Dyslipidemia

Question 1

Explain enterohepatic recycling

Answer 1

bile acids from the liver travel through the bile ducts along with cholesterol into the small intestine where they help with fat absorption.
Intestines have an acidic environment so the bile acids are converted to bile salts here which are recycled from the intestine and then return to the liver

Question 2

How does disrupting the enterohepatic recyling process lead to lowered cholesterol?

Answer 2

By blocking absorption of free cholesterol in the intestine (ezetimibe) or the enterohepatic recirculation of bile salts (colesevelam) cholesterol then decreases

Question 3

How do statins help with cholesterol?

Answer 3

they reduce the formation of cholesterol by inhibiting HMG-CoA reductase to stop conversion of HMG-CoA to mevalonate (rate limiting step in cholesterol synthesis)

Question 4

Describe HDL

Answer 4

good cholesterol
delivers cholesterol from blood to the liver where it is removed from the body
want Hdl to be High

Question 5

describe lipoprotein

Answer 5

genetic variant of LDL, when elevated=elevated ASCVD risk

Question 6

At what level can TGs cause pancreatitis

Answer 6

> 500 mg/dl

Question 7

What are primary hypercholesterolemias

Answer 7

genetic defect that causes cholesterol elevations

HeFH and HoFH

Question 8

When is LDL considered severely elevated?

Answer 8

> 190

Question 9

What is the Friedewald equation?

Answer 9

LDL = Tc - HDL - (TG/5)

*only use if TG is <400

Question 10

Desirable HDL levels

Answer 10

men: >/= 40
women: >/= 50

Question 11

What is the desirable level for TGs?

Answer 11

<150

Question 12

What does ASCVD risk tell us?

Answer 12

estimate of patient’s risk of having their first CV event in the next 10 years

Question 13

What are parameters are assessed when calculating ASCVD risk?

Answer 13

gender, age, race
TC and HDL
Systolic blood pressure 
use of HTN meds 
diabetes 
smoking status

Question 14

What CAC score indicates a statin should be initiated?

Answer 14

CAC >/= 100

Question 15

Drug of choice for high non-HDL and LDL

Answer 15

statins!

Question 16

Drug options if statin-intolerant or additional cholesterol-lowering needed

Answer 16

ezetimibe

PCSK9 inhibitors

Question 17

What lab parameter should be monitored when patients are using cholesterol-lowering medication due to side effect profile

Answer 17

AST and ALT

liver damage is possible

Question 18

What drugs can cause liver damage?

Answer 18

niacin, fibrates, statins, ezetimibe

Question 19

When should we not initate cholesterol medication in regards to liver function

Answer 19

AST or ALT are >3x upper normal limit

Question 20

High intensity statin indications

Answer 20

clinical ASCVD
LDL >/=190
diabetes + age 40-75 + LDL >70 + multiple risk factors
40-75yo + LDL >70 + ASCVD risk >/= 20%

Question 21

moderate intensity statin indications

Answer 21

diabetes + age 40-75 + LDL >70

40-75yo + LDL >70 + ASCVD risk >7.5% + risk factors

Question 22

High intensity statins

Answer 22

Atorva: 40 +
Rosuva: 20 +

Question 23

moderate intensity statins

Answer 23

atorv 10 - 20 
rosuva 5-10
simvastatin 20+
pravastatin 40+
lovastatin 40+
pitavastain: 2 +

Question 24

low intensity statins

Answer 24

sim: 10
prav: 10-20
lova 20
pita: 1

Question 25

statin equivalents

Answer 25

Pharmacists Rock At Saving Lives & Preventing Fatty-deposits pita: 2 rosu: 5 ator: 10 simva: 20 lova: 40 prava: 40 fluvastatin: 80

Question 26

Is statin-induced muscle soreness symmetrical or asymmetrical?

Answer 26

symmetrical

Question 27

What CPK value can indicate rhabdomyolysis

Answer 27

CPK > 10,000 + muscle in urine

Question 28

What can rhabdomyolysis lead to?

Answer 28

acute kidney failure

Question 29

Can we rechallenge with a statin if myalgias occur?

Answer 29

yes after 2- 4 weeks of holding with same statin at same or lower dose

Question 30

CIs of statin therapy

Answer 30

pregnancy, breastfeeding liver disease or unexplained elevated LFT use with cyclosporine

Question 31

which statins interact with CYP34A inhibitors

Answer 31

simva | lova

Question 32

Which drug needs to be started at a low dose in Asian patients due to risk of higher exposure

Answer 32

rosuvastatin

Question 33

which statins should be taken in the evening

Answer 33

fluvastatin lovastatin simvastatin

Question 34

which statins have less drug interactions

Answer 34

rosuvastatin | pravastatin

Question 35

Statin drug interactions

Answer 35

``` Ghosts love PACMAN Grapefruit Protease inhibitors Azole Cyclosporine/Cobicistat Macrolides Amiodarone Non-DPH CCBs ```

Question 36

Side effects with ezetimibe

Answer 36

myalgias diarrhea sinusitis

Question 37

Which drug should not be used with ezetimibe due to risk of cholelithiasis

Answer 37

gemfibrozil | fenofibrate (caution)

Question 38

PCSK9 Inhibitor MOA

Answer 38

Mabs that block PCSK9 from binding to LDL receptors and therefore increases LDL degradation by decreasing their receptor degradation

Question 39

Bile acid sequestrants MOA

Answer 39

bind bile acids in the intestine forming a complex that's excreted in feces, disruption enterohepatic circulation

Question 40

List of bile acid sequestraants

Answer 40

cholestyramine colesevelam colestipol

Question 41

Which drug can be considered for cholesterol control in a pregnant patient?

Answer 41

colesevelam

Question 42

Counseling points for bile acid sequestrant

Answer 42

good oral hygeine needed due to possilbe tooth decay separate from other meds by about 4 hours take a multivitamin and separate from these meds

Question 43

Fibrates MOA

Answer 43

PPAR alpha activators: increase expression of apolipoprotein and thus lipase activity. This leads to catabolism of VLDL particles and decreases TG

Question 44

CI fibrates

Answer 44

``` liver disease gallbladder disease renal disease breastfeeding use with simvastatin! ```

Question 45

What fibrate can not be given with ezetimibe or statins

Answer 45

gemfibrozil

Question 46

niacin MOA

Answer 46

decreases synthesis of VLDL and LDL and increases the rate of TG removal from plasma

Question 47

other names for niacin

Answer 47

B3 | nicotinic acid

Question 48

Is niacin a good options for patients with hepatic dysfunction?

Answer 48

NO! CI!

Question 49

When are fish oils indicated

Answer 49

when TG > 500 they can be used as an adjunct to diet changes

Question 50

Interaction concern with fish oils

Answer 50

warfarin, they can prolong bleeding so watch INR

Question 51

How long can PCSK9s be kept out of the fridge?

Answer 51

30 days