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Dyslipidemia Flashcards

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1
Q

How is LDL calculated using the Friedwald equation?

A

LDL= TC-HDL- (TG/5)

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2
Q

What is a desirable non-HDL?

A

<130

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3
Q

What is a desirable LDL-C?

A

<100

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4
Q

What is a desirable HDL?

A

Men: ≥40
Women: ≥50

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5
Q

What is a desirable TG?

A

<150

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6
Q

What are risk factors for calulating 10 year ASCVD risk of first CV event?

A
  1. sex, age (20-79), race
  2. Smoking
  3. TC, HDL, LDL, and statin use
  4. SBP and antihypertensive treatment
  5. Hx DM
  6. aspirin use
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7
Q

When does ASCVD not need to be calculated and statin therapy immediately initiated?

A
  1. clinical ASCVD
  2. DM
  3. LDL≥190
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8
Q

What drugs increase LDL and TG?

A
  1. Diuretics
  2. Efavirenz
  3. Immunosuppressants (cyclosporine/tacrolimus)
  4. Atypical antipsychotics
  5. Protease inhibitors
  6. retinoids
  7. systematic steroids
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9
Q

What drugs increase LDL?

A
  1. Fibrates
  2. Fish oils (not Vascepa)
  3. anabolic steroids
  4. progestins
  5. SGLT2i
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10
Q

What drugs increase TG?

A
  1. IV lipid emulsions
  2. Propofol
  3. Clevidipine
  4. Bile acid sequestrants (~5%)
  5. estrogen
  6. tamoxifen
  7. beta blockers
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11
Q

What conditions increase LDL and/or TG?

A
  1. Obesity
  2. Poor diet (high saturated fat)
  3. Alcohol use disorder
  4. Hypothyroidism
  5. Smoking
  6. Diabetes
  7. Renal/Liver disease
  8. Nephrotic syndrome
  9. pregnant
  10. PCOS
  11. anorexia
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12
Q

When is coronary artery calcium score used?

A

Help determine if statins should be initiated in ASCVD risk 7.5-19.9; score ≥100 statin is indicated

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13
Q

What lifestyle modifications can lower cholesterol?

A
  1. BMI: 18.5-24.9
  2. High fiber fruits/veg/whole grain
  3. Healthy protein: low-fat dairy, poultry, fish, nuts
  4. Limit saturated fat (5-6% calories), trans fat, sweets, sugar sweetened drinks
  5. Aerobic physical exercise 3-4x/week
  6. Avoid tobacco/limit alcohol
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14
Q

What natural products can lower cholesterol?

A
  1. Red yeast rice (natural HMGCoA inhibitor)
  2. Plant sterols/stanols/fiber
  3. OTC fish oil (may increase LDL)
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15
Q

What is the statin benefit group 1? What intensity statin is indicated?

A
  1. Clinical ASCVD; secondary prevention
  2. High
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16
Q

What is statin benefit group 2?

A
  1. Primary severe dyslipidemia: LDL≥190
  2. High
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17
Q

What is statin benefit group 3? What intensity statin is indicated?

A
  1. Diabetes ages 40-75
  2. High: multiple RFs
    Moderate: regardless of risk
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18
Q

What is statin benefit group 4? What intensity statin is indicated?

A
  1. 40-75y/o and LDL 70-189
  2. High: ASCVD risk ≥20%
    Moderate: ASCVD risk 7.5-19.9% and RFs
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19
Q

What doses of statins are equivalent?

A

Pitavastatin 2mg
Rosuvastatin 5mg
Atorvastatin 10mg
Simvastatin 20mg
Lovastatin 40mg
Pravastatin 40mg
Fluvastatin 80mg
Pharmacists Rock At Saving Lives Preventing Fatty deposits

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20
Q

How does muscle damage present with statins?

A

Presents as muscle soreness, tiredness, or weakness that is symmetrical in large muscle groups (legs/back/arms), usually occurring within 6 weeks of starting a statin

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21
Q

What is the difference between myalgia/myositis/myopathy/rhabdomyolysis?

A
  1. Myalgia: muscle soreness/tenderness
  2. Myopathy: muscle weakness +/- CPK elevation
  3. Myositis: muscle inflammation
  4. Rhabdomyolysis: muscle symptoms with very high CPK + muscle protein in the urine (myoglobinuria) may lead to acute renal failure
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22
Q

How are myalgias managed?

A
  1. Hold statin, check CPK, consider other causes
  2. After 2-4 weeks rechallenge with the same statin at the same dose
  3. If myalgia returns, D/C statin
  4. Once muscle symptoms resolve, use a low dose of a different statin and gradually titrate up
  5. If unable to tolerate after 2 attempts consider non-stain
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23
Q

How are myalgias prevented?

A
  1. Avoid drug interactions (check OTC)
  2. Avoid Simvastatin 80mg/d
  3. Do Not use gemfibrozil +statin
  4. Supplement with Coenzyme Q10
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24
Q

What increases the risk of myalgias with statins?

A
  1. Higher doses
  2. Advanced age
  3. Concurrent use Niacin or Fibrates
  4. Hypothyroidism (uncontrolled)
  5. Renal imapirment
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25
What are CIs with statins?
1. Liver disease (includes unexplained high LFTs) 2. Breastfeeding 3. Strong CYP3A4 inhibitors with lovastatin/simvastatin 4. Cylosporine + pitavastatin
26
What are warnings with statins?
1. Muscle damage with elevated CPK +/- acute renal failure 2. Avoid use in pregnancy; may continue if at high risk of CV events 3. Elevates A1C/ fasting BG 4. Hepatotoxicity with elevated LFTs (rare) 5. hemorrhagic stroke; if recent stroke/TIA (Atorvastatin) 6. proteinuria/hematuria usually transient (Rosuvastatin)
27
What are SEs with statins?
Myalgia/Myopathy
28
What should be monitored with statins?
1. Lipid panel (baseline, 4-12 weeks after starting/changing therapy, then every 3-12 months; usually annually) 2. LFTs at baseline and if sx of hepatotoxicity occur 3. CPK if symptoms of muscle damage 4. Scr/BUN if decreased urine output
29
What effects do statins have on lipid panel?
1. Decrease LDL ~20-55% 2. Increase HDL ~5-15% 3. Decrease TGs ~10-30%
30
Which statins can be taken at any time of day?
1. Rosuvastatin 2. Atorvastatin 3. Pitavastatin 4. Lescol XL (fluvastatin) 5. Pravastatin
31
Which statins need dosed at night?
1. Fluvastatin (IR) 2. Simvastatin 3. Lovastatin
32
Which statins require renal dose adjustments?
CrCl<30: use lower starting dose of lovastatin/simvastatin/lovastatin eGFR<60: use lower starting dose of pitavastatin
33
Which statin should be taken on an empty stomach?
FloLipid (simvastatin oral suspension)
34
Which stain should be taken with the evening meal?
IR lovastatin
35
Which statin may require a lower dose in asain patients due to exposures being 2x higher?
Rosuvastatin
36
What drugs interact with statins?
CYP3A4: Grapefruit Protease inhibitors Azole antifungals Cyclosporine/Cobicistat Macrolides (not azythromicin) Amiodarone Non-DHP CCBs
37
What drugs cannot be used with simvastatin or lovastatin due to increased risk of rhabdo?
1. Grapefruit 2. Protease inhibitors 3. Azole antifungals 4. Cyclosporine/Cobicistat 5. Macrolides (not azythromicin)
38
What is the max dose of simvastain/lovastatin that can be given to someone on Amiodarone?
1. Simvastatin: 20mg/d max 2. Lovastatin: 40mg/d max
39
What is the max dose of simvastain/lovastatin that can be given to someone on a Non-DHP CCB?
1. Simvastatin: 10mg/d max 2. Lovastatin: 20mg/d max
40
Which statins interact with amlodipine, elevating statin concentrations?
1. Simvastatin 20mg/d max 2. Atorvastatin 3. Lovastatin
41
Which statins have the least amount of drug interactions?
1. Rosuvastatin 2. Pravastatin
42
Atorvastatin
Lipitor Atorvaliq (oral suspension)
43
Fluvastatin
Lescol XL
44
Lovastatin
Altoprev
45
Atorvastatin + Amlodipine
Caduet
46
Pitavastatin
Livalo Zypitamag
47
Pravastatin
Pravachol
48
Rosuvastatin
Crestor Ezallor Sprinkle
49
Simvastatin
Zocor FloLipid (suspension)
50
Simvastatin + Ezetimibe
Vytorin
51
When is add on treatment apporpriate for someone is statin benefit group 1?
LDL >55
52
When is add on treatment apporpriate for someone is statin benefit group 2?
LDL >70
53
When is add on treatment apporpriate for someone is statin benefit group 3?
LDL >70
54
When is add on treatment apporpriate for someone is statin benefit group 4?
LDL ≥100
55
What is the MOA of ezetimebe?
inhibits absorption of cholesterol in the small intestine
56
What are warnings with ezetimbe?
1. Avoid use in moderate/severe hepatic impairment (LFTs 3x ULN) 2. Skeletal muscle effects; risk increases when used with statins 3. Pregnancy: risk unknown 4. Breast feeding: avoid
57
What are SEs with ezetimibe?
1. Myalgia 2. arthalgia 3. pain in extremities 4. URTIs 5. sinusitis
58
What should be monitored while on ezetimibe?
LFTs (baseline and when clinically indicated)
59
How does ezetimibe effect cholesterol?
1. Decreases LDL 18-23% 2. Increases HDL 1-3% 3. Decreases TGs 5-10%
60
What drugs interact with ezetimibe?
1. Elevated levels of ezetimibe and cyclosporine when used together 2. Bile acid sequestrants decrease ezetimibe; give zetia 2h before or 4 h after 3. Increased risk of cholelithiasis when used with fibrates/gemfibrozil
61
What is the MOA of PCSK9 monoclonal antibodies?
block degradation of LDL receptors by PCSK9, decreasing LDL
62
What are warnings with PCSK9i?
Allergic reaction
63
What are SEs with PCSK9i?
1. Injection site reactions 2. nasopharingitis/influenza/URTIs 3. UTIs 4. back pain (evolocumab) 5. elevated LFTs (alirocumab)
64
What should be monitored with PCSK9i?
LDL (baseline and 4-8 weeks)
65
How is PCSK9i administered?
Prior to administration allow prefilled pen to warm to room temperature; inject SQ every 2 weeks or monthly
66
How are PCSK9i stored?
1. Store in the refrigerator in the original container to protect from light 2. Up to 30 days at room temperature, then discard
67
Alirocumab
Praluent
68
Evolocumab
Repatha Repatha SureClick Pushtronