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Flashcards in 38. Dyslipidemia Deck (84):
1

Possible side effects of Lovaza include: (Select ALL that apply.)

A. Burping
B. Arthralgias
C. Dyspepsia
D. Taste perversions
E. Flatulence

A, C, D. Lovaza is well-tolerated, but side effects can include dyspepsia, burping, taste perversion, and nausea.

Fish Oils: may be due to reduction of hepatic synthesis of TG. Indicated as adjunct to diet in patients with TG ≥500. Warning: caution with known hypersensitivity to fish/shellfish. SE: eructation (burping), dyspepsia, taste perversions (Lovaza, Epanova), arthralgias (Vascepa), pregnacy (C), can increase LDL. Stop prior to elective surgery (increase bleed risk)

Lovaza: may increase LDL. possible recurrences of Afib

Vascepa: taken following meals

Epanova: may increase LDL

Omtryg: take with meals

2

What precentage on the 10-year ASCVD risk assessment score is used as the cut point to start statin therapy?

A. ≥ 2.5%
B. ≥ 5%
C. ≥ 7.5%
D. ≥ 10%
E. ≥ 15%

C. An estimated 10-year ASCVD risk score of ≥ 7.5% is an indication to start statin therapy.

4 Groups indicated for Statin Therapy:

1. Clinical ASCVD: coronary heart disease (ACS, MI, angina, coronary revascularization), cerebral vascular disease (stroke, TIA), peripheral artery disease (PAD). ≤75 y/o = high intensity. >75 y/o = moderate intensity

2. Primary elevations of LDL ≥190mg/dL. high intensity

3. Diabetes and 40-75 year old with LDL 70-189mg/dL. 10-year ASCVD risk: ≥7.5% = high intensity, <7.5% = moderate intensity

4. 40-75 year old with LDL 70-189mg/dL and estimated 10-year ASCVD risk of ≥7.5% (using Global Risk Assessment Tool). moderate-to-high intensity, if <7.5% can consider risk benefit

3

What condition is a contraindication to using mipomersen (Kynamro)?

A. Renal disease or moderate to severe renal impairment
B. Hepatic disease or moderate to severe hepatic impairment
C. Pregnancy
D. Concurrent use with strong CYP3A4 inhibitors
E. Arterial hemorrhage

B. Hepatic disease or moderate to severe hepatic impairment is contraindicated in mipomersen

mipomersen (Kynamro): inhibitor of Apo-B-100 synthesis. SQ weekly. Boexed warning: hepatotoxicity (REMS). CI: liver disease, mod-severe liver impairment. Warning: hepatotoxicity. SE: injection site reactions, flu-like symptoms, nausea, headache, increase ALT, antibody formation, fatigue, pregnancy (B)

4

A patient begins Niaspan and finds she suffers from red, itchy skin. She does not believe she can tolerate the medicine. Which of the following statements are correct that the pharmacist should provide to the patient? (Select ALL that apply.)

A. If your doctor permits it, take 325 mg of aspirin 30 minutes before the Niaspan; this should help reduce the problem.
B. Take Benadryl to reduce the problem since this is due to a histamine response.
C. Avoid alcohol, hot beverages and spicy food near the time of the medicine.
D. This problem should lessen as you take the medicine continuously.
E. Take the Niaspan at bedtime; most of the problem will occur while you sleep.

A, C, D, E. Flushing with niacin is prostaglandin-mediated therefore, an antihistamine such as Benadryl will not help.

Niacin: decreases rate of hepatic synthesis of VLDL and LDL to decrease LDL and TG, and increase HDL. Mainly used to decrease TG. Also known as nicotinic acid or vitamin B3. CI: active liver disease, active PUD, arterial bleeding, arterial hemorrhage. Warning: caution in unstable angina or acute phase of MI, hepatoxicity. SE: flushing (take ASA prior), pruritis, NVD, GI distress, hyperglycemia, hyperuricemia, cough, hepatotoxicity, orthostatic hypotension, hypophosphatemia. Take with food, but avoid hot liquids and spicy food which can worsen flushing.

niacin IR (Niacor): higher incidence of flushing (can take ASA prior)

niacin ER (Niaspan): best SE profile

niacin CR/SR (Slo-Niacin): high incidence of increase LFTs (monitor LFTs)

5

HL, a 42 year old male, has gained 40 pounds over the last 5 years since he injured his left knee and can no longer play basketball. He has a sedentary lifestyle including a job that requires him to be at a desk all day. HL has tried the Atkins diet, South Beach diet, and many other popular diets but has gained the weight back. HL does not smoke and admits to having 1-3 alcoholic beverages per month. Lifestyle modifications have been inadequate in controlling his weight gain.   
Allergies:  NKDA
Current Medications: 
Vasotec 10 mg daily 
Norvasc 10 mg daily 
Crestor 20 mg daily
Glucophage 850 mg BID 
Claritin 10 mg daily 
Tylenol 500 mg Q4-6H PRN 
MVI daily   
Past Medical History: 
Allergic rhinitis 
Dyslipidemia 
Diabetes mellitus
Hypertension   
Vitals: 
Height: 5'11"                   Weight: 225 lbs 
BP: 140/80 mmHg           HR: 85 BPM            RR: 20 BPM 
Temp: 98.6ºF                   Pain: 1/10       
4/14/14 Labs:
AST (units/L) = 37 (10 - 40)
ALT (units/L) = 32 (10 - 40)
CH, T (mg/dL) = 247 (125 - 200)
TG (mg/dL) = 242 (< 150)
HDL (mg/dL) = 34 (> 40)
LDL (mg/dL) = 183 ( < 100)
GLU (mg/dL) = 108 (65 - 99)
Na (mEq/L) = 143 (135 - 145)                     
K (mEq/L) = 4.1 (3.5 - 5)                            
Cl (mEq/L) = 102 (95 - 103)                        
HCO3 (mEq/L) = 26 (24 - 30)                      
BUN (mg/dL) = 15 (7 - 20)                         
SCr (mg/dL) = 0.8 (0.6 - 1.3)                
Mg (mEq/L) = 1.8 (1.3 - 2.1)
PO4 (mg/dL) = 4.1 (2.3 - 4.7)
Ca (mg/dL) = 9.7 (8.5 - 10.5)
TSH (mIU/L) = 2.2 (0.3 - 3.0)
Hgb A1C = 7.9% (4 - 6%)  
10/9/14 Labs: 
AST (units/L) = 168 (10 - 40)
ALT (units/L) = 145 (10 - 40)
CH, T (mg/dL) = 224 (125 - 200)
TG (mg/dL) = 218 (< 150)
HDL (mg/dL) = 35 (> 40)
LDL (mg/dL) = 145 ( < 100)
GLU (mg/dL) = 108 (65 - 99)
Na (mEq/L) = 142 (135 - 145)                      
K (mEq/L) = 4.2 (3.5 - 5)                           
Cl (mEq/L) = 97 (95 - 103)                       
HCO3 (mEq/L) = 29 (24 - 30)                      
BUN (mg/dL) = 18 (7 - 20)                         
SCr (mg/dL) = 0.9 (0.6 - 1.3)               
Mg (mEq/L) = 1.9 (1.3 - 2.1)
PO4 (mg/dL) = 4.3 (2.3 - 4.7)
Ca (mg/dL) = 9.5 (8.5 - 10.5)
TSH (mIU/L) = 1.8 (0.3 - 3.0)
Hgb A1C = 7.8% (4 - 6%)    
What intervention would be most appropriate on the 10/9/14 visit?

A. Increase statin dose
B. Decrease statin dose
C. Discontinue statin therapy
D. Add a bile acid sequestrant
E. Add niacin

C. AST or ALT levels are elevated and statin therapy should be discontinued when LFTs are greater than 3 times the upper limit of normal.

4 Groups indicated for Statin Therapy:

1. Clinical ASCVD: coronary heart disease (ACS, MI, angina, coronary revascularization), cerebral vascular disease (stroke, TIA), peripheral artery disease (PAD). ≤75 y/o = high intensity. >75 y/o = moderate intensity

2. Primary elevations of LDL ≥190mg/dL. high intensity

3. Diabetes and 40-75 year old with LDL 70-189mg/dL. 10-year ASCVD risk: ≥7.5% = high intensity, <7.5% = moderate intensity

4. 40-75 year old with LDL 70-189mg/dL and estimated 10-year ASCVD risk of ≥7.5% (using Global Risk Assessment Tool). moderate-to-high intensity, if <7.5% can consider risk benefit

6

Select the correct mechanisms of action of the statins. (Select ALL that apply.)

A. Statins inhibit the enzyme HMG-CoA reductase.
B. Statins block the rate-limiting step in cholesterol synthesis.
C. Statins reduce cholesterol absorption at the brush-border.
D. Statins are peroxisome proliferator alpha activators.
E. Statins bind to and inhibit microsomal triglyceride transfer protein (MTP) in the endoplasmic reticulum.

A, B. The statins block cholesterol synthesis by inhibiting the enzyme HMG-CoA reductase, which catalyzes the rate-limiting step in cholesterol synthesis.

Statins: inhibits HMG-CoA reductase preventing the conversion of HMG-CoA to mevalonate (the rate-limiting step in cholesterol synthesis) resulting in LDL reduction (20-55%), TG reduction (10-30%), increasing HDL (5-15%). CI: active liver disease, pregnancy (X), breastfeeding, concurrent 3A4 inhibitors (with simvastatin & lovastatin) cyclosporine use (pitavastatin only). Warning: skeletal muscle effects (myopathy, rhabdomyolysis), diabetes, liver enzyme elevations. SE: myalgias, arthralgias, myopathy, diarrhea, increase CPK, rhabdomyolysis, cognitive impairment (memory loss, confusion), increase blood glucose, increase A1C, increase LFTs, risk of cataracts. Reduce dose when CrCl <30 (except with Lipitor). Dosed the evening: simvastatin, lovastatin, fluvastatin ("Sam Loathes the Flu")

atorvastatin (Lipitor): equiv dose = 10. Does not need dose reduction when CrCl <30.

simvastatin (Zocor), Vytorin (simvastatin/ezetimibe): equiv dose = 20. 3A4 substrate (avoid inhibitors)

rosuvastatin (Crestor): equiv dose = 5

pravastatin (Pravachol): equiv dose = 40

lovastatin (Mevacor, Altoprev): equiv dose = 40. with food. 3A4 substrate (avoid inhibitors)

fluvastatin (Lescol): equiv dose = 80. with food, may increase INR in patients taking warfarin

pitavastatin (Livalo): equiv dose = 2. Reduce dose when CrCl <60. minimal CYP metabolism. CI with cyclosporine. monitor PT/INR after dose initiation of dose change of warfarin

