Anti-Lipid Pharmacology

Question 1

What LDL levels would indicate high intensity treatment?

Answer 1

LDL >190, those with proven ASCVD,
diabetics with >7.5% risk,
those 40-75 with >7.5% risk

Question 2

What LDL levels would indicate moderate intensity treatment?

Answer 2

70-189

Question 3

If we needed to reduce the LDL levels by greater than 50%, what medications would allow us to do that?

Answer 3

Atorvastatin & Rousuvastatin (at their highest doses)

Question 4

What is the drug class of atorvastatin?

Answer 4

HMG-CoA reductase inhibitor

Question 5

What is the MOA of the drug class HMG-CoA reductase inhibitor?

Answer 5

Inhibits cholesterol synthesis

Question 6

Are there any side effects associated with the HMG-CoA reductase inhibitor medications?

Answer 6

Yes, diarrhea, arthralgia, nausea, myopathy, and rhabdomyolysis

Question 7

Of the side effects associated with the HMG-CoA reductase inhibitor medications, which ones are of the most concern?

Answer 7

Myopathy & Rhabdomyolysis

Question 8

If a patient has myopathy, what do you do?

Answer 8

Hold the medication, get a CK if elevated – wait for it to return to normal, then start the patient on a lower dose

Question 9

Are there any patients that we need to be cautious about using HMG-CoA reductase inhibitors?

Answer 9

Yes, those with liver or renal impairments

Question 10

What are the other drugs that make up the class of HMG-CoA reductase inhibitors?

Answer 10

Atorvastatin, lovastatin, pravastatin, rosuvastatin, simvastatin, and fluvastatin

Question 11

What medication do you have to be cautious if the patient has an eGFR less than 30?

Answer 11

Lovastatin

Question 12

What is the best medication, of the statins, at reducing both the LDL & triglycerides?

Answer 12

Atorvastatin

Question 13

What medication is 2nd best at reducing both LDL & triglycerides?

Answer 13

Rosuvastatin

Question 14

What medication, of the statins, must be taken twice daily?

Answer 14

Fluvastatin

Question 15

What medications are bile-acid sequestrants?

Answer 15

Cholestyramine & Colesevelam

Question 16

How do bile-acid medications work?

Answer 16

Work by binding bile acids, inhibiting enterohepatic circulation of cholesterol

Question 17

What is the main goal for bile-acid medications? Who are they for?

Answer 17

To decrease LDL.

For- hypercholesterolemia & diabetes

Question 18

What is the major concern with bile-acids? Why?

Answer 18

They are usually not well tolerated

They cause side effects of constipation, nausea, bloating, and belching.

Question 19

When would you usually use a bile-acid medication?

Answer 19

as an adjunct medication

Question 20

How good are bile-acids at lower cholesterol? Do they lower triglycerides too?

Answer 20

Moderately effective ~15%

They don’t lower triglycerides (may increase)

Question 21

What is the goal of the fibric acid medications?

Answer 21

Lower triglycerides AKA treating hypertriglyceridema

Question 22

How do fibric acids lower triglycerides?

Answer 22

Unknown, but theorized to decrease VLDL metabolism

Question 23

What are our two fibric acid medications?

Answer 23

Gemfibrazil & Fenofibrate

Question 24

What medication is most effective at lower triglycerides?

Answer 24

Fenofibrate – works in about 2 weeks as compared to 3-4 weeks.

Question 25

When can you not use fibric acid medications?

Answer 25

Hepatic or renal disease OR gallbladder disease

Question 26

What medications are contraindicated with fibric acids?

Answer 26

Clopidogrel & Warfarin

Question 27

What is the purpose of nicotinic acid medications? How do they work?

Answer 27

Hypertriglyceridemia | - Works by inhibiting fatty acid release from adipose tissue and decreasing VLDL production

Question 28

What medication is our nicotininc acid?

Answer 28

Niacin AKA Vitamin B3

Question 29

What is critical to first use of Niacin?

Answer 29

Must use aspirin 30mins prior in order to prevent flushing & itching

Question 30

What patients can you not use niacin in?

Answer 30

alcoholics and those with history of peptic ulcers

Question 31

What is important about dosing niacin?

Answer 31

To titrate dose slowly

Question 32

What medication is our cholesterol absorption inhibitor?

Answer 32

Exetimibe

Question 33

What is exetimibe used for?

Answer 33

Hypercholesterolemia

Question 34

How does exetimibe work?

Answer 34

By decreasing absorption of cholesterol from the GI tract

Question 35

What patients can you not use exetimibe in?

Answer 35

Those with hepatic disease

Question 36

When would you want to use ezetimibe?

Answer 36

add it to statin therapy for MODEST benefit

Question 37

When would you use an Omega 3 Fatty Acid medication?

Answer 37

High VLDL despite diet, alcohol restriction, and fibrates

Question 38

What medication do you not want to use with omega 3 fatty acids?

Answer 38

Anticoagulants

Question 39

What medication is our PCSK9 inhibitor?

Answer 39

Evolocumab

Question 40

When would you utilize evolocumab?

Answer 40

drug resistant hyperlipidemia (especially with familial)

Question 41

How is evolocumab given?

Answer 41

Administered subQ

Question 42

To review, what medications are good for reducing triglycerides?

Answer 42

Fibric acids, nicotinic acid, and omega 3 fatty acids

Question 43

What herbal supplement might reduce the effect of atorvastatin?

Answer 43

St.John’s Wort

Question 44

If your patient is an alcoholic with LDL >190, what medication can you use?

Answer 44

Pravastatin, because it is metabolized by CYP450

Question 45

What other medication could you use for a patient with liver damage and high LDL?

Answer 45

Niacin

Question 46

What is the biggest side effect of niacin?

Answer 46

Flushing

Question 47

What medications together could give you slightly increased cholesterol reduction?

Answer 47

Statin + Fibric acid

Question 48

If you combine a Statin + Fibric acid, what must you be aware of?

Answer 48

There is now an INCREASED risk of myopathy

Question 49

If someone develops myopathy while taking a statin + fibric acid what do you do?

Answer 49

Stop the fibric acid and lower the statin dose

Question 50

What are fibric acids contraindicated with? Why?

Answer 50

Biliary disease. Because it can increase the risk of obstruction

Question 51

If we prescribe a fibric acid, what must we tell our patients about?

Answer 51

Take one hour BEFORE or 4 hours AFTER other prescriptions