Chapter 8: Hyperlipidemia treatment Flashcards Preview

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Flashcards in Chapter 8: Hyperlipidemia treatment Deck (119):
1

 

 

HMG-CoA Reductase Inhibitors are also called

 

 

Statins

2

 

 

Is cholesterole water or lipid soluble?

 

 

Lipid

3

 

 

Major lipoproteins 

(chylomicrons)

 

  • Very low density lipoprotein (VLDL)
  • intermediate lipoprotein (ILP)
  • Low density lipoprtein (LDL)
  • High density lipoprotein (HDL)

4

 

 

Which is the "bad cholesterol" and what does it do?

 

 

LDL

It carries cholesterol from the liver to the rest of the body

5

 

 

Which is the "good" cholesterol and what does it do?

 

 

HDL 

it carries cholesterol from the body to the liver

6

 

 

What does VLDL do?

 

 

carries fat from liver to adipose tissue

7

 

 

LDL goal

 

 

< 100mg/dL

8

 

 

Total cholesterol goal

 

 

<200 mg/dL

9

 

 

HDL goal

 

 

> 40mg/dL

10

 

 

Preffered drug type for lowering LDL

 

 

statins

11

 

 

Which drug class is the first-line treatment for hyperlipidemia and why?

 

 

Statins

Reduces the risk of MI, stroke, and cardiovascular death

12

 

 

what labs should be monitored when a patient is on statins?

 

 

LFTs, creatinine kinase, lipids

13

 

 

If a patient taking a statin develops persistent muscle weakness/discomfort or brown urine what labs should be done and why?

 

 

Creatinine kinase (CK) to assess for rhabdomyolysis

value will be increased

14

 

Assessing for signs of myopathy with statin use

 

 

6-12 weeks after begining regimen and every visit thereafter

15

 

 

When can peak effect for statins be seen?

 

 

After approximately 4 weeks

16

 

 

What do statins do?

 

 

decrese total cholesterol, LDL, triglycerides

Increase HDL

17

 

 

How do statins work?

 

 

block the enzyme that catalyzes early cholesterol synthesis

18

 

Statin drug names

  • lovastatin (Mevacor)
  • pravastatin (Pravachol)
  • simvastatin (Zocor)
  • fluvastatin (Lescol)
  • atorvastatin (Lipitor)
  • rosuvastatin (Crestor)

19

 

 

Statins: Absorption

 

 

 

Rapid with 24% bioavailability due to first pass metabolism

20

 

 

Statins: Distribution

 

 

Highly protein bound

enter breast milk, placenta, and blood-brain barrier

21

 

 

Statins: metabolism/excretion

 

 

Metabolized in liver with minimal excretion in urine

22

 

 

Statin: half-life

 

 

 

Varies

See page 125

23

 

 

Rule of 6

 

 

Statins are most effective at starting dose, longer dosing times only 6%

24

 

 

Patient education for statins

 

 

 

  • symptoms of myopathy
  • grapefruit juice increases levels (rhabdo risk)
  • photosensitivities
  • diet restriction and exercise
  • report any muscle pain/weakness

25

 

 

Statin: pregnancy category

 

 

 

X

26

 

 

Statin side effects: CV

 

 

chest pain

peripheral edema

27

 

 

DERM side effects: Statins

 

 

rash

28

 

 

EENT side effects: statins

 

 

rhinitis

29

 

 

Statin side effects: GI

 

 

 

abdominal cramps

diarrhea/constipation

gas

heart burn

altered taste

liver toxicity (elevation in LFTS)

30

 

 

Statin side effects: MS

 

SERIOUS myopathy

(rhabdomyolysis, depletion of CoQ10, mylagias)

31

 

 

Statin side effects: NEURO

 

dizziness

insomnia

headache

weakness

32

 

drugs that increase serum concentration of Statins

 

CYP450 enzyme inhibitors

grapefruit juice

33

 

 

drugs that decrease effectiveness of statins

 

 

St. John's wort

bile acid sequestrants

34

 

 

why would you coadminister statins and CoQ10

 

 

decrease muscle symptoms

35

 

When a patient is on statins, which drugs should you be extremely cautious with?

  • gemfibrozil
  • protease inhibitors
  • niacin
  • cyclosporine
  • amiodarone
  • erythromycin

36

 

Purpose of bile acid sequestrants 

 

 

lower LDL, not triglycerides

(may worsen if triglycerides elevated)

lowers LDL by only 13-30%

37

 

 

How do bile acid sequestrants work?

 

 

 

 

Bind to bile acids and form an insoluble complex that is excreted in the feces

38

 

 

Bile acid sequestrant drug names

 

cholestryramine (Questran, Prevalite)

colestipol (Colestid)

colesevelam (Welchol)

39

 

Contraindications for statins

 

liver disease/alcoholism

persistent unexplained elevated LFT

pregnancy

hypersensitivities

asians

40

 

 

Pregnancy category of bile acid sequestrants

 

 

 

 

Category B

safe

41

 

 

Common side effect of cholestyramine

 

 

Pruritus

42

 

 

Bile resin side effects: EENT

 

 

irritation of tongue

43

 

 

BIle resin side effects: GI

 

nausea

constipation

gas/bloating

fecal obstructionn

44

 

 

Bile acid sequestrants can lead to deficiencies in what vitamins?

 

A, D, E, K

45

 

 

Bile acid sequestrant side effects: NEURO

 

 

lightheadedness, weakness, insomnia

46

 

 

Why do patients often stop using bile acid sequestrants?

 

 

GI side effects

47

 

 

Bile resins and triglyceride levels

 

 

 

 

 

Not for monotherapy if triglycerides > 400mg/dL

OK as monotherapy if triglycerides < 200mg/dL

48

 

Patien education of bile resins

 

Powder: how to prepare

Tablets: swallow dont chew

increase fiber to avoid constipation/bloating

more effective if taken before meals

49

 

 

Bile resins prevention absorption of which medications?

fat soluble vitamins

digoxin

warfarin

thyroxin

thiazides

beta blockers

folic acid

50

 

 

How can interactions between bile resins and other medications be avoided?

 

 

take 1 hour before or 4 hours after meals

51

 

 

Bile resin contraindications

 

 

liver disease

biliary obstruction

caution with history of constipation or bowel obstruction

52

 

 

Nicotinic acid is also known as

 

 

Vitamin B3

Niacin

53

 

 

When is use of B3 indicated for cholesterol treatment?

 

 

High LDL

low HDL

elevated triglycerides

54

 

What is the benefit of combining B3 with a statin?

 

 

decreased progression of atherosclerosis

reduce CHD events

55

 

 

Maximum dose of Niacin

 

2mg for ER

5mg for immediate release

56

 

 

Ways to reduce flushing with Niacin

 

ASA or NSAID 30 minutes prior

take with food

avoid hot liquids

avoid alcohol

57

 

A patient taking Niacin long term should be instructed to report

what symptoms

darkening of urine

light colored stools

anorexia

severe stomach pain

jaundice

(signs of hepatotoxicity)

58

 

How does niacin work?

 

inhibits fatty acid release from adipose tissue

inhibits fatty acid ang triglyceride synthesis in the liver

59

 

decreases LDL

prevents recurrent MI

reduces atherosclerosis

60

 

 

Niacin: absorption

 

 

rapid and extensive

61

 

 

Niacin: distribution

 

 

widely distributed after converted to niacinamide

62

 

 

Niacin: metabolism

 

 

must be converted to niacinamide, which concentrates in liver, kidneys, and adipose tissue

63

 

 

Niacin: excretion

 

 

urine

64

 

 

Niacin half-life

 

 

45 minutes

65

 

 

side effects of niacin: CV

 

 

orthostatic hypotension

cardiac arrhythmias

pakpitations

syncope

66

 

 

side effects of niacin: DERM

 

flushing

pruritus

67

 

 

side effects of niacin: EENT

 

 

blurry vision

68

 

 

side effects of niacin: GI

 

 

upper GI distress

hepatotoxicity with long term use

69

 

 

side effects of niacin: HEM

 

Niaspan ER is associated with platelet count reduction

70

 

 

side effects of niacin: META

 

 

can interefere with BG in diabetics

can exacerbate gout

71

 

 

side effects of niacin: NEURO

 

 

nervousness

panic

72

 

 

Niacin contraindications

 

liver disease

caution with diabetes, peptic ulcer disease, hyperuricemia

73

 

Cholesterol absorption inhibitor:

drug names

 

 

ezetimbe (zetia)

estetrol

74

 

 

What does Zetia do?

 

 

reduce total cholesterol, LDL, apo B, and triglycerides

increase HDL

75

 

 

How does Zetia work?

 

 

inhibits absorption of cholesterol in small intestine.  This lowers the amount of cholesterol available to the liver which reduces circulating cholesterol and hepatic stores

76

 

 

Zetia: absorption

 

 

easily absorbed and conjugated to an active phenolic complex (ezetimibe-glucuronide)

77

 

 

Zetia: distribution

 

 

highly distributed bound to plasma protein

78

 

 

Zetia: metabolism

 

 

in intestine and liver

79

 

 

Zetia: excretion

 

 

biliary and fecal

80

 

 

Zetia: half-life

 

 

22 hours

81

 

 

Coadministration of zetia and statins or fenofibrates

 

 

May be taken at the same time

82

 

 

Coadministration of Zetia and bile resins

 

 

2 hours before or 4 hours after bile resin is taken

83

 

 

Side effects of zetia: DERM

 

 

rash

84

 

 

side effects of zetia: GI

 

 

elevated LFT

abdominal distress

cholecystitis

cholelithiasis

nausea

85

 

 

side effects of zetia: HEM

 

 

MAY CAUSE ANGIOEDEMA

86

 

 

side effects of zetia: META

 

 

fatigue

87

 

 

side effects of zetia: MS

 

 

arthralgia

back pain

88

 

 

when is zetia most effective?

 

 

when given with statins

89

 

 

which medications does zetia interact with?

 

 

antacids

cholestyramine

cyclosporin

90

 

 

zetia contraindications

 

 

zetia/statin combo is contraindicated with liver disease or unexplained elevated LFT

91

 

 

What do fibric acids do?

 

 

decrease triglycerides

increase HDL

increase size and decrease density of LDL

92

 

 

What is the most effective type of drug for lowering triglycerides?

 

 

Fibric acids

93

 

 

Why is fenofibrate preferred when used in combination with a statin?

 

 

Because of better renal clearance

94

 

 

Fibric acid drug names

 

 

gemfibrozil (Lopid)

fenofibrate (TriCor)

clofibrate (Atromind-S)

95

 

 

benefits of fibric acids

 

 

prevents cardiovascular disease

96

 

 

how do fibric acids work?

 

 

activate a nuclear receptor which inhibits triglyceride synthesis

(also facilitates liver uptake of LDL)

97

 

 

What is heightened with coadministration of fibric acids and statins?

 

 

risk for rhabdomyolysis

98

 

 

fibric acids: absorption

 

 

reduced by bile resins

99

 

 

fibric acids: distribution

 

 

unknow: upt to 99% protein bound

100

 

 

fibric acids: metabolism

 

 

converted to fenofibric acid (active metabolite) which is metabolized in the liver

101

 

 

fibric acids: excretion

 

 

in urine

102

 

 

fibric acid side effects: CV

 

 

arrhythmias

103

 

 

fibric acid side effects: DERM

 

 

rash

104

 

 

fibric acid side effects: GI

 

 

dyspepsia, abdominal pain, diarrhea, gas, liver dysfunction, gall bladder disease, pancreatitis

105

 

 

when are GI side effects of fibric acids increased?

 

 

when coadministered with statins

106

 

 

fibric acid side effects: MS

 

 

muscle pain, myopathy, rhabdomyolysis

107

 

 

fibric acid side effects: NEURO

 

 

fatigue, weakness, headache

108

 

 

coadministration of a fibrate and warfarin

 

 

increased bleeding risk

109

 

 

coadminstration of a fibrate and statin

 

 

increased risk of rhabdomyolysis

110

 

 

fibric acid contraindications

 

 

gall bladder, liver, or kidney dysfunction

breastfeeding women

111

 

 

fibric acids in pregnancy

 

 

safety not determined use only if necessary

112

 

 

When is combination therapy indicated?

 

 

when goals are not reached with statin monotherapy and lifestyle modifications

113

 

 

which 2 drugs make up Vytorin?

 

 

Ezetimibe/simvastatin

114

 

 

Considerations with Vytorin

 

slightly increased risk of rhabdomyolysis

64% reduction in LDL

adjunt to diet

115

 

 

What 2 drugs make up Simcor?

 

 

Niacin/simvastatin

116

 

 

Considerations with Somcor

 

watch for flushing. pruritis, GI distress

single dose at half strength with low fat snack

used in patients with hypercholesterolemia and dyslipidemia

117

 

NCEP guidelines: screening

 

 

should be done with fasting labs every 5 years in patients over 20

118

 

 

NCEP guidelines: goal for LDL (all patients)

 

 

<100 mg/dL

119

 

 

NCEP guidelines: LDL goal for those at risk for or with coronary or vascular disease

 

 

70 mg/dL