7

HL, a 42 year old male, has gained 40 pounds over the last 5 years since he injured his left knee and can no longer play basketball. He has a sedentary lifestyle including a job that requires him to be at a desk all day. HL has tried the Atkins diet, South Beach diet, and many other popular diets but has gained the weight back. HL does not smoke and admits to having 1-3 alcoholic beverages per month. Lifestyle modifications have been inadequate in controlling his weight gain.   
Allergies:  NKDA
Current Medications: 
Vasotec 10 mg daily 
Norvasc 10 mg daily 
Glucophage 850 mg BID 
Claritin 10 mg daily 
Tylenol 500 mg Q4-6H PRN 
MVI daily   
Past Medical History: 
Allergic rhinitis 
Dyslipidemia 
Diabetes mellitus
Hypertension   
Vitals: 
Height: 5'11"                   Weight: 225 lbs 
BP: 140/80 mmHg           HR: 85 BPM            RR: 20 BPM 
Temp: 98.6ºF                   Pain: 1/10       
4/14/14 Labs:
AST (units/L) = 37 (10 - 40)
ALT (units/L) = 32 (10 - 40)
CH, T (mg/dL) = 247 (125 - 200)
TG (mg/dL) = 242 (< 150)
HDL (mg/dL) = 34 (> 40)
LDL (mg/dL) = 183 ( < 100)
GLU (mg/dL) = 108 (65 - 99)
Na (mEq/L) = 143 (135 - 145)                     
K (mEq/L) = 4.1 (3.5 - 5)                            
Cl (mEq/L) = 102 (95 - 103)                        
HCO3 (mEq/L) = 26 (24 - 30)                      
BUN (mg/dL) = 15 (7 - 20)                         
SCr (mg/dL) = 0.8 (0.6 - 1.3)                
Mg (mEq/L) = 1.8 (1.3 - 2.1)
PO4 (mg/dL) = 4.1 (2.3 - 4.7)
Ca (mg/dL) = 9.7 (8.5 - 10.5)
TSH (mIU/L) = 2.2 (0.3 - 3.0)
Hgb A1C = 7.9% (4 - 6%)  
10/9/14 Labs: 
AST (units/L) = 168 (10 - 40)
ALT (units/L) = 145 (10 - 40)
CH, T (mg/dL) = 224 (125 - 200)
TG (mg/dL) = 218 (< 150)
HDL (mg/dL) = 35 (> 40)
LDL (mg/dL) = 145 ( < 100)
GLU (mg/dL) = 108 (65 - 99)
Na (mEq/L) = 142 (135 - 145)                      
K (mEq/L) = 4.2 (3.5 - 5)                           
Cl (mEq/L) = 97 (95 - 103)                       
HCO3 (mEq/L) = 29 (24 - 30)                      
BUN (mg/dL) = 18 (7 - 20)                         
SCr (mg/dL) = 0.9 (0.6 - 1.3)               
Mg (mEq/L) = 1.9 (1.3 - 2.1)
PO4 (mg/dL) = 4.3 (2.3 - 4.7)
Ca (mg/dL) = 9.5 (8.5 - 10.5)
TSH (mIU/L) = 1.8 (0.3 - 3.0)
Hgb A1C = 7.7% (4 - 6%)    
HL's estimated 10-year ASCVD risk is calculated at 6.9%. According to the ACC/AHA Treatment of Blood Cholesterol Guideline, what would be the most appropriate statin regimen to initiate on the 4/14/14 visit?

A. Simvastatin 10 mg daily
B. Simvastatin 40 mg daily
C. Atorvastatin 40 mg daily
D. Pravastatin 20 mg daily
E. Pravastatin 40 mg daily

E. HL has diabetes, is between 40-75 years, has an LDL between 70-189 mg/dL, and an estimated 10-year ASCVD risk < 7.5%. Therefore he will require a moderate intensity statin. Although simvastatin 40 mg is considered moderate intensity, HL is also on amlodipine and should not exceed simvastatin 20 mg due to CYP3A4 interaction. Therefore, pravastatin 40 mg is the most appropriate statin. All other choices are not moderate intensity.

4 Groups indicated for Statin Therapy:

1. Clinical ASCVD: coronary heart disease (ACS, MI, angina, coronary revascularization), cerebral vascular disease (stroke, TIA), peripheral artery disease (PAD). ≤75 y/o = high intensity. >75 y/o = moderate intensity

2. Primary elevations of LDL ≥190mg/dL. high intensity

3. Diabetes and 40-75 year old with LDL 70-189mg/dL. 10-year ASCVD risk: ≥7.5% = high intensity, <7.5% = moderate intensity

4. 40-75 year old with LDL 70-189mg/dL and estimated 10-year ASCVD risk of ≥7.5% (using Global Risk Assessment Tool). moderate-to-high intensity, if <7.5% can consider risk benefit

Statin Therapy Intensity

High (lowers LDL ≥50%): atorvastatin 40-80, rosuvastatin 20-40

Moderate (lowers LDL 30-49%): atorvastatin 10-20, rosuvastatin 5-10, simvastatin 20-40, pravastatin 40-80, lovastatin 40, fluvastatin 80, pitavastatin 2-4

Low (lower LDL <30%): simvastatin 10, pravastatin 10-20, lovastatin 20, fluvastatin 20-40, pitavastatin 1

8

DL is a 61 y/o male being seen for routine follow up including his risk for ASCVD.
Current Medications: 
Inderal LA 80 mg daily 
Hydrochlorothiazide 25 mg daily 
Prinivil 10 mg daily
Mylanta 20 mL Q6H
Plavix 75 mg daily
Aspirin 81 mg
Nitroglycerin 0.3 mg PRN
MVI daily   
Past Medical History: 
Hypertension
Dyslipidemia
GERD
s/p MI  
Vitals:
Height: 5'11"                   Weight: 202 lbs
BP: 140/80 mmHg           HR: 85 BPM           RR: 20 BPM
Temp: 98.6ºF                   Pain: 1/10   
Labs: 
AST (units/L) =  32 (10 - 40)
ALT (units/L) = 20 (10 - 40)
CH, T (mg/dL) = 221 (125 - 200)
TG (mg/dL) = 238 (< 150)
HDL (mg/dL) = 32 (> 40)
LDL (mg/dL) = 
GLU (mg/dL) = 108 (65 - 99)
Na (mEq/L) = 143 (135 - 145)                     
K (mEq/L) = 4.1 (3.5 - 5)                           
Cl (mEq/L) = 102 (95 - 103)                        
HCO3 (mEq/L) = 26 (24 - 30)                      
BUN (mg/dL) = 15 (7 - 20)                          
SCr (mg/dL) = 0.8 (0.6 - 1.3)                
Mg (mEq/L) = 1.8 (1.3 - 2.1)
PO4 (mg/dL) = 4.1 (2.3 - 4.7)
Ca (mg/dL) = 9.7 (8.5 - 10.5)
TSH (mIU/L) = 1.8 (0.3 - 3.0)
Free T4 (mg/dL) = 0.7 (0.9 - 2.3)  
According to the ACC/AHA Treatment of Blood Cholesterol Guideline, what would be the most appropriate statin regimen for DL?

A. Pravastatin 40 mg daily
B. Rosuvastatin 20 mg daily
C. Lovastatin 40 mg daily
D. Atorvastatin 20 mg daily
E. Pitavastatin 4 mg daily

B. DL has ASCVD evidenced by his history of myocardial infarction and is ≤ 75 years of age. According to the ACC/AHA treatment guidelines, DL should receive high intensity therapy.

4 Groups indicated for Statin Therapy:

1. Clinical ASCVD: coronary heart disease (ACS, MI, angina, coronary revascularization), cerebral vascular disease (stroke, TIA), peripheral artery disease (PAD). ≤75 y/o = high intensity. >75 y/o = moderate intensity

2. Primary elevations of LDL ≥190mg/dL. high intensity

3. Diabetes and 40-75 year old with LDL 70-189mg/dL. 10-year ASCVD risk: ≥7.5% = high intensity, <7.5% = moderate intensity

4. 40-75 year old with LDL 70-189mg/dL and estimated 10-year ASCVD risk of ≥7.5% (using Global Risk Assessment Tool). moderate-to-high intensity, if <7.5% can consider risk benefit

Statin Therapy Intensity

High (lowers LDL ≥50%): atorvastatin 40-80, rosuvastatin 20-40

Moderate (lowers LDL 30-49%): atorvastatin 10-20, rosuvastatin 5-10, simvastatin 20-40, pravastatin 40-80, lovastatin 40, fluvastatin 80, pitavastatin 2-4

Low (lower LDL <30%): simvastatin 10, pravastatin 10-20, lovastatin 20, fluvastatin 20-40, pitavastatin 1

9

A pharmacist instructs a patient to contact the doctor right away if he is passing brown or dark-colored urine, feeling more tired than usual or if his skin and/or whites of the eyes become yellow. Which of the following drugs is the most likely to need this counseling?

A. Questran
B. Zetia
C. Advicor
D. Lovaza
E. Metamucil

C. Advicor contains a statin (lovastatin) and niacin extended-release. There is a heightened risk of muscle toxicity. Instruct patients to report at once any unexplained muscle pain, tenderness, or weakness. Zetia rarely causes liver dysfunction on its own; the risk is increased when it is used in combination with a statin.

Questran (cholestyramine)

Zetia (ezetimibe)

10

Which of the following products are statin-niacin combinations? (Select ALL that apply.)

A. Advicor
B. Simcor
C. Juvisync
D. Liptruzet
E. Vytorin

A, B. Lovastatin/niacin is Advicor and simvastatin/niacin is Simcor. With these combinations, there is a higher risk of muscle toxicity; patients must be self-monitoring for symptoms.

11

A patient's triglycerides were recorded at 510 mg/dL. Which of the following agents will help to lower triglycerides? (SelectALL that apply.)

A. Lovaza
B. Trilipix
C. Niacin
D. Vascepa
E. WelChol

A, B, C, D. The bile-acid binding resins can raise triglycerides modestly (about 5%) and cannot be used if the triglycerides are elevated.

Niacin: decreases rate of hepatic synthesis of VLDL and LDL to decrease LDL (5-25%) and TG (20-50%), and increase HDL (15-35%). Mainly used to decrease TG. Also known as nicotinic acid or vitamin B3. CI: active liver disease, active PUD, arterial bleeding, arterial hemorrhage. Warning: caution in unstable angina or acute phase of MI, hepatoxicity. SE: flushing (take ASA prior), pruritis, NVD, GI distress, hyperglycemia, hyperuricemia, cough, hepatotoxicity, orthostatic hypotension, hypophosphatemia. Take with food, but avoid hot liquids and spicy food which can worsen flushing.

niacin IR (Niacor): higher incidence of flushing (can take ASA prior)

niacin ER (Niaspan): best SE profile

niacin CR/SR (Slo-Niacin): high incidence of increase LFTs (monitor LFTs)

Fibrates: peroxisome proliferator receptor alpha (PPARa) activators, which upregulates the expression of apolipoprotein CII and apolipoprotein A-I to reduce TG (20-50%) and LDL (5-20%), and increase HDL (15%). Mainly used to decrease TG. CI: severe liver disease, severe renal disease (CrCl <30), gallbladder disease, nursing mothers. Warning: myopathy, increase risk with statin (elderly, diabetes, renal failure, hypothyroidism). SE: increase LFts, abdominal pain, increase CPK, dyspepsia, URTIs

fenofibrate, fenofibric acid (TriCor, Trilipix):

gemfibrozil (Lopid): taken 30 minutes before breakfast and dinner. CI with repaglinide

Fish Oils: may be due to reduction of hepatic synthesis of TG. Reduce TG (45%) and increase HDL (9%). Indicated as adjunct to diet in patients with TG ≥500. Warning: caution with known hypersensitivity to fish/shellfish. SE: eructation (burping), dyspepsia, taste perversions (Lovaza, Epanova), arthralgias (Vascepa), pregnacy (C), can increase LDL. Stop prior to elective surgery (increase bleed risk)

Lovaza: may increase LDL. possible recurrences of Afib

Vascepa: taken following meals

Epanova: may increase LDL

Omtryg: take with meals

12

DL is a 61 y/o male being seen for routine follow up including his risk for ASCVD.
Current Medications: 
Inderal LA 80 mg daily 
Hydrochlorothiazide 25 mg daily 
Prinivil 10 mg daily
Mylanta 20 mL Q6H
Plavix 75 mg daily
Aspirin 81 mg
Nitroglycerin 0.3 mg PRN
MVI daily   
Past Medical History: 
Hypertension
Dyslipidemia
GERD
s/p MI  
Vitals:
Height: 5'11"                   Weight: 202 lbs
BP: 140/80 mmHg           HR: 85 BPM           RR: 20 BPM
Temp: 98.6ºF                   Pain: 1/10   
Labs: 
AST (units/L) =  32 (10 - 40)
ALT (units/L) = 20 (10 - 40)
CH, T (mg/dL) = 221 (125 - 200)
TG (mg/dL) = 238 (< 150)
HDL (mg/dL) = 32 (> 40)
LDL (mg/dL) = 
GLU (mg/dL) = 108 (65 - 99)
Na (mEq/L) = 143 (135 - 145)                     
K (mEq/L) = 4.1 (3.5 - 5)                           
Cl (mEq/L) = 102 (95 - 103)                        
HCO3 (mEq/L) = 26 (24 - 30)                      
BUN (mg/dL) = 15 (7 - 20)                          
SCr (mg/dL) = 0.8 (0.6 - 1.3)                
Mg (mEq/L) = 1.8 (1.3 - 2.1)
PO4 (mg/dL) = 4.1 (2.3 - 4.7)
Ca (mg/dL) = 9.7 (8.5 - 10.5)
TSH (mIU/L) = 1.8 (0.3 - 3.0)
Free T4 (mg/dL) = 0.7 (0.9 - 2.3)  
DL was prescribed Crestor 40 mg, but his insurance will not cover a brand name statin, and no generic of Crestor is available. Which generic statin would be an appropriate alternative?

A. Atorvastatin 20 mg
B. Pravastatin 40 mg
C. Atorvastatin 40 mg
D. Atorvastatin 80 mg
E. Pravastatin 80 mg

D. Rosuvastatin 5 mg is equivalent to atorvastatin 10 mg. Therefore, an appropriate equivalent dose would be atorvastatin 80 mg. The other statins are not equivalent to rosuvastatin 40 mg.

atorvastatin (Lipitor): equiv dose = 10. Does not need dose reduction when CrCl <30.

simvastatin (Zocor), Vytorin (simvastatin/ezetimibe): equiv dose = 20. 3A4 substrate (avoid inhibitors)

rosuvastatin (Crestor): equiv dose = 5

pravastatin (Pravachol): equiv dose = 40

lovastatin (Mevacor, Altoprev): equiv dose = 40. with food. 3A4 substrate (avoid inhibitors)

fluvastatin (Lescol): equiv dose = 80. with food, may increase INR in patients taking warfarin

pitavastatin (Livalo): equiv dose = 2. Reduce dose when CrCl <60. minimal CYP metabolism. CI with cyclosporine. monitor PT/INR after dose initiation of dose change of warfarin

13

Maurice is a 58 year-old male with dyslipidemia and prostate enlargement. He was started on and is currently taking pravastatin 40 mg daily and tamsulosin 0.4 mg daily. Today he reports with muscle aches. The physician discontinued the pravastatin and evaluated Maurice for other conditions that can increase muscle damage and found none. According to the ACC/AHA Blood Cholesterol Guidelines, what would be an appropriate next step for treating Maurice's dyslipidemia?

A. If muscle aches resolve, restart pravastatin at 20 mg daily.
B. If muscle aches do not resolve, restart pravastatin at 20 mg daily.
C. If muscle aches resolve, start rosuvastatin at 20 mg daily.
D. If muscle aches do not resolve, start rosuvastatin at 20 mg daily.
E. If muscle aches resolve, do not use statin therapy again.

A. If muscle symptoms resolve, it is recommended to restart the same statin at the same or lower dose.

14

Which formulation of niacin has the highest risk for liver damage?

A. Niaspan
B. Slo-Niacin
C. Niacor
D. Inositol hexanicotinate
E. Inositol hexaniacinate

B. Slo-Niacin has the highest risk of hepatotoxicity.

Niacin: decreases rate of hepatic synthesis of VLDL and LDL to decrease LDL (5-25%) and TG (20-50%), and increase HDL (15-35%). Mainly used to decrease TG. Also known as nicotinic acid or vitamin B3. CI: active liver disease, active PUD, arterial bleeding, arterial hemorrhage. Warning: caution in unstable angina or acute phase of MI, hepatoxicity. SE: flushing (take ASA prior), pruritis, NVD, GI distress, hyperglycemia, hyperuricemia, cough, hepatotoxicity, orthostatic hypotension, hypophosphatemia. Take with food, but avoid hot liquids and spicy food which can worsen flushing.

niacin IR (Niacor): higher incidence of flushing (can take ASA prior)

niacin ER (Niaspan): best SE profile

niacin CR/SR (Slo-Niacin): high incidence of increase LFTs (monitor LFTs)

15

A patient gave the pharmacist a prescription for Crestor 10 mg PO daily. Which of the following is an appropriate generic substitution for Crestor?

A. Atorvastatin
B. Lovastatin
C. Pravastatin
D. Simvastatin
E. Rosuvastatin

E. The generic name of Crestor is rosuvastatin.

atorvastatin (Lipitor)

lovastatin (Mevacor, Altoprev)

pravastatin (Pravachol)

simvastatin (Zocor)

16

A patient gave the pharmacist a prescription for Lipitor 40 mg PO daily. Which of the following is an appropriate generic substitution for Lipitor?

A. Atorvastatin
B. Lovastatin
C. Pravastatin
D. Simvastatin
E. Rosuvastatin

A. The generic name of Lipitor is atorvastatin.

lovastatin (Mevacor, Altoprev)

pravastatin (Pravachol)

simvastatin (Zocor)

rosuvastatin (Crestor)

17

Which of the following patient types would benefit from moderate-intensity statin therapy according to the ACC/AHA Blood Cholesterol Guidelines? (Select ALL that apply.)

A. Those unable to tolerate high-intensity statin therapy
B. A 35 year old with a LDL of 140 mg/dL and no other comorbidities
C. A 80 year old patient who is S/P MI
D. A 45 year old patient with diabetes and a LDL of 140 mg/dL and no other comorbidities; 10-year ASCVD risk score is 6.5%
E. A 32 year old with a LDL of 195 mg/dL and no other comorbidities

A, C, D. These represent the patient types that benefit from moderate-intensity statin treatment according to the ACC/AHA Blood Cholesterol Guidelines.

4 Groups indicated for Statin Therapy:

1. Clinical ASCVD: coronary heart disease (ACS, MI, angina, coronary revascularization), cerebral vascular disease (stroke, TIA), peripheral artery disease (PAD). ≤75 y/o = high intensity. >75 y/o = moderate intensity

2. Primary elevations of LDL ≥190mg/dL. high intensity

3. Diabetes and 40-75 year old with LDL 70-189mg/dL. 10-year ASCVD risk: ≥7.5% = high intensity, <7.5% = moderate intensity

4. 40-75 year old with LDL 70-189mg/dL and estimated 10-year ASCVD risk of ≥7.5% (using Global Risk Assessment Tool). moderate-to-high intensity, if <7.5% can consider risk benefit

18

Maria has been given a prescription for simvastatin 20 mg PO QHS. Which of the following statements are correct? (SelectALL that apply.)

A. Mary can take this medication in the morning if it works better for her schedule.
B. Simvastatin can cause pancreatitis; triglycerides should be monitored.
C. The brand name of simvastatin is Zocor.
D. The dose of simvastatin can be titrated to a max dose of 40 mg/day.
E. She needs to take her simvastatin with food.

C, D. Simvastatin is taken at bedtime, with or without food. Simvastatin has a short half life and must be in the body during sleep when most cholesterol synthesis occurs. The max dose for new starts is 40 mg/day.

Statins: inhibits HMG-CoA reductase preventing the conversion of HMG-CoA to mevalonate (the rate-limiting step in cholesterol synthesis) resulting in LDL reduction (20-55%), TG reduction (10-30%), increasing HDL (5-15%). CI: active liver disease, pregnancy (X), breastfeeding, concurrent 3A4 inhibitors (with simvastatin & lovastatin) cyclosporine use (pitavastatin only). Warning: skeletal muscle effects (myopathy, rhabdomyolysis), diabetes, liver enzyme elevations. SE: myalgias, arthralgias, myopathy, diarrhea, increase CPK, rhabdomyolysis, cognitive impairment (memory loss, confusion), increase blood glucose, increase A1C, increase LFTs, risk of cataracts. Reduce dose when CrCl <30 (except with Lipitor). Dosed in the evening: simvastatin, lovastatin, fluvastatin ("Sam Loathes the Flu")

atorvastatin (Lipitor): equiv dose = 10. Does not need dose reduction when CrCl <30.

simvastatin (Zocor), Vytorin (simvastatin/ezetimibe): equiv dose = 20. 3A4 substrate (avoid inhibitors)

rosuvastatin (Crestor): equiv dose = 5

pravastatin (Pravachol): equiv dose = 40

lovastatin (Mevacor, Altoprev): equiv dose = 40. with food. 3A4 substrate (avoid inhibitors)

fluvastatin (Lescol): equiv dose = 80. with food, may increase INR in patients taking warfarin

pitavastatin (Livalo): equiv dose = 2. Reduce dose when CrCl <60. minimal CYP metabolism. CI with cyclosporine. monitor PT/INR after dose initiation of dose change of warfarin

19

How should Welchol tablets be administered?

A. On an empty stomach
B. With a meal and liquid
C. At bedtime
D. With liquids only
E. Without regards to meals

B. Welchol tablets should be administered with a meal and liquid.

Bile Acid Sequestrants/Bile Acid Binding Resins: binds bile acids in the intestine forming a complex that is excreted in the feces to reduce LDL (10-30%), but increase HDL (3-5%)/TG (5%). SE: constipation, dyspepsia, nausea, abdominal pain, cramping, gas, bloating, hypertriglyceridemia, esophageal obstruction, increase LFTs. Do not use when TG ≥300. Separate by 4 hours between other medications

cholestyramine (Questran): with meals. CI in complete biliary obstruction. pregnancy (C)

colesevelam (Welchol): take with meal or liquid. CI : bowel obstruction, TG>500, history of hypertriglyceridemia-induced pancreatitis. pregnancy (B)

colestipol (Colestid): pregnancy (C)

20

A patient gave the pharmacist a prescription for Mevacor 40 mg PO nightly with dinner. Which of the following is an appropriate generic substitution for Mevacor?

A. Atorvastatin
B. Lovastatin
C. Pravastatin
D. Simvastatin
E. Rosuvastatin

B. The generic name of Mevacor is lovastatin.

atorvastatin (Lipitor)

pravastatin (Pravachol)

simvastatin (Zocor)

rosuvastatin (Crestor)

21

Adjunct to diet, Myalept is indicated to treat:

A. Hypertriglyceridemia without congenital or acquired generalized lipodystrophy
B. Leptin deficiency with congenital or acquired generalized lipodystrophy
C. Leptin deficiency without congenital or acquired generalized lipodystrophy
D. HIV-related dystrophy
E. Metabolic disease

B. Myalept is indicated in leptin deficiency with congenital or acquired generalized lipodystrophy

22

Which fibrate has an indication for use with a statin?

