Chapter 27: Dyslipidemia Flashcards
(134 cards)
1
Q
What is atherosclerosis?
A
Atherosclerosis is the formation of plaque on the inner walls of arteries from a buildup of fats, cholesterol, and other substances.
2
Q
What is the relationship between cholesterol and atherosclerotic cardiovascular disease (ASCVD)?
A
Elevated cholesterol increases the risk of atherosclerosis, which can lead to ASCVD, including myocardial infarction, stroke/transient ischemic attack, stable angina, and peripheral arterial disease.
3
Q
How can cholesterol levels be decreased?
A
Cholesterol can be decreased by:
* Reducing formation (statins)
* Blocking absorption (ezetimibe)
* Blocking enterohepatic recirculation (bile acid sequestrants such as colesevelam).
4
Q
What is the best practice for taking lipid panels?
A
After a 9-12 hour fast
5
Q
Why is fasting important for lipid panels?
A
To avoid falsely elevated triglyceride (TG) levels
6
Q
What is the Friedewald equation used for?
A
Calculating LDL cholesterol
7
Q
What is the formula for LDL cholesterol using the Friedewald equation?
A
LDL = TC - HDL - (TG/5)
8
Q
When is the Friedewald equation not valid?
A
When TGs are > 400 mg/dL
9
Q
What are the three major types of lipoproteins included in total cholesterol (TC)?
A
- LDL
- HDL
- VLDL
10
Q
What does high HDL cholesterol do?
A
Lowers ASCVD risk
11
Q
What is non-HDL cholesterol?
A
Cholesterol that includes lipoproteins contributing to ASCVD risk
12
Q
How is non-HDL cholesterol calculated?
A
non-HDL = TC - HDL
13
Q
What triglyceride level is associated with acute pancreatitis?
A
TGs ≥ 500 mg/dL
14
Q
What are the desirable non-HDL cholesterol levels?
A
< 130 mg/dL
15
Q
What are the desirable LDL cholesterol levels?
A
< 100 mg/dL
16
Q
What is considered very high LDL cholesterol?
A
≥ 190 mg/dL
17
Q
What are the desirable HDL cholesterol levels?
A
≥ 40 mg/dL (for men)
≥ 50 mg/dL (for women)
18
Q
What are the desirable triglyceride levels?
A
< 150 mg/dL
19
Q
What is considered very high triglycerides?
A
≥ 500 mg/dL
20
Q
What is dyslipidemia?
A
Abnormal lipoprotein levels
21
Q
What are the two classifications of dyslipidemia?
A
Familial and secondary
22
Q
What is familial hypercholesterolemia (FH)?
A
A genetic defect causing severe cholesterol elevations
23
Q
What is the purpose of the ASCVD risk calculator?
A
To estimate an individual’s risk of a first cardiovascular event in the next 10 years
24
Q
What factors does the ASCVD risk calculator consider?
A
- Sex, age, race, smoking status,
- TC, HDL, LDL, statin use,
- blood pressure, antihypertensive treatment,
- diabetes history, aspirin use
25
Name drug that can increase both LDL and triglycerides.
1. Diuretics
2. Efavirenz
3. immunosuppressants
4. Atypical antipsychotic
5. Protease inhibitors
26
Which drug class is known to only increase LDL?
1. Fibrates
2. Fish oils (except Vascepa)
27
What conditions can contribute to dyslipidemia?
Obesity, poor diet, alcohol use disorder, hypothyroidism, smoking, diabetes, renal/liver disease, nephrotic syndrome
28
Which patients do not need an ASCVD risk score?
Patients with clinical ASCVD, diabetes, or LDL ≥ 190 mg/dL should be started on a statin without needing a risk score.
29
List drugs that increase TG only!
1. IV lipid emulsion
2. Propofol
3. Clevidipine
4. Bile acid sequestrant
30
What is the healthy BMI range?
18.5 - 24.9 kg/m²
31
What dietary components should be included to maintain a healthy weight?
Rich in vegetables, fruits, whole grains, high-fiber foods, and healthy protein sources such as low-fat dairy, poultry, fish, and nuts.
32
What should be limited in a healthy diet?
Saturated fat, trans fat, sweets, sugar-sweetened beverages, and red meat.
33
How often should aerobic physical activity be engaged in?
3 - 4 times per week, lasting 40 minutes per session.
34
What is the effect of aerobic activity on LDL levels?
Decreases LDL by 3 - 6 mg/dL.
35
What lifestyle habits should be avoided?
Tobacco products and excessive alcohol use.
36
Which natural product contains HMG-CoA reductase inhibitors?
Red yeast rice.
37
What is the primary use of OTC fish oils?
To lower triglycerides (TG).
38
What are the drugs of choice for treating high LDL?
Statins.
39
What additional drugs may be used for LDL lowering if statins are insufficient?
Ezetimibe and/or PCSK9 monoclonal antibodies.
40
Which cholesterol-lowering drugs may cause liver damage?
Niacin, fibrates, potentially statins, and ezetimibe.
41
When should cholesterol-lowering drugs not be used?
If AST or ALT is > 3 times the upper limit of normal.
42
What enzyme do statins inhibit?
3-hydroxy-3-methylglutaryl coenzyme A (HMG-CoA) reductase.
43
What is the rate-limiting step in cholesterol synthesis?
The conversion of HMG-CoA to mevalonate.
44
Which statins provide high-intensity LDL lowering?
Atorvastatin and rosuvastatin.
45
What is the LDL reduction percentage for high-intensity statins?
≥ 50% reduction from baseline.
46
What is the treatment for patients with clinical ASCVD?
High-intensity statin treatment.
47
What are the criteria for primary prevention with statin treatment?
1. Primary severe dyslipidemia,
2. diabetes (age 40-75 years) with multiple ASCVD risk factors,
3. baseline LDL ≥ 190 mg/dL,
4. 40-75 yo, LDL 70-189, ASCVD risk 20%
48
What is the recommended statin intensity for a 10-year ASCVD risk ≥ 20%?
High-intensity.
49
For patients aged 40-75 years with LDL between 70-189 mg/dL and a 10-year ASCVD risk of 7.5-19.9%, what is the recommended statin intensity?
Moderate-intensity.
50
What is a consideration for patients over 75 years with LDL 70-189 mg/dL?
Consider moderate-intensity statin
51
What is the definition of high-intensity statin treatment?
LDL reduction ≥ 50%
52
What is the definition of moderate-intensity statin treatment?
LDL reduction 30-49%
53
What is the definition of low-intensity statin treatment?
LDL reduction < 30%
54
What are the high-intensity doses of atorvastatin?
40-80 mg
55
What is the common adverse effect of statins?
Muscle damage
56
How soon can muscle effects from statins develop after starting treatment?
Within six weeks
57
What is rhabdomyolysis?
Muscle symptoms with very high CPK (> 10,000 IU/L) and myoglobinuria
58
What are the high-intensity alternatives to atorvastatin?
Rosuvastatin 20 mg or 40 mg daily
59
What should be done to reduce the risk of statin-related issues?
* Avoid Drug interactions, including OTC products
* Avoid simvastatin 80 mg/day
* Avoid gemfibrozil + statin
60
What is the most potent statin on a 'mg' basis?
Pitavastatin
61
What is the most potent statin to lower LDL?
Rosuvastatin
62
What should be done if myalgia occurs?
Hold statin, check CPK, investigate other causes
63
If a patient is unable to tolerate a statin after two attempts, what treatment may be considered?
Non-statin treatment
64
Statin equivalent doses are
Remember: Pharmacists Rock At Saving Lives and Preventing Fatty deposits
Pitavastatin 2 mg
Rosuvastatin 5 mg
Atorvastatin 10 mg
Simvastatin 20 mg
Lovastatin 40 mg
Pravastatin 40 mg
Fluvastatin 80 mg
65
What is the brand name for Atorvastatin?
Lipitor
66
Which statins should be taken in the evening?
* Fluvastatin
* Lovastatin
* Simvastatin
67
Lovastatin brand name
Altoprev
68
What are the contraindications for statins?
* Breastfeeding
* Liver disease (including unexplained T LFTs)
* Concurrent use of strong CYP3A4 inhibitors (with simvastatin and lovastatin)
* Concurrent use of cyclosporine (with pitavastatin)
69
What warning is associated with statins regarding muscle damage?
Myopathy/rhabdomyolysis with increase CPK +/- acute renal failure; higher risk with higher doses
70
What are common side effects of statins?
* Myalgia
* Myopathy
71
What should be monitored when prescribing statins?
* Lipid panel (TC, LDL, HDL, TG) at baseline, 4-12 weeks after starting or adjusting treatment, then every 3-12 months
* LFTs at baseline and if symptoms of hepatotoxicity
* CPK if symptoms of muscle damage and SCr/BUN if decreased urine output
72
Which statins can be taken at any time of day?
* Rosuvastatin
* Atorvastatin
* Pitavastatin
* Lescol XL
* Pravastatin
73
G ❤️PACMAN interactions
* Grapefruit
* Protease inhibitors
* Azole anti fungal
* Cyclosporine, Cobicistat
* Macrolides
* Amiodarone
* Non-DHP CCB
74
What is the max daily dose of simvastatin if taking Amlodipine?
Simvastatin 20 mg/daily
75
What are the maximum daily doses for Atorvastatin and Cobicistat?
Atorvastatin 20 mg/day max (cobicistat only)
76
What are the maximum daily doses for Rosuvastatin and cyclosporine?
5mg daily
77
What are the maximum daily doses for Simvastatin and Amiodarone?
20 mg daily
78
What are the maximum daily doses for Lovastatin and Amiodarone?
40 mg daily
79
What are the maximum daily doses for Simvastatin and non-DHP CCB?
10 mg daily
80
What are the initial non-statin therapies generally recommended in clinical guidelines?
Ezetimibe and/or PCSK9 mAbs
81
When might non-statin treatment be warranted?
After multiple trials of a statin with adverse effects or when additional LDL-lowering is required
82
What are other treatment options besides ezetimibe and PCSK9 mAbs?
Bempedoic acid and inclisiran
83
What is the LDL threshold to add non-statin therapy for patients with clinical ASCVD and very high risk?
≥ 55 mg/dL
84
What are the safety warnings associated with ezetimibe?
Avoid use in moderate or severe hepatic impairment
85
List some common side effects of ezetimibe.
* Myalgia
86
What is the effect of ezetimibe on LDL?
LDL 18-23% reduction
87
True or False: Ezetimibe should be used with______.
gemfibrozil
88
What should be monitored when a patient is on ezetimibe?
Liver function tests (LFTs) at baseline and as clinically indicated thereafter
89
What is the LDL threshold to add non-statin therapy for patients with no clinical ASCVD but a baseline LDL ≥ 190 mg/dL?
≥ 100 mg/dL
90
Ezetimibe MOA
inhibits absorption of cholesterol in the small intestine.
91
What are the effects of bile acid sequestrants when used with ezetimibe?
Give ezetimibe two hours before or four hours after bile acid sequestrants to avoid interaction and maximize efficacy.
92
What do PCSK9 monoclonal antibodies do?
They block the ability of PCSK9 to bind to the LDL receptor.
93
What is the effect of PCSK9 mAbs on LDL cholesterol levels?
They dramatically lower LDL (60%) and reduce the risk of cardiovascular events.
94
In which patients are PCSK9 monoclonal antibodies indicated?
Patients with established ASCVD or familial hypercholesterolemia.
95
Alirocumab brand name
Praluent
96
Evolocumab
Repatha
97
What do bile acid sequestering agents do?
They bind bile acids in the intestine, preventing their reabsorption.
98
What is the dosing for Colesevelam (Welchol)?
3.75 grams daily or in divided doses with a meal and liquid.
99
What are contraindications for Colesevelam?
Bowel obstruction
100
What is a common side effect of bile acid sequestering agents?
* Constipation.
* Abdominal pain
* Cramping
* Bloating
* increase TG
101
Which lipid lowering agent is an option for pregnant patients?
Colesevelam (Welchol)
102
What drug has fewer interactions than other bile acid sequestrants?
Colesevelam
103
What medications should be taken four hours prior to colesevelam?
* Cyclosporine
* Sulfonylureas
* **Levothyroxine**
* Olmesartan
* Phenytoin
* Oral contraceptives containing ethinyl estradiol and norethindrone
104
When should other drugs be taken in relation to cholestyramine or colestipol?
At least 1-4 hours before or 4-6 hours after the bile acid sequestrant
105
What vitamins and minerals may be affected by bile acid sequestrants?
* Fat-soluble vitamins (A, D, E, K)
* Folate
* Iron
106
What effect does colesevelam have on metformin ER levels?
It can increase levels of metformin ER
107
What are fibrates classified as?
Peroxisome proliferator-activated receptor alpha (PPARa) agonists
108
What is the effect of fibrates on triglycerides (TG)?
Decrease TG significantly
109
fenofibrate brand name
Tricor, Trilipix
110
What are the contraindications for fibrates?
* Severe liver disease
* Severe renal disease (CrCl ≤ 30 mL/min)
* Gallbladder disease
* Breastfeeding
* Concurrent use with repaglinide or simvastatin
111
What are some warnings associated with fibrates?
* Myopathy
* Increased risk when coadministered with a statin
* Cholelithiasis
* Reversible increased serum creatinine (> 2 mg/dL)
112
What is a common side effect of gemfibrozil?
Dyspepsia
113
Gemfibrozil brand name
Lopid
114
Fibrates can increase the effects of ___and ____.
sulfonylureas & warfarin
115
Niacin MOA
Decreases the rate of hepatic synthesis of VLDL and LDL
116
What is another name for niacin?
Nicotinic acid or vitamin B3
117
How is IR/ER/CR formulations of niacin given?
IR & CR with food
ER at bed time after a low fat snack
118
Warnings associated with Niacin
1. Rhabdomyolysis
2. Hepatotoxicity
3. Increase BG and uric acid
119
What are some common side effects of niacin?
* Flushing
* Pruritus (itching)
* Vomiting
* Diarrhea
* Increased blood glucose
* Hyperuricemia (or gout)
120
What is the preferred formulation of niacin and why?
Extended-release (ER) formulation due to less flushing and hepatotoxicity, but it is the most expensive
121
How can flushing caused by niacin be reduced?
* Take aspirin 325 mg (or ibuprofen 200 mg) 30-60 minutes before the dose
* Take with food, avoiding spicy food, alcohol, and hot beverages
122
What lipid effects does niacin have?
* Increases HDL by 15-35%
123
When should niacin be taken in relation to bile acid sequestrants?
4 - 6 hours after bile acid sequestrants
124
When are fish oils indicated as an adjunct to diet?
When TG ≥ 500 mg/dL
125
What is the recommended fish oil for ASCVD risk reduction
Icosapent ethyl (Vascepa) in select patients when triglycerides are 135 - 499 mg/dL despite maximally tolerated statin
126
Omega-3 Acid Ethyl Esters brand name
Lovaza
127
Icosapent ethyl brand name
Vascepa
128
What are the potential side effects of fish oil?
Eructation, dyspepsia, taste perversions
129
What should be done prior to elective surgeries for patients taking fish oils?
Stop due to increased risk of bleeding
130
What lipid effects can fish oils have?
Can decrease TG up to 45%, T HDL ~9%, can T LDL (up to 44% with Lovaza, no T seen with Vascepa)
131
What is a significant drug interaction concern with omega-3 fatty acids?
Can prolong bleeding time; caution with antiplatelets, anticoagulants
132
What is the mechanism of action (MOA) of Bempedoic Acid (Nexletol)?
Inhibits cholesterol synthesis in the liver by inhibiting ACL
133
What is Bempedoic Acid approved for?
HeFH or ASCVD in combination with a statin
134
What is the MOA of Inclisiran (Leqvio)?
Inhibits intracellular production of PCSK9 via RNA interference
