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Therapeutics II > Pathophysiology and Evaluation of Dyslipidemia > Flashcards

Pathophysiology and Evaluation of Dyslipidemia Flashcards

1
Q

What is the significance of dyslipidemia?

A

-Lipoprotein abnormalities can contribute to increased risk for coronary, cerebrovascular, and peripheral arterial disease
-Coronary atherosclerosis contributes to ischemic heart disease

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2
Q

Examples of lipids

A

-Cholesterol
-Cholesterol esters
-Triglycerides
-Phospholipids

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3
Q

Examples of lipoproteins

A

-LDL
-HDL
-VLDL

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4
Q

Examples of apolipoproteins

A

-Apo-B
-Apo-A1
-Apo-CIII

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5
Q

Symptoms of dyslipidemia

A

-Largely asymptomatic
-Chest pain
-Palpitations
-Sweating
-Anxiety
-Shortness of breath
-Loss of consciousness
-Abdominal pain
-Sudden death

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6
Q

Warning signs of dyslipidemia

A

-Pancreatitis
-Eruptive xanthomas
-Peripheral polyneuropathy
-Increased BP
-Waist size (>40 inches in men) (>35 inches in women)
-BMI over 30

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7
Q

Significant lab parameters associated with dyslipidemia

A

-Increased non-HDL-C
-Increased TC
-Increased LDL-C
-Increased TG
-Increased Apo-B
-Increased CRP
-Increased LDL-P
-Decreased HDL

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8
Q

What is included in a fasting lipid panel?

A

-TC
-TG
-HDL-C
-LDL-C
-Calculated using the Friedewald equation

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9
Q

What is the Friedewald equation?

A

LDL = TC - HDL - TG/5

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10
Q

When is the Friedewald equation not valid?

A

When TG is over 400

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11
Q

How do you calculate non-HDL-C using the Friedewald equation?

A

non-HDL-C = LDL-C + TG/5

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12
Q

What are the non-pharmacologic ways to treat dyslipidemia?

A

-DASH dietary pattern, USDA food pattern, or AHA diet
-Reduce percent of calories from saturated and trans fat
-Lower sodium intake
-Engage in moderate-to-vigorous intensity aerobic physical exercise
-Smoking cessation

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13
Q

What are some examples of foods that would be an appropriate diet to treat dyslipidemia?

A

-Vegetables, fruits and whole grains
-Low-fat dairy products, poultry, fish, legumes
-Non-tropical vegetable oils and nuts
-Limit sweets and red meats

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14
Q

What percent of saturated fats is acceptable when treating dyslipidemia?

A

5-6% calories from saturated fats

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15
Q

How much should you lower daily sodium intake by when treating dyslipidemia?

A

-Less than 1500 mg/day
-Aim for a reduction of at least 1000 mg/day for most adults

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16
Q

How much exercise would people with dyslipidemia do weekly?

A

90-150 min per week

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17
Q

What were the results of the REDUCE-IT trial?

A

3.1% of patients taking icosapent ethyl were hospitalized for AF or atrial flutter compared to 2.1% of the placebo group

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18
Q

What were the results of the OMEMI trial?

A

7.2% of patients taking n-3 PUFA (EPA and DHA) had AF compared to 4% of placebo patients

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19
Q

What were the results of the STRENGTH trial?

A

Omega-3 carboxylic acid-treated group 2.2% had AF compared to 1.3% in the corn oil group

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20
Q

What are the HMG-CoA reductase inhibitors?

A

-Lovastatin
-Pravastatin
-Pitavastatin
-Simvastatin
-Fluvastatin
-Atorvastatin
-Rosuvastatin

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21
Q

What are the low intensity statins?

A

-Simvastatin 10 mg
-Pravastatin 10-20 mg
-Lovastatin 20 mg
-Fluvastatin 20-40 mg

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22
Q

What are the moderate intensity statins?

A

-Atorvastatin 10-20 mg
-Rosuvastatin 5-10 mg
-Simvastatin 20-40 mg
-Pravastatin 40-80 mg
-Lovastatin 40-80 mg
-Fluvastatin 40 mg BID
-Fluvastatin XL 80 mg
-Pitavastatin 1-4 mg

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23
Q

What are the high intensity statins?

A

-Atorvastatin 40-80 mg
-Rosuvastatin 20-40 mg

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24
Q

Which statins are hydrophilic?

A

-Pravastatin
-Rosuvastatin

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25
Q

Which statins are degraded by CYP 3A4?

A

-Lovastatin
-Simvastatin
-Atorvastatin

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26
Q

Important considerations for statins

A

-Usually well-tolerated
-Obtain LFTs at baseline (DC if LFTs 3x upper limit of normal)
-Serious muscle toxicity (myopathy and rhabdomyolysis)
-Watch for unusual muscle pain and darkened urine
-Avoid large quantities of grapefruit juice (>1 quart daily)
-Contraindicated in pregnant women or women who may become pregnant

27
Q

Characteristics that predispose individuals to statin adverse effects

A

-Impaired renal or hepatic function
-Prior statin intolerance or muscle disorders
-Unexplained ALT elevations of 3x ULN
-Other drugs that affect statin metabolism
-Over 75 years of age

28
Q

What to do when patient experiences muscle symptoms or fatigue while on statin

A

-DC statin and evaluate for rhabdomyolysis
-Evaluate for exacerbating conditions
-Restart same or lower dose statin once symptoms resolve

29
Q

Statin contraindications

A

-Acute liver disease
-Unexplained, persistent elevations of serum transaminases
-Pregnancy
-Breastfeeding

30
Q

How do you manage statin treatment for a patient experiencing symptoms of muscle injury?

A

-Ensure the patient has a valid indication for statins
-Assess if muscle pain is exercise-related
-DC the statin and see if muscle pain resolves
-Switch to a lower risk statin (hydrophilic statins)
-Consider alternative dosing strategies
-Consider DC the statin/using alternative agents

31
Q

Alternative dosing strategies for statins

A

-Every other day and once weekly statin dosing has been suggested to improve utilization or tolerability and decrease cost
-Initial data for atorvastatin, fluvastatin, and rosuvastatin suggest that double the daily dose is necessary for every other day dosing to achieve similar LDL lowering

32
Q

Contraindications with simvistatin

A

-Itraconazole
-Ketoconazole
-Posaconazole
-Erythromycin
-Clarithromycin
-Telithromycin
-HIV protease inhibitors
-Nefazodone
-Gemfibrozil
-Cyclosporine
-Danazol

33
Q

Which drugs should you not exceed 10 mg simvastatin daily with?

A

-Verapamil
-Diltiazem

34
Q

Which drugs should you not exceed 20 mg simvastatin daily with?

A

-Amiodarone
-Amlodipine
-Ranolazine

35
Q

When should FLP be monitored when on a statin?

A

-At baseline
-4-12 weeks following statin initiation
-Every 2-12 months, as clinically indicated

36
Q

What are the bile acid resins?

A

-Cholestyramine
-Colestipol
-Colesevelam

37
Q

Disadvantages associated with BARs

A

-May increase TG
-Must take other medications one hour before or 4 hours after BAR

38
Q

Adverse effects associated with BARs

A

-Constipation
-Bloating
-Nausea
-Flatulence
-Impaired absorption of fat-soluble vitamins
-Hypernatremia
-Hyperchloremia
-GI obstruction

39
Q

What is cholestyramine contraindicated in?

A

Complete biliary obstruction

40
Q

What is colesevelam contraindicated in?

A

-History of bowel obstruction
-Serum TG over 500
-History of hypertriglyceridemia-induced pancreatitis

41
Q

What can BARs interact with?

A

May decrease the effects of:
-Acetaminophen
-TZDs
-Oral contraceptives
-Corticosteroids
-Ezetimibe
-Fibrates
-Thiazide diuretics
-Warfarin
-Digoxin

42
Q

Niacin contraindications

A

-Active hepatic disease
-Significant or unexplained persistent liver transaminase elevations
-Active peptic ulcer
-Arterial hemorrhage

43
Q

What is the cholesterol absorption inhibitor?

A

Ezetimibe

44
Q

What is the combination product that contains ezetimibe and simvistatin?

A

Vytorin

45
Q

How much can ezetimibe decrease LDL by when paired with a statin?

A

12-20%

46
Q

Adverse effects associated with ezetimibe

A

-Fatigue
-Diarrhea
-GI upset

47
Q

Ezetimibe contraindications

A

-Concomitant use with a statin and active hepatic disease or unexplained persistent serum transaminase elevations
-Pregnancy (when used with a statin)
-Breast feeding (when used with a statin)

48
Q

Fibrate side effects

A

-GI disturbances
-Rash
-Myalgia
-Dizziness

49
Q

Fibrate contraindications

A

-History of gallbladder disease
-ESRD or dialysis
-Persistent liver disease

50
Q

What can fibrates increase the levels of?

A

-Statins
-Ezetimibe
-Sulfonylureas
-Warfarin

51
Q

What are the PCSK9 monoclonal antibodies?

A

-Alirocumab
-Evolocumab

52
Q

What are PCSK9 inhibitors indicated in?

A

Adjunct to diet and statin to reduce LDL in familial heterozygous hypercholesterolemia or atherosclerotic CVD

53
Q

PCSK9 adverse effects

A

-GI upset
-Increased LFTs
-Injection site reaction
-Myalgia
-Influenza

54
Q

Inclisiran indication

A

Adjunct to diet and statin to reduce LDL in familial heterozygous hypercholesterolemia or atherosclerotic CVD

55
Q

Inclisiran adverse effects

A

-Injection site reactions
-Arthralgia
-Urinary tract infection
-Diarrhea
-Bronchitis
-Pain in extremities
-Dyspnea

56
Q

Bempedoic acid indication

A

Adjunct to diet and statin to reduce LDL in familial heterozygous hypercholesterolemia or atherosclerotic CVD

57
Q

Adverse reactions to bempedoic acid

A

-URTI
-Muscle spasms
-Hyperuricemia
-Back pain
-Abdominal pain
-Bronchitis
-Pain in extremity
-Anemia
-Elevated liver enzymes

58
Q

Warnings and precautions to bempedoic acid

A

-May increase blood uric acid levels and lead to the development of gout
-Risk of tendon rupture
-Avoid concomitant use with simvastatin >20 mg and pravastatin >40 mg (myopathy)

59
Q

What is in red yeast rice that allows it to be used as an additional medication?

A

Lovastatin

60
Q

How is persistent hypertriglyceridemia defined?

A

Fasting TG over 150 following at least 4-12 weeks of lifestyle intervention, a stable dose of a maximally tolerated statin, and a secondary cause evaluation

61
Q

What is defined as moderate hypertriglyceridemia?

A

150-499

62
Q

What is defined as severe hypertriglyceridemia?

A

over 500

63
Q

Lifestyle modifications to reduce TG

A

-Targeting 5-10% weight loss = 20% decrease in TG
-Very low fat diet (10-15% of diet); restriction of alcohol, sugar, and reined carbs
-Moderate or high intensity physical exercise (150 or more min per week)

64
Q

Pharmacologic treatment of TG

A

Fibrates or omega-3 fatty acids are the go-to

Therapeutics II (33 decks)

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