A. Trilipix
B. Tricor
C. Lofibra
D. Lipofen
E. Fibricor

A. Only Trilipix has the indication to be used with a statin.

23

Jerry is a 70 year-old patient who was started on immediate-release niacin therapy. He is taking his medicine with food, and using an aspirin prior to the evening dose, but still gets hot, flushed and itchy. He asks if there is any form of niacin which would cause less flushing and itching. Which of the following niacin formulations have less flushing and itching? (Select ALLthat apply.)

A. Red yeast rice
B. Slo-Niacin
C. Niacor
D. Nicotine
E. Niaspan

B, E. Sustained-release and extended-release niacin have less (but still significant) flushing and itching.

Niacin: decreases rate of hepatic synthesis of VLDL and LDL to decrease LDL (5-25%) and TG (20-50%), and increase HDL (15-35%). Mainly used to decrease TG. Also known as nicotinic acid or vitamin B3. CI: active liver disease, active PUD, arterial bleeding, arterial hemorrhage. Warning: caution in unstable angina or acute phase of MI, hepatoxicity. SE: flushing (take ASA prior), pruritis, NVD, GI distress, hyperglycemia, hyperuricemia, cough, hepatotoxicity, orthostatic hypotension, hypophosphatemia. Take with food, but avoid hot liquids and spicy food which can worsen flushing.

niacin IR (Niacor): higher incidence of flushing (can take ASA prior)

niacin ER (Niaspan): best SE profile

niacin CR/SR (Slo-Niacin): high incidence of increase LFTs (monitor LFTs)

24

Which of the following patient types would benefit from high-intensity statin therapy according to the ACC/AHA Blood Cholesterol Guidelines? (Select ALL that apply.)

A. A 60 year old patient who is S/P MI
B. A 35 year old with a LDL of 140 mg/dL and no other comorbidies
C. A 80 year old patient who is S/P MI
D. A 45 year old patient with diabetes and a LDL of 140 mg/dL and no other comorbidities; 10-year ASCVD risk score is 6.5%
E. A 32 year old with a LDL of 195 mg/dL and no other comorbidites

A, E. Choices 1 and 5 represent the patient types that benefit from high-intensity statin treatment.

4 Groups indicated for Statin Therapy:

1. Clinical ASCVD: coronary heart disease (ACS, MI, angina, coronary revascularization), cerebral vascular disease (stroke, TIA), peripheral artery disease (PAD). ≤75 y/o = high intensity. >75 y/o = moderate intensity

2. Primary elevations of LDL ≥190mg/dL. high intensity

3. Diabetes and 40-75 year old with LDL 70-189mg/dL. 10-year ASCVD risk: ≥7.5% = high intensity, <7.5% = moderate intensity

4. 40-75 year old with LDL 70-189mg/dL and estimated 10-year ASCVD risk of ≥7.5% (using Global Risk Assessment Tool). moderate-to-high intensity, if <7.5% can consider risk benefit

25

Which of the following cholesterol-lowering agents can increase bleeding risk and should be used cautiously in at-risk patients?

A. Questran
B. Vascepa
C. Lipitor
D. Tricor
E. Trilipix

B. There is a theoretical risk of heightened bleeding risk which was not seen in clinical studies. To be on the safe side, watch for patients with increased bleeding risk and counsel on symptoms of bleeding. With warfarin use, the INR and bleeding signs and symptoms should be monitored. Use fish oils cautiously with the use of aspirin or other antiplatelets. The risk may be higher with higher doses.

Fish Oils: may be due to reduction of hepatic synthesis of TG. Reduce TG (45%) and increase HDL (9%). Indicated as adjunct to diet in patients with TG ≥500. Warning: caution with known hypersensitivity to fish/shellfish. SE: eructation (burping), dyspepsia, taste perversions (Lovaza, Epanova), arthralgias (Vascepa), pregnacy (C), can increase LDL. Stop prior to elective surgery (increase bleed risk)

Lovaza: may increase LDL. possible recurrences of Afib

Vascepa: taken following meals

Epanova: may increase LDL

Omtryg: take with meals

26

SJ is a 40 year old female being for evaluated for her dyslipidemia. She has an estimated ASCVD risk of 6.4%.
Current Medications: 
Hydrochlorothiazide 25 mg daily
Ambien 5 mg QHS PRN
Levothyroxine 112 mcg daily
Prenatal MVI daily 
Past Medical History:
Dyslipidemia
Hypertension
Insomnia
Hypothyroidism
Vitals:
Height: 5'6"                 Weight: 160 lbs
BP: 140/80 mmHg      HR: 85 BPM          RR: 20 BP
Temp: 98.6ºF              Pain: 1/10 
AST (units/L) =  24 (10 - 40)
ALT (units/L) = 21 (10 - 40)
CH, T (mg/dL) = 242 (125-200)
TG (mg/dL) = 189 (< 150)
HDL (mg/dL) = 38 ( > 40)
LDL (mg/dL) = 166 (< 100)
GLU (mg/dL) = 108 (65 - 99)
Na (mEq/L) = 141 (135 - 145)                    
K (mEq/L) = 4.2 (3.5 - 5)                         
Cl (mEq/L) = 100 (95 - 103)                      
HCO3 (mEq/L) = 28 (24 - 30)                     
BUN (mg/dL) = 18 (7 - 20)                        
SCr (mg/dL) = 0.9 (0.6 - 1.3)               
Mg (mEq/L) = 1.9 (1.3 - 2.1)
PO4 (mg/dL) = 4.4 (2.3 - 4.7)
Ca (mg/dL) = 9.5 (8.5 - 10.5)
TSH (mIU/L) = 2.2 (0.3 - 3.0)
hCG+    
What statin therapy is most appropriate for her?

A. Simvastatin 10 mg daily
B. Lovastatin 20 mg daily
C. Atorvastatin 20 mg daily
D. Rosuvastatin 20 mg daily
E. Statin therapy is not appropriate

E. Patient is hCG+, statins are pregnancy category X and should not be given to pregnant patients.

4 Groups indicated for Statin Therapy:

1. Clinical ASCVD: coronary heart disease (ACS, MI, angina, coronary revascularization), cerebral vascular disease (stroke, TIA), peripheral artery disease (PAD). ≤75 y/o = high intensity. >75 y/o = moderate intensity

2. Primary elevations of LDL ≥190mg/dL. high intensity

3. Diabetes and 40-75 year old with LDL 70-189mg/dL. 10-year ASCVD risk: ≥7.5% = high intensity, <7.5% = moderate intensity

4. 40-75 year old with LDL 70-189mg/dL and estimated 10-year ASCVD risk of ≥7.5% (using Global Risk Assessment Tool). moderate-to-high intensity, if <7.5% can consider risk benefit

27

What are the individual medicines included in the combination drug Vytorin?

A. Atorvastatin + Niacin
B. Atorvastatin + Ezetimibe
C. Lovastatin + Niacin
D. Simvastatin + Ezetimibe
E. Simvastatin + Niacin

D. Vytorin contains simvastatin and ezetimibe.

28

A prescriber ordered TriCor 145 mg daily for his patient. The pharmacy did not have this exact strength, but did have Lofibra134 mg. Can the pharmacist substitute Lofibra for the Tricor?

A. No, they are not interchangeable.
B. Yes, if the pharmacist does not have anything better.
C. Yes, because the doses are similar.
D. Yes, because Lofibra 134 mg is bioequivalent to TriCor 145 mg.
E. Yes, because he checked the Red Book.

A. The fenofibrates come in different strengths and often with different delivery mechanisms. If you want to dispense a generic, you may need to call prescriber for a close strength and try to match one with a similar delivery technology. Some formulations, such as the micronized formulations, are used to improve bioavailability.

29

A patient's triglycerides were recorded at 282 mg/dL. In which of the following conditions are the fenofibrate agents contraindicated? (Select ALL that apply.)

A. Heart failure
B. Gout
C. Gallbladder disease
D. Pregnancy
E. Severe liver disease

C, E. In addition to the above conditions, these drugs cannot be used in nursing mothers or in severe kidney disease.

Fibrates: peroxisome proliferator receptor alpha (PPARa) activators, which upregulates the expression of apolipoprotein CII and apolipoprotein A-I to reduce TG (20-50%) and LDL (5-20%), and increase HDL (15%). Mainly used to decrease TG. CI: severe liver disease, severe renal disease (CrCl <30), gallbladder disease, nursing mothers. Warning: myopathy, increase risk with statin (elderly, diabetes, renal failure, hypothyroidism). SE: increase LFts, abdominal pain, increase CPK, dyspepsia, URTIs, pregnancy (C)

fenofibrate, fenofibric acid (TriCor, Trilipix):

gemfibrozil (Lopid): taken 30 minutes before breakfast and dinner. CI with repaglinide

30

Which of the following cholesterol-lowering drug classes require liver enzyme monitoring at baseline due to a risk of hepatotoxicity? (Select ALL that apply.)

A. Fish oils
B. Niacins
C. Fenofibrates
D. Statins
E. Bile acid sequestrants

B, C, D. Niacins, statin, and the fibrates could possibly cause liver damage and liver enzymes should be monitored. In recent years it has been recognized that statins do not cause liver damage worse than placebo in most patients, but the guidelines state to check at baseline and consider if the statin could be contributory if the liver is damaged and no other cause can be identified.

31

Which of the following medications should be avoided with simvastatin? (Select ALL that apply.)

A. Lopid
B. VFEND
C. Theo-24
D. Plavix
E. Biaxin

A, B, E. Biaxin, Lopid and VFEND should be avoided with simvastatin (and lovastatin) therapy.

simvastatin (Zocor), Vytorin (simvastatin/ezetimibe): equiv dose = 20. 3A4 substrate (avoid inhibitors)

32

Which of the following drugs could raise lipoprotein levels? (Select ALL that apply.)

A. Montelukast
B. Cyclosporine
C. Amiodarone
D. Prednisone
E. Beta-blockers

B, C, D, E.

Drugs (increase LDL): diuretics, cyclosporine, tacrolimus, glucocorticoids, amiodarone, some progestins, danazol, isotretinoin, thiazolidinediones, anabolic steroids, sodium-glucose cotransporter 2 inhibitors, fibric acids, protease inhibitors, atypical antipsychotics

Drugs (increase TG): oral estrogen, glucocorticoids, bile acid sequestrants, protease inhibitors, retinoids, anabolic steroids, sirolimus, cyclosporine, tacrolimus, raloxifene, tamoxifen, beta blockers (not carvedilol), thiazides, atypical antipsychotics, alpha interferons, propofol

33

What is the indication for Lovaza?

A. To lower LDL cholesterol in patients with an LDL cholesterol ≥ 200 mg/dL.
B. To lower triglycerides in patients with TGs ≥ 500 mg/dL as an adjunct to diet.
C. To increase HDL in patients with familial-induced low HDL levels.
D. To reduce the risk of statin-induced muscle damage.
E. To lower triglycerides in patients with TGs ≥ 400 mg/dL as an adjunct to diet.

B. Lovaza is indicated in patients with TGs ≥ 500 mg/dL as an adjunct to diet.

Fish Oils: may be due to reduction of hepatic synthesis of TG. Reduce TG (45%) and increase HDL (9%). Indicated as adjunct to diet in patients with TG ≥500. Warning: caution with known hypersensitivity to fish/shellfish. SE: eructation (burping), dyspepsia, taste perversions (Lovaza, Epanova), arthralgias (Vascepa), pregnacy (C), can increase LDL. Stop prior to elective surgery (increase bleed risk)

Lovaza: may increase LDL. possible recurrences of Afib

Vascepa: taken following meals

Epanova: may increase LDL

Omtryg: take with meals

34

How often should the Global Risk Assessment tool be done if a patient is classified as low risk?

A. Yearly
B. Semi-annually
C. Every 3 years
D. Every 4-6 years
E. Every 10 years

D. According the the ACC/AHA Blood Cholesterol Guidelines, the Global Risk Assessment tool should be repeated every 4-6 years in low risk patients.

35

In addition to an approval for lowering cholesterol when statins alone are not enough or when statins cannot be tolerated,Welchol has an additional indication for the following condition:

A. To reduce pain in rheumatoid arthritis.
B. To help lower postprandial blood glucose in diabetes.
C. To reduce uric acid in gout.
D. To decrease cardiac remodeling in heart failure.
E. To decrease symptoms associated with Crohn's disease or ulcerative colitis.

B. Welchol can lower hemoglobin A1C ~ 0.5% by decreasing postprandial blood glucose.

36

Which of the following statin regimens are considered high-intensity statin therapy? (Select ALL that apply.)

A. Crestor 40 mg daily
B. Lipitor 20 mg daily
C. Crestor 10 mg daily
D. Lipitor 40 mg daily
E. Zocor 40 mg daily

A, D.

Statin Therapy Intensity

High (lowers LDL ≥50%): atorvastatin 40-80, rosuvastatin 20-40

Moderate (lowers LDL 30-49%): atorvastatin 10-20, rosuvastatin 5-10, simvastatin 20-40, pravastatin 40-80, lovastatin 40, fluvastatin 80, pitavastatin 2-4

Low (lower LDL <30%): simvastatin 10, pravastatin 10-20, lovastatin 20, fluvastatin 20-40, pitavastatin 1

37

Maurice is a 58 year-old male with dyslipidemia and prostate enlargement. His only medication is tamsulosin 0.4 mg daily. He states that he cannot tolerate pravastatin due to muscle aches and joint pain. His cholesterol panel has the following values: Total CH 188 mg/dL, HDL 36 mg/dL, and TG 338 mg/dL. Calculate the patient's LDL cholesterol:

A. 64 mg/dL
B. 84 mg/dL
C. 104 mg/dL
D. 114 mg/dL
E. 125 mg/dL

B. LDL is calculated using the Friedewald equation LDL = TC - HDL - (TG/5). (TC is the total cholesterol). This formula cannot be used to estimate the LDL if the TGs are > 400 mg/dL; in this case, the LDL must be measured directly.

38

A patient is going to start niacin therapy. Which of the following are side effects of niacin? (Select ALL that apply.)

A. Renal impairment
B. Increase in blood sugar
C. Increase in blood pressure
D. Increase in uric acid
E. Flushing

B, D, E. Niacin does not increase BP (it can lower it) or cause renal impairment.

Niacin: decreases rate of hepatic synthesis of VLDL and LDL to decrease LDL (5-25%) and TG (20-50%), and increase HDL (15-35%). Mainly used to decrease TG. Also known as nicotinic acid or vitamin B3. CI: active liver disease, active PUD, arterial bleeding, arterial hemorrhage. Warning: caution in unstable angina or acute phase of MI, hepatoxicity. SE: flushing (take ASA prior), pruritis, NVD, GI distress, hyperglycemia, hyperuricemia, cough, hepatotoxicity, orthostatic hypotension, hypophosphatemia. Take with food, but avoid hot liquids and spicy food which can worsen flushing.

niacin IR (Niacor): higher incidence of flushing (can take ASA prior)

niacin ER (Niaspan): best SE profile

niacin CR/SR (Slo-Niacin): high incidence of increase LFTs (monitor LFTs)

39

A patient with a history of gout is going to start niacin therapy. Which of the following statements are correct?

A. Niacin is contraindicated in gout, even if controlled with a uric acid lowering agent.
B. Niacin does not have an effect on uric acid.
C. Niacin will decrease the risk of the patient developing gout.
D. Niacin blocks xanthine oxidase.
E. Niacin should be used with caution if a patient has gout.

E. Niacin can raise uric acid levels and should be used with caution in patients with gout.

Niacin: decreases rate of hepatic synthesis of VLDL and LDL to decrease LDL (5-25%) and TG (20-50%), and increase HDL (15-35%). Mainly used to decrease TG. Also known as nicotinic acid or vitamin B3. CI: active liver disease, active PUD, arterial bleeding, arterial hemorrhage. Warning: caution in unstable angina or acute phase of MI, hepatoxicity. SE: flushing (take ASA prior), pruritis, NVD, GI distress, hyperglycemia, hyperuricemia, cough, hepatotoxicity, orthostatic hypotension, hypophosphatemia. Take with food, but avoid hot liquids and spicy food which can worsen flushing.

niacin IR (Niacor): higher incidence of flushing (can take ASA prior)

niacin ER (Niaspan): best SE profile

niacin CR/SR (Slo-Niacin): high incidence of increase LFTs (monitor LFTs)

40

Which of the following parameters are assessed on the Global Risk Assessment tool? (Select ALL that apply.)

A. Age
B. LDL level
C. Total cholesterol
D. HDL
E. Gender

A, C, D, E. These are part of the 9 parameters that are evaluated on the Global Risk Assessment tool.

Global risk assessment done every 4-6 years.

Gender, age, race, TC, HDL, SBP, BP treatment, diabetes, smoking

41

A patient gave the pharmacist a prescription for Livalo 2 mg PO daily. Which of the following is the generic name for Livalo?

A. Fluvastatin
B. Lovastatin
C. Pravastatin
D. Pitavastatin
E. Rosuvastatin

D. The generic name of Livalo is pitavastatin.

fluvastatin (Lescol)

lovastatin (Mevacor, Altoprev)

pravastatin (Pravachol)

rosuvastatin (Crestor)

42

Lovaza should be dispensed with caution to a patient with this allergy:

A. Fish or shellfish
B. Dairy
C. Sulfa
D. Soy or peanuts
E. Fenofibrate medications

A. Lovaza is concentrated omega-3 fatty acids from fish and should be used with caution in a patient with fish and/or shellfish allergy. Usually, people are allergic to the meat of the fish and this product would not be expected to produce a reaction. However, caution is advised.

Fish Oils: may be due to reduction of hepatic synthesis of TG. Reduce TG (45%) and increase HDL (9%). Indicated as adjunct to diet in patients with TG ≥500. Warning: caution with known hypersensitivity to fish/shellfish. SE: eructation (burping), dyspepsia, taste perversions (Lovaza, Epanova), arthralgias (Vascepa), pregnacy (C), can increase LDL. Stop prior to elective surgery (increase bleed risk)

Lovaza: may increase LDL. possible recurrences of Afib

Vascepa: taken following meals

Epanova: may increase LDL

Omtryg: take with meals

43

Which three statins undergo first pass metabolism by which CYP enzyme?

A. Simvastatin, lovastatin, rosuvastatin; CYP3A4
B. Simvastatin, fluvastatin, atorvastatin; CYP2D6
C. Simvastatin, lovastatin, pravastatin; CYP2C19
D. Simvastatin, lovastatin, atorvastatin; CYP3A4
E. Simvastatin, lovastatin, atorvastatin; CYP2D6

D. Simvastatin, atorvastatin, and lovastatin all undergo first pass metabolism by CYP3A4. Therefore these three statins have many drug interactions and doses need to be adjusted accordingly.

44

What effects can gemfibrozil have on lipids? (Select ALL that apply.)

A. Decreases TG
B. Increases HDL
C. Decreases LDL
D. Increases LDL
E. Decreases HDL

A, B, C, D. Fibrates, such as gemfibrozil, generally decrease TG by 20-50%, increase HDL by 15%, and decrease LDL by 5-20%. However, if TG levels are high, LDL can actually be increased.

Fibrates: peroxisome proliferator receptor alpha (PPARa) activators, which upregulates the expression of apolipoprotein CII and apolipoprotein A-I to reduce TG (20-50%) and LDL (5-20%), and increase HDL (15%). Mainly used to decrease TG. CI: severe liver disease, severe renal disease (CrCl <30), gallbladder disease, nursing mothers. Warning: myopathy, increase risk with statin (elderly, diabetes, renal failure, hypothyroidism). SE: increase LFts, abdominal pain, increase CPK, dyspepsia, URTIs, pregnancy (C)

fenofibrate, fenofibric acid (TriCor, Trilipix):

gemfibrozil (Lopid): taken 30 minutes before breakfast and dinner. CI with repaglinide

45

DL is a 61 y/o male being seen for routine follow up including his risk for ASCVD.
Current Medications: 
Inderal LA 80 mg daily 
Hydrochlorothiazide 25 mg daily 
Prinivil 10 mg daily
Mylanta 20 mL Q6H
Plavix 75 mg daily
Aspirin 81 mg
Nitroglycerin 0.3 mg PRN
MVI daily   
Past Medical History: 
Hypertension
Dyslipidemia
GERD
s/p MI  
Vitals:
Height: 5'11"                   Weight: 202 lbs
BP: 140/80 mmHg           HR: 85 BPM           RR: 20 BPM
Temp: 98.6ºF                   Pain: 1/10   
Labs: 
AST (units/L) =  32 (10 - 40)
ALT (units/L) = 20 (10 - 40)
CH, T (mg/dL) = 221 (125 - 200)
TG (mg/dL) = 238 (< 150)
HDL (mg/dL) = 32 (> 40)
LDL (mg/dL) = 
GLU (mg/dL) = 108 (65 - 99)
Na (mEq/L) = 143 (135 - 145)                     
K (mEq/L) = 4.1 (3.5 - 5)                           
Cl (mEq/L) = 102 (95 - 103)                        
HCO3 (mEq/L) = 26 (24 - 30)                      
BUN (mg/dL) = 15 (7 - 20)                          
SCr (mg/dL) = 0.8 (0.6 - 1.3)                
Mg (mEq/L) = 1.8 (1.3 - 2.1)
PO4 (mg/dL) = 4.1 (2.3 - 4.7)
Ca (mg/dL) = 9.7 (8.5 - 10.5)
TSH (mIU/L) = 1.8 (0.3 - 3.0)
Free T4 (mg/dL) = 0.7 (0.9 - 2.3)  
What is DL’s calculated LDL? 

A. 129 mg/dL
B. 141 mg/dL
C. 149 mg/dL
D. 161 mg/dL
E. 173 mg/dL

B. LDL is calculated using the Friedewald equation

Friedewald equation: LDL = TC – HDL – (TG/5)

46

Which of the following statements regarding Lovaza are true? (Select ALL that apply.)

A. Lovaza can be tried as an alternative to fenofibrates for lowering TGs.
B. Lovaza must be used in addition to a low-fat diet.
C. If the patient uses OTC fish oils, they may need to double the amount of capsules to get similar TG lowering.
D. Lovaza does not increase LDL levels.
E. The max dose of Lovaza is 2 capsules per day.

A, B, C. The usual dose of Lovaza is 4 capsules daily, which can be divided BID. OTC fish oils, which are not regulated by the FDA, may not have uniform potency of the fish oils and more capsules may be need to get the same TG-lowering effect.

47

A patient brings a prescription for Niacor to the pharmacy, but it is not in stock. However, Niaspan is in stock and Slo-Niacin is available over the counter. What should be recommended?

A. Dispense Niaspan only
B. Dispense Slo-Niacin only
C. Dispense Niaspan or Slo-Niacin
D. Dispense Niaspan and Slo-Niacin and recommend concurrent use
E. Do not dispense

E. Do not substitute an immediate release formulation for an extended release formulation. These formulations are not interchangeable.

48

Which of the following statements are correct concerning bile acid sequestrants? (Select ALL that apply.)

A. Sipping or holding the cholestyramine suspension in the mouth can lead to tooth decay.
B. These agents can lower TGs significantly.
C. These agents can cause diarrhea.
D. The patient should be told to take a multivitamin at a separate time due to a possible risk of decreased A, D, E and K absorption.
E. Colesevelam is only available as tablets.

A, D. The agents in this class can cause constipation and adequate fluid and fiber intake is required; a laxative may be needed. Instruct the patient to maintain adequate fluid intake and to take a multivitamin at another time of day.

Bile Acid Sequestrants/Bile Acid Binding Resins: binds bile acids in the intestine forming a complex that is excreted in the feces to reduce LDL (10-30%), but increase HDL (3-5%)/TG (5%). SE: constipation, dyspepsia, nausea, abdominal pain, cramping, gas, bloating, hypertriglyceridemia, esophageal obstruction, increase LFTs. Do not use when TG ≥300. Separate by 4 hours between other medications

cholestyramine (Questran): with meals. CI in complete biliary obstruction. pregnancy (C)

colesevelam (Welchol): take with meal or liquid. CI : bowel obstruction, TG>500, history of hypertriglyceridemia-induced pancreatitis. pregnancy (B)

colestipol (Colestid): pregnancy (C)

49

Which of the following side effects are associated with statin use? (Select ALL that apply.)

A. Risk of diabetes
B. Memory loss
C. Cough
D. Myopathy
E. Gingival hyperplasia

A, B, D. Alopecia and gingival hyperplasia are not side effects of statin therapy.

Statins: inhibits HMG-CoA reductase preventing the conversion of HMG-CoA to mevalonate (the rate-limiting step in cholesterol synthesis) resulting in LDL reduction (20-55%), TG reduction (10-30%), increasing HDL (5-15%). CI: active liver disease, pregnancy (X), breastfeeding, concurrent 3A4 inhibitors (with simvastatin & lovastatin) cyclosporine use (pitavastatin only). Warning: skeletal muscle effects (myopathy, rhabdomyolysis), diabetes, liver enzyme elevations. SE: myalgias, arthralgias, myopathy, diarrhea, increase CPK, rhabdomyolysis, cognitive impairment (memory loss, confusion), increase blood glucose, increase A1C, increase LFTs, risk of cataracts. Reduce dose when CrCl <30 (except with Lipitor). Dosed in the evening: simvastatin, lovastatin, fluvastatin ("Sam Loathes the Flu")

atorvastatin (Lipitor): equiv dose = 10. Does not need dose reduction when CrCl <30.

simvastatin (Zocor), Vytorin (simvastatin/ezetimibe): equiv dose = 20. 3A4 substrate (avoid inhibitors)

rosuvastatin (Crestor): equiv dose = 5

pravastatin (Pravachol): equiv dose = 40

lovastatin (Mevacor, Altoprev): equiv dose = 40. with food. 3A4 substrate (avoid inhibitors)

fluvastatin (Lescol): equiv dose = 80. with food, may increase INR in patients taking warfarin

pitavastatin (Livalo): equiv dose = 2. Reduce dose when CrCl <60. minimal CYP metabolism. CI with cyclosporine. monitor PT/INR after dose initiation of dose change of warfarin

50

A patient with chronic angina is currently taking aspirin, diltiazem, metoprolol and ranolazine. The physician wants to start the patient on simvastatin. Which of the following statements is correct regarding simvastatin in this patient?

A. The maximum dose of simvastatin is 10 mg daily due to the drug interaction with ranolazine.
B. The maximum dose of simvastatin is 40 mg daily due to the drug interaction with ranolazine.
C. The maximum dose of simvastatin is 10 mg daily due to the drug interaction with diltiazem.
D. The maximum dose of simvastatin is 20 mg daily due to the drug interaction with diltiazem.
E. Simvastatin is contraindicated in patients with chronic angina.

C. The maximum dose of simvastatin is 10 mg daily when a patient is taking diltiazem and 20 mg daily when taking ranolazine.

51

Select the correct mechanism of action of Welchol:

A. It reduces cholesterol absorption at the brush-border.
B. It is a peroxisome proliferator alpha activator.
C. It increases HDL synthesis.
D. It inhibits the enzyme HMG-CoA reductase.
E. It binds to bile acids in the gut.

E. Bile acid sequestrants bind bile acids in the intestines and block reabsorption. The bound bile acids are eliminated in the stool. The body will then need to use more cholesterol to make more bile acids. This reduces the serum cholesterol level.

Bile Acid Sequestrants/Bile Acid Binding Resins: binds bile acids in the intestine forming a complex that is excreted in the feces to reduce LDL (10-30%), but increase HDL (3-5%)/TG (5%). SE: constipation, dyspepsia, nausea, abdominal pain, cramping, gas, bloating, hypertriglyceridemia, esophageal obstruction, increase LFTs. Do not use when TG ≥300. Separate by 4 hours between other medications

cholestyramine (Questran): with meals. CI in complete biliary obstruction. pregnancy (C)

colesevelam (Welchol): take with meal or liquid. CI : bowel obstruction, TG>500, history of hypertriglyceridemia-induced pancreatitis. pregnancy (B)

colestipol (Colestid): pregnancy (C)

52

A patient was prescribed atorvastatin 20 mg daily and returns to the clinic after having blood tests performed. His transaminases are elevated two times above the upper limit of normal (ULN). His primary care physician asks at what level should his statin therapy be discontinued due to elevated hepatic transaminase levels?

A. 2 times ULN; discontinue therapy now
B. 3 times ULN
C. 4 times ULN
D. 5 times ULN
E. 10 times ULN

B. Statins should be stopped once the LFTs are 3 times above the upper limit of normal (ULN).

53

Which statins can be taken any time of the day? (Select ALL that apply.)

A. Crestor
B. Simvastatin
C. Lovastatin
D. Lipitor
E. Livalo

A, D, E. Crestor, Lipitor, Livalo, Lescol XL and Pravachol can be taken at any time of day. Simvastatin is taken in the evening. Lovastatin IR is taken in the evening while lovastatin ER is taken at bedtime.

Dosed in the evening: simvastatin, lovastatin, fluvastatin ("Sam Loathes the Flu")

54

A patient gave the pharmacist a prescription for Pravachol 40 mg PO daily. Which of the following is an appropriate generic substitution for Pravachol?

A. Atorvastatin
B. Lovastatin
C. Pravastatin
D. Pitavastatin
E. Rosuvastatin

C. The generic name of Pravachol is pravastatin.

atorvastatin (Lipitor)

lovastatin (Mevacor, Altoprev)

pitavastatin (Livalo)

rosuvastatin (Crestor)

55

What effects do statins have on cholesterol values? (Select ALL that apply.)

A. Raises HDL
B. Lowers HDL
C. Raises triglycerides
D. Lowers LDL
E. Lowers triglycerides

A, D, E. Statins raise HDL and lower TGs and LDL.

Statins: inhibits HMG-CoA reductase preventing the conversion of HMG-CoA to mevalonate (the rate-limiting step in cholesterol synthesis) resulting in LDL reduction (20-55%), TG reduction (10-30%), increasing HDL (5-15%). CI: active liver disease, pregnancy (X), breastfeeding, concurrent 3A4 inhibitors (with simvastatin & lovastatin) cyclosporine use (pitavastatin only). Warning: skeletal muscle effects (myopathy, rhabdomyolysis), diabetes, liver enzyme elevations. SE: myalgias, arthralgias, myopathy, diarrhea, increase CPK, rhabdomyolysis, cognitive impairment (memory loss, confusion), increase blood glucose, increase A1C, increase LFTs, risk of cataracts. Reduce dose when CrCl <30 (except with Lipitor). Dosed in the evening: simvastatin, lovastatin, fluvastatin ("Sam Loathes the Flu")

56

Nancy, a 64 year old female, has diabetes, heart failure and hyperlipidemia. She has been using atorvastatin 40 mg daily for the past four months. She is adherent with therapy. Her LDL was taken today and reported to be 124 mg/dL. Nancy's physician determines her LDL goal should be <100 mg/dL. Her physician wishes to double the atorvastatin dose; he states this will help Nancy reach her LDL goal. Choose the correct statement.

A. Doubling the atorvastatin dose will likely lower the LDL to below 100 mg/dL.
B. The patient may be able to reach the correct LDL goal if she switches to pitavastatin.
C. Her LDL goal should be less than 130 mg/dL; therefore, she is at goal.
D. Atorvastatin is contraindicated in patients with heart failure.
E. According to the ACC/AHA Blood Cholesterol Guidelines, treating to specific LDL targets is no longer recommended.

E. Nancy is currently taking the appropriate intensity statin therapy and the guidelines no longer treat to a specific LDL goal.

4 Groups indicated for Statin Therapy:

1. Clinical ASCVD: coronary heart disease (ACS, MI, angina, coronary revascularization), cerebral vascular disease (stroke, TIA), peripheral artery disease (PAD). ≤75 y/o = high intensity. >75 y/o = moderate intensity

2. Primary elevations of LDL ≥190mg/dL. high intensity

3. Diabetes and 40-75 year old with LDL 70-189mg/dL. 10-year ASCVD risk: ≥7.5% = high intensity, <7.5% = moderate intensity

4. 40-75 year old with LDL 70-189mg/dL and estimated 10-year ASCVD risk of ≥7.5% (using Global Risk Assessment Tool). moderate-to-high intensity, if <7.5% can consider risk benefit

Statin Therapy Intensity

High (lowers LDL ≥50%): atorvastatin 40-80, rosuvastatin 20-40

Moderate (lowers LDL 30-49%): atorvastatin 10-20, rosuvastatin 5-10, simvastatin 20-40, pravastatin 40-80, lovastatin 40, fluvastatin 80, pitavastatin 2-4

Low (lower LDL <30%): simvastatin 10, pravastatin 10-20, lovastatin 20, fluvastatin 20-40, pitavastatin 1

57

A patient with atrial fibrillation is currently taking aspirin, metoprolol, digoxin and verapamil. The physician wants to start the patient on lovastatin. Which of the following statements is correct regarding lovastatin in this patient?

A. The maximum dose of lovastatin is 20 mg daily due to the drug interaction with verapamil.
B. The maximum dose of lovastatin is 40 mg daily due to the drug interaction with verapamil.
C. The maximum dose of lovastatin is 20 mg daily due to the drug interaction with digoxin.
D. The maximum dose of lovastatin is 40 mg daily due to the drug interaction with digoxin.
E. Lovastatin is contraindicated in patients with atrial fibrillation.

