or 80mg XL)
“Pharmacist Rock At Saving Lives & Preventing Fats”
A moderate intensity statin will decrease LDL on average 30-49%
What are the low intensity statins and doses?
what does it mean to be on a low intensity statin?
Simvastatin 10mg
Pravastatin 10mg-20mg
Lovastatin 20mg
Fluvastatin 20-40mg
A low intensity statin will decrease LDL on average less than < 30%
CAC = _____
Coronary Artery Calcium score:
- a score > or equal to 100 Agatson units indicates statins should be initiated
If LDL is still above 70 mg/dL despite patient being on a high intensity statin then consider _______
Zetia ($)
or PCSK9 inhibitor ($$$)
Calculating ASCVD Risk
What are those components to calculate the 10-year risk?
*if patient has already had an event, then we DO NOT USE calculator. Calculator is for primary prevention.
Sex
Age (20-79)
total cholesterol
HDL-c
SBP (treatment Y or N)
Smoking (Y or N)
Race (white or other)
Diabetes (Y or N)
Statin medications
Indications:
MOA:
Contraindications:
Warnings:
Side effects:
Monitoring:
Note/Pearls:
Drug-Drug Interactions:
MOA: inhibit the rate-limiting step of cholesterol synthesis
Lipid effects:
- decrease LDL 20-55%, increase HDL 5-15%, decreased TG 10-30%
Contraindications:
- active liver disease
- pregnancy category X “ meaning absolutely DO NOT USE”
- breastfeeding
-taking concurrent strong 3A4 inhibitors (simvastatin, lovastatin)
Side effects:
myalgias, arthralgias, myopathy, increase CPK, rhabdomyolysis (break down of muscle), blood glucose elevations, increase A1C, increased risk of cataracts, increased LFTs,
Renal considerations:
Reduce dose when CrCl < 30mL/min, except with Lipitor. When CrCl < 60mL/min reduce Livalo dose
Statins & Myalgias
-statins can cause muscle damage with varying severity
Myalgia:
Myopathy:
Myositis:
Rhabdomyolysis:
Management of Myalgias
Reduce the risk
-
-
-
Myalgia: muscle soreness/tenderness, “think pain” a very general feeling of weakness, tiredness,
Myopathy: muscle weakness (+/-) with or without CPK elevation, more
Myositis: muscle inflammation
Rhabdomyolysis: muscle symptoms + CPK elevation (severe elevations), which can lead to acute renal failure
-Avoid drug interactions
-Do NOT Use simvastatin 80mg/day
-Do not combine gemfibrozil + statin
Manage symptoms
-hold statin, check CPK
-After 2-4 weeks: rechallenge with same statin at same or lower dose
-If myalgias return, discontinue statin
- once symptoms resolve, try a low dose of a different statin and gradually increase the dose.
What biomarker is used to determine muscle damage?
CPK
Lipitor*
Class
Indications
Dosing
MOA
Contraindications
Warnings
Side effects
Monitoring
Notes/Pearls
Drug-Drug interactions:
atorvastatin
Class: Statin
Indications: Dyslipidemia
Dosing: 10-80mg daily
MOA: inhibits the enzyme HMG-CoA reductase (3-hydroxy-3-methylglutaryl coenzyme A reductase), which prevents the conversion of HMG-CoA to mevalonate. “Inhibiting the rate-limiting step in cholesterol synthesis”
Lipid effects:
Contraindications:
Warnings:
Side effects:
Monitoring:
Note/Pearls:
Drug-Drug Interactions:
Caduet
atorvastatin + amlodipine
Lescol
fluvastatin
Class:
Indications:
Dosing:
MOA:
Contraindications:
Warnings:
Side effects:
Monitoring:
Note/Pearls:
Drug-Drug Interactions:
Altoprev*
lovastatin
Class:
Indications:
Dosing:
MOA:
Contraindications:
Warnings:
Side effects:
Monitoring:
Note/Pearls:
Drug-Drug Interactions:
Mevacor**
lovastatin brand D/C
Class:
Indications:
Dosing:
MOA:
Contraindications:
Warnings:
Side effects:
Monitoring:
Note/Pearls:
Drug-Drug Interactions:
