Chapter 8: Hyperlipidemia treatment Flashcards
(119 cards)
1
Q
HMG-CoA Reductase Inhibitors are also called
A
Statins
2
Q
Is cholesterole water or lipid soluble?
A
Lipid
3
Q
Major lipoproteins
(chylomicrons)
A
- Very low density lipoprotein (VLDL)
- intermediate lipoprotein (ILP)
- Low density lipoprtein (LDL)
- High density lipoprotein (HDL)
4
Q
Which is the “bad cholesterol” and what does it do?
A
LDL
It carries cholesterol from the liver to the rest of the body
5
Q
Which is the “good” cholesterol and what does it do?
A
HDL
it carries cholesterol from the body to the liver
6
Q
What does VLDL do?
A
carries fat from liver to adipose tissue
7
Q
LDL goal
A
< 100mg/dL
8
Q
Total cholesterol goal
A
<200 mg/dL
9
Q
HDL goal
A
> 40mg/dL
10
Q
Preffered drug type for lowering LDL
A
statins
11
Q
Which drug class is the first-line treatment for hyperlipidemia and why?
A
Statins
Reduces the risk of MI, stroke, and cardiovascular death
12
Q
what labs should be monitored when a patient is on statins?
A
LFTs, creatinine kinase, lipids
13
Q
If a patient taking a statin develops persistent muscle weakness/discomfort or brown urine what labs should be done and why?
A
Creatinine kinase (CK) to assess for rhabdomyolysis
value will be increased
14
Q
Assessing for signs of myopathy with statin use
A
6-12 weeks after begining regimen and every visit thereafter
15
Q
When can peak effect for statins be seen?
A
After approximately 4 weeks
16
Q
What do statins do?
A
decrese total cholesterol, LDL, triglycerides
Increase HDL
17
Q
How do statins work?
A
block the enzyme that catalyzes early cholesterol synthesis
18
Q
Statin drug names
A
- lovastatin (Mevacor)
- pravastatin (Pravachol)
- simvastatin (Zocor)
- fluvastatin (Lescol)
- atorvastatin (Lipitor)
- rosuvastatin (Crestor)
19
Q
Statins: Absorption
A
Rapid with 24% bioavailability due to first pass metabolism
20
Q
Statins: Distribution
A
Highly protein bound
enter breast milk, placenta, and blood-brain barrier
21
Q
Statins: metabolism/excretion
A
Metabolized in liver with minimal excretion in urine
22
Q
Statin: half-life
A
Varies
See page 125
23
Q
Rule of 6
A
Statins are most effective at starting dose, longer dosing times only 6%
24
Q
Patient education for statins
A
- 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