A. The maximum dose of lovastatin is 20 mg daily when a patient is taking verapamil.

58

Which of the following statins should be taken with the evening meal?

A. Atorvastatin
B. Lovastatin immediate-release
C. Pravastatin
D. Simvastatin
E. Lovastatin extended-release

B. Only lovastatin immediate-release (Mevacor) needs to be taken with the evening meal.

atorvastatin (Lipitor): equiv dose = 10. Does not need dose reduction when CrCl <30.

simvastatin (Zocor), Vytorin (simvastatin/ezetimibe): equiv dose = 20. 3A4 substrate (avoid inhibitors)

rosuvastatin (Crestor): equiv dose = 5

pravastatin (Pravachol): equiv dose = 40

lovastatin (Mevacor, Altoprev): equiv dose = 40. with food. 3A4 substrate (avoid inhibitors)

fluvastatin (Lescol): equiv dose = 80. with food, may increase INR in patients taking warfarin

pitavastatin (Livalo): equiv dose = 2. Reduce dose when CrCl <60. minimal CYP metabolism. CI with cyclosporine. monitor PT/INR after dose initiation of dose change of warfarin

59

Which fibrate is given twice daily?

A. Trilipix
B. Tricor
C. Lofibra
D. Antara
E. Lopid

E. Lopid is dosed 600 mg BID, 30 minutes before breakfast and dinner.

Fibrates: peroxisome proliferator receptor alpha (PPARa) activators, which upregulates the expression of apolipoprotein CII and apolipoprotein A-I to reduce TG (20-50%) and LDL (5-20%), and increase HDL (15%). Mainly used to decrease TG. CI: severe liver disease, severe renal disease (CrCl <30), gallbladder disease, nursing mothers. Warning: myopathy, increase risk with statin (elderly, diabetes, renal failure, hypothyroidism). SE: increase LFts, abdominal pain, increase CPK, dyspepsia, URTIs, pregnancy (C)

fenofibrate, fenofibric acid (TriCor, Trilipix):

gemfibrozil (Lopid): taken 30 minutes before breakfast and dinner. CI with repaglinide

60

Which groups would find benefit from statin therapy according to the ACC/AHA Blood Cholesterol Guidelines? (Select ALLthat apply.)

A. Patients who have a coronary stent placed 4 years ago
B. Patients who have a LDL value > 160 mg/dL
C. A 45 year old patient with diabetes and a LDL of 95 mg/dL
D. A 25 year old patient with diabetes and a LDL of 101 mg/dL
E. A 55 year old patient with an estimated 10 year ASCVD risk of 6%

A, C. There are 4 high risk groups that should be started on statin therapy. Choices 1 and 3 represent patients included in these groups.

4 Groups indicated for Statin Therapy:

1. Clinical ASCVD: coronary heart disease (ACS, MI, angina, coronary revascularization), cerebral vascular disease (stroke, TIA), peripheral artery disease (PAD). ≤75 y/o = high intensity. >75 y/o = moderate intensity

2. Primary elevations of LDL ≥190mg/dL. high intensity

3. Diabetes and 40-75 year old with LDL 70-189mg/dL. 10-year ASCVD risk: ≥7.5% = high intensity, <7.5% = moderate intensity

4. 40-75 year old with LDL 70-189mg/dL and estimated 10-year ASCVD risk of ≥7.5% (using Global Risk Assessment Tool). moderate-to-high intensity, if <7.5% can consider risk benefit

61

What statements are true about lomitapide? (Select ALL that apply.)

A. It is pregnancy category X
B. It has a boxed warning for renal toxicity
C. It is indicated for homozygous familial hypercholesterolemia
D. It has a boxed warning for hepatotoxicity
E. Enrollment in REMS program is not required

A, C, D. Lomitapide is indicated for homozygous familial hypercholesterolemia, is pregnancy X, and has a boxed warning for hepatotoxicity. Enrollment in the REMS program is required for use. There is no boxed warning for renal toxicity.

lomitapide (Juxtapid): binds to and inhibits microsomal triglyceride transfer protein (MTP) to prevent assembly of Apo-B containing lipoproteins. PO daily. Boxed warning: hepatotoxicity (REMS). CI: pregnancy (X), use with mod-strong 3A4 inhibitors, mod-severe hepatic impairment, active liver disease. Warning: GI effects may affect absorption of PO meds. SE: diarrhea, nausea, vomiting, dyspepsia, abdominal pain, constipation, flatulence, increase LFTs, chest/back pain, fatigue

62

A 42 year old patient returns to clinic to initiate statin therapy. He has diabetes, hypertension, HIV, and an ASCVD risk of 8.6%. His calculated LDL is 159 mg/dL. He is on Glucophage, Zestril, Vascepa, Prezista, Norvir, and Truvada. Patient is a non-smoker but has an alcoholic drink twice a month. Which statin regimen should be recommended?

A. Atorvastatin 80 mg
B. Rosuvastatin 10 mg
C. Atorvastatin 20 mg
D. Atorvastatin 40 mg
E. Rosuvastatin 20 mg

E. Patient requires a high intensity statin which is either atorvastatin 40 – 80 mg or rosuvastatin 20 - 40 mg. However, since he is on darunavir/ritonavir, his atorvastatin dose should not exceed 20 mg. Therefore, the most appropriate choice is rosuvastatin 20 mg.

63

What other names is niacin known by? (Select ALL that apply.)

A. B1
B. B2
C. B3
D. Biotin
E. Nicotinic Acid

C, E. Niacin is also known as nicotinic acid or B3.

Niacin: decreases rate of hepatic synthesis of VLDL and LDL to decrease LDL (5-25%) and TG (20-50%), and increase HDL (15-35%). Mainly used to decrease TG. Also known as nicotinic acid or vitamin B3. CI: active liver disease, active PUD, arterial bleeding, arterial hemorrhage. Warning: caution in unstable angina or acute phase of MI, hepatoxicity. SE: flushing (take ASA prior), pruritis, NVD, GI distress, hyperglycemia, hyperuricemia, cough, hepatotoxicity, orthostatic hypotension, hypophosphatemia. Take with food, but avoid hot liquids and spicy food which can worsen flushing.

niacin IR (Niacor): higher incidence of flushing (can take ASA prior)

niacin ER (Niaspan): best SE profile

niacin CR/SR (Slo-Niacin): high incidence of increase LFTs (monitor LFTs)

64

Which of the following formulations of niacin have less flushing and itching and relatively lower risk of hepatotoxicity?

A. Niaspan
B. Slo-Niacin
C. Niacor
D. Advicor
E. Simcor

A. The best clinical choice is Niaspan, which has decreased side effects without an increased risk of liver damage.

Niacin: decreases rate of hepatic synthesis of VLDL and LDL to decrease LDL (5-25%) and TG (20-50%), and increase HDL (15-35%). Mainly used to decrease TG. Also known as nicotinic acid or vitamin B3. CI: active liver disease, active PUD, arterial bleeding, arterial hemorrhage. Warning: caution in unstable angina or acute phase of MI, hepatoxicity. SE: flushing (take ASA prior), pruritis, NVD, GI distress, hyperglycemia, hyperuricemia, cough, hepatotoxicity, orthostatic hypotension, hypophosphatemia. Take with food, but avoid hot liquids and spicy food which can worsen flushing.

niacin IR (Niacor): higher incidence of flushing (can take ASA prior)

niacin ER (Niaspan): best SE profile

niacin CR/SR (Slo-Niacin): high incidence of increase LFTs (monitor LFTs)

65

Which counseling point is true for niacin?

A. Separate niacin and multivitamins by at least 2 hours
B. Avoid dairy-containing products
C. Take niacin 4-6 hours after bile acid sequestrants
D. Take with hot beverages
E. Take with spicy food

C. Take niacin 4-6 hours after bile acid sequestrants to avoid decreased absorption. Hot beverages and spicy food should be avoided to decrease flushing.

66

A patient comes to the pharmacy with a prescription for Niaspan. Which is the best way to counsel the patient regarding administration?

A. Take this medication in the morning, at breakfast.
B. Take this medication at dinner.
C. Take with medication on an empty stomach.
D. Take this medication at bedtime, after a low fat snack.
E. Take this medication after a low fat snack.

D. Niaspan is taken at bedtime after a low-fat snack.

67

A 47 year old patient comes to the clinic for routine follow up. The patient has hypertension and is a smoker. The Global Risk Assessment score for this patient is 8.5%. Laboratory assessment reveals the following:
Na+ 135 mEq/L, K+ 4.5 mEq/L, SCr 2.1 mg/dL, AST 187 units/L, ALT 217 units/L, A1C 6.2%, LDL 140 mg/dL.
Which of the following would be the best recommendation to treat according to the ACC/AHA Blood Cholesterol Guidelines?

A. Initiate simvastatin 20 mg daily
B. Initiate ezetimibe 10 mg daily
C. Initiate gemfibrozil 600 mg BID
D. Initiate atorvastatin 40 mg daily
E. None of the above options are appropriate.

E. This patient should not be started on a statin, ezetimibe, or a fibrate due to liver impairment.

68

Lifestyle recommendations should be made to patients with hyperlipidemia. These recommendations include: (Select ALLthat apply.)

A. BMI should be between 18.5-24.9 kg/m2
B. Exercise 2-3 sessions per week, each session lasting 20-30 minutes
C. Saturated fat intake should be 5-6% of total daily calories
D. Consume vegetables, fruits and whole grains
E. Be careful to consume more eggs, bacon, and sausage

A, C, D. Moderate-to-vigorous intensity exercise 3-4 sessions per week with each session lasting 40 minutes is recommended in the lifestyle management to reduce cardiovascular risk guideline.

69

Which of the following cholesterol medications should not be taken with grapefruit or grapefruit juice?

A. Trilipix
B. Welchol
C. Zocor
D. Vascepa
E. Pravachol

C. Lovastatin, simvastatin and atorvastatin cannot be taken with grapefruit. The other statins do not have a grapefruit interaction. Counsel patients to avoid grapefruit (the juice and the fruit), or try an alternative drug that does not interact. Separating the time a person drinks or eats grapefruit from the drug will not work, unless it is separated by at least several days. Grapefruit inhibits the drug-metabolizing enzyme; it is not a gut-binding interaction that could be helped by separation.

70

Which of the following statements concerning simvastatin is correct?

A. Simvastatin should be taken with food.
B. Liver enzymes should be checked at baseline.
C. Simvastatin should be taken with breakfast.
D. The brand name of simvastatin is Crestor.
E. Simvastatin can cause an increase in fractures in the elderly.

B. Simvastatin is taken at bedtime, with or without food. Simvastatin has a short half life and must be in the body during sleep when most cholesterol synthesis occurs. The risk of liver damage is considered negligible, however liver enzymes are checked at baseline. If liver damage occurs and another etiology cannot be identified then the statin therapy should be stopped.

71

Tyrone, a 51 year old male, is being seen for a routine physical exam. His past medical history is significant for hypertension and a previous ischemic stroke. Which of the following actions would be in accordance with the ACC/AHA Blood Cholesterol Guidelines?

A. Assess ASCVD risk by using the Global Risk Assessment tool
B. Check a lipid panel to decide if Tyrone should be started on statin therapy
C. Initiate Crestor 20 mg daily
D. Initiate Lipitor 20 mg daily
E. Tyrone does not need to be started on statin therapy at this time. Reassess in 5 years.

C. Tyrone has clinical ASCVD as evidence by his previous ischemic stroke. He should be started on high-intensity statin therapy given this and his age.

4 Groups indicated for Statin Therapy:

1. Clinical ASCVD: coronary heart disease (ACS, MI, angina, coronary revascularization), cerebral vascular disease (stroke, TIA), peripheral artery disease (PAD). ≤75 y/o = high intensity. >75 y/o = moderate intensity

2. Primary elevations of LDL ≥190mg/dL. high intensity

3. Diabetes and 40-75 year old with LDL 70-189mg/dL. 10-year ASCVD risk: ≥7.5% = high intensity, <7.5% = moderate intensity

4. 40-75 year old with LDL 70-189mg/dL and estimated 10-year ASCVD risk of ≥7.5% (using Global Risk Assessment Tool). moderate-to-high intensity, if <7.5% can consider risk benefit

72

Which lipid lowering therapy is contraindicated in a patient with active peptic ulcer disease?

A. Crestor
B. Niaspan
C. Tricor
D. Zetia
E. Vascepa

B. Niacin is contraindicated in patients with active PUD.

Niacin: decreases rate of hepatic synthesis of VLDL and LDL to decrease LDL (5-25%) and TG (20-50%), and increase HDL (15-35%). Mainly used to decrease TG. Also known as nicotinic acid or vitamin B3. CI: active liver disease, active PUD, arterial bleeding, arterial hemorrhage. Warning: caution in unstable angina or acute phase of MI, hepatoxicity. SE: flushing (take ASA prior), pruritis, NVD, GI distress, hyperglycemia, hyperuricemia, cough, hepatotoxicity, orthostatic hypotension, hypophosphatemia. Take with food, but avoid hot liquids and spicy food which can worsen flushing.

niacin IR (Niacor): higher incidence of flushing (can take ASA prior)

niacin ER (Niaspan): best SE profile

niacin CR/SR (Slo-Niacin): high incidence of increase LFTs (monitor LFTs)

73

A patient with hypertriglyceridemia develops acute pancreatitis after a lipid lowering therapy is initiated. Which dyslipidemia therapy is associated with an increase in triglycerides?

A. Lopid
B. Lofibra
C. Zetia
D. Lescol
E. Questran

E. Bile acid sequestrants can increase TGs.

Bile Acid Sequestrants/Bile Acid Binding Resins: binds bile acids in the intestine forming a complex that is excreted in the feces to reduce LDL (10-30%), but increase HDL (3-5%)/TG (5%). SE: constipation, dyspepsia, nausea, abdominal pain, cramping, gas, bloating, hypertriglyceridemia, esophageal obstruction, increase LFTs. Do not use when TG ≥300. Separate by 4 hours between other medications

cholestyramine (Questran): with meals. CI in complete biliary obstruction. pregnancy (C)

colesevelam (Welchol): take with meal or liquid. CI : bowel obstruction, TG>500, history of hypertriglyceridemia-induced pancreatitis. pregnancy (B)

colestipol (Colestid): pregnancy (C)

74

Which of the following dosing regimens would be appropriate for a patient using niacin immediate-release?

A. Start with ½ of a 500 mg tablet with dinner, can increase weekly up to 6 grams daily (divide the doses and take with meals)
B. Start at 500 mg QHS x 4 weeks (after a light snack), followed by 1,000 mg QHS x 4 weeks, can increase to 2,000 mg QHS
C. Start with 1,000 mg tablet with dinner, can increase weekly up to 6 grams daily (divide the doses and take with meals)
D. Start with 2,000 mg tablet with dinner, can increase weekly up to 5 grams daily (divide the doses and take with meals)
E. Start at 1,500 mg QHS x 4 weeks (after a light snack), followed by 2,000 mg QHS x 4 weeks, can increase to 5,000 mg QHS

A. Niacin immediate-release must be started very slowly or it will not be tolerated. Niacin extended-release (Niaspan) is started at 500 mg QHS x 4 weeks (after a light snack), followed by 1,000 mg QHS x 4 weeks, can increase to 2,000 mg QHS. The maximum dose of this formulation is 2 grams daily, versus 6 grams daily for the immediate-release.

75

Which statin can be taken in the morning without significantly affecting the LDL-lowering effectiveness?

A. Fluvastatin
B. Simvastatin
C. Atorvastatin
D. Lovastatin
E. Myostatin

C. Atorvastatin (and others) has a long half-life and does not need to be given in the evening to maximize inhibition of cholesterol synthesis which peaks in the early morning hours.

Dosed in the evening: simvastatin, lovastatin, fluvastatin ("Sam Loathes the Flu")

76

A patient with dyslipidemia has been on simvastatin for the past year. His primary care physician wishes to initiate a fibrate. Which fibrate has the highest risk of myopathy when combined with a statin?

A. Tricor
B. Triglide
C. Lopid
D. Antara
E. Lofibra

C. Lopid can increase the risk of myopathy more than the fenofibrates.

77

Which statin is the least potent?

A. Pravastatin
B. Lovastatin
C. Fluvastatin
D. Pitavastatin
E. Rosuvastatin

C. Fluvastatin is the least potent statin.

atorvastatin (Lipitor): equiv dose = 10. Does not need dose reduction when CrCl <30.

simvastatin (Zocor), Vytorin (simvastatin/ezetimibe): equiv dose = 20. 3A4 substrate (avoid inhibitors)

rosuvastatin (Crestor): equiv dose = 5

pravastatin (Pravachol): equiv dose = 40

lovastatin (Mevacor, Altoprev): equiv dose = 40. with food. 3A4 substrate (avoid inhibitors)

fluvastatin (Lescol): equiv dose = 80. with food, may increase INR in patients taking warfarin

pitavastatin (Livalo): equiv dose = 2. Reduce dose when CrCl <60. minimal CYP metabolism. CI with cyclosporine. monitor PT/INR after dose initiation of dose change of warfarin

78


A patient with heart failure is currently taking amiodarone, digoxin and furosemide. The physician wants to start the patient on simvastatin. Which of the following statements is correct?

A. The maximum dose of simvastatin is 10 mg daily due to the drug interaction with amiodarone.
B. The maximum dose of simvastatin is 20 mg daily due to the drug interaction with amiodarone.
C. The maximum dose of simvastatin is 10 mg daily due to the drug interaction with digoxin.
D. The maximum dose of simvastatin is 20 mg daily due to the drug interaction with digoxin.
E. Simvastatin is contraindicated in patients with heart failure.

B. The maximum dose of simvastatin is 20 mg daily when taking amiodarone.

79

What is the correct mechanism of action of fenofibrates?

A. Fenofibrates inhibit the enzyme HMG-CoA reductase.
B. Fenofibrates bind to bile acids in the gut.
C. Fenofibrates reduce cholesterol absorption at the brush-border.
D. Fenofibrates are peroxisome proliferator alpha activators.
E. Fenofibrates bind to and inhibit microsomal triglyceride transfer protein (MTP) in the endoplasmic reticulum.

D. Fenofibrates are peroxisome proliferator alpha activators.

Fibrates: peroxisome proliferator receptor alpha (PPARa) activators, which upregulates the expression of apolipoprotein CII and apolipoprotein A-I to reduce TG (20-50%) and LDL (5-20%), and increase HDL (15%). Mainly used to decrease TG. CI: severe liver disease, severe renal disease (CrCl <30), gallbladder disease, nursing mothers. Warning: myopathy, increase risk with statin (elderly, diabetes, renal failure, hypothyroidism). SE: increase LFts, abdominal pain, increase CPK, dyspepsia, URTIs, pregnancy (C)

fenofibrate, fenofibric acid (TriCor, Trilipix):

gemfibrozil (Lopid): taken 30 minutes before breakfast and dinner. CI with repaglinide

80

A patient is started on Lipitor 20 mg daily. According to the ACC/AHA Blood Cholesterol Guidelines, when should the lipid panel be checked?

A. In 1-2 weeks
B. In 3-4 weeks
C. In 4-6 weeks
D. In 4-12 weeks
E. In 6-12 months

D. The lipid panel should be assessed 4-12 weeks after initiation or up titration of therapy.

81

Which lipid lowering therapy is contraindicated in patients with a history of gallstones?

A. Fibrates
B. Statins
C. Ezetimibe
D. Bile acid resins
E. Fish oils

A. Fibrates are contraindicated in patients with gallstones.

Fibrates: peroxisome proliferator receptor alpha (PPARa) activators, which upregulates the expression of apolipoprotein CII and apolipoprotein A-I to reduce TG (20-50%) and LDL (5-20%), and increase HDL (15%). Mainly used to decrease TG. CI: severe liver disease, severe renal disease (CrCl <30), gallbladder disease, nursing mothers. Warning: myopathy, increase risk with statin (elderly, diabetes, renal failure, hypothyroidism). SE: increase LFts, abdominal pain, increase CPK, dyspepsia, URTIs, pregnancy (C)

fenofibrate, fenofibric acid (TriCor, Trilipix):

gemfibrozil (Lopid): taken 30 minutes before breakfast and dinner. CI with repaglinide

82

Which of the following represent the correct definition of high-intensity statin therapy?

A. A weekly dose that decreases TGs by ≥ 50%
B. A daily dose that decreases TGs by ≥ 50%
C. A weekly dose that decreases LDL by ≥ 50%
D. A daily dose that decreases LDL by ≥ 50%
E. A daily dose that decreases LDL by 30-50%

D. High-intensity statin therapy is defined as a daily dose that decreases LDL ≥ 50%.

83

A patient is admitted to the hospital with an acute myocardial infarction. Which statin regimen, when initiated immediately, has been shown to improve short term outcomes by reducing the risk of recurrent ischemia?

A. Simvastatin 40 mg daily
B. Lovastatin 80 mg daily
C. Rosuvastatin 10 mg daily
D. Atorvastatin 80 mg daily
E. Pravastatin 40 mg daily

D. High-intensity statin therapy initiated within 96 hours of hospitalization for an acute coronary syndrome has been shown to reduce the incidence of recurrent ischemia. The statin and regimen used in these studies (MIRACL and PROVE-IT TIMI 22) was atorvastatin 80 mg daily.

84

Rank the following statins in order of milligram potency (least potent = 1 to most potent = 5).  Drag and drop the choices into the correct order.

A. Lescol
B. Mevacor
C. Zocor
D. Lipitor
E. Crestor

A, B, C, D, E.

pitavastatin = 2

rosuvastatin = 5

atorvastatin = 10

simvastatin = 20

pravastatin = 40

lovastatin = 40

fluvastatin = 80

PRASPLF = "Prasp Loft"

atorvastatin (Lipitor): equiv dose = 10. Does not need dose reduction when CrCl <30.

simvastatin (Zocor), Vytorin (simvastatin/ezetimibe): equiv dose = 20. 3A4 substrate (avoid inhibitors)

rosuvastatin (Crestor): equiv dose = 5

pravastatin (Pravachol): equiv dose = 40

lovastatin (Mevacor, Altoprev): equiv dose = 40. with food. 3A4 substrate (avoid inhibitors)

fluvastatin (Lescol): equiv dose = 80. with food, may increase INR in patients taking warfarin

pitavastatin (Livalo): equiv dose = 2. Reduce dose when CrCl <60. minimal CYP metabolism. CI with cyclosporine. monitor PT/INR after dose initiation of dose change of warfarin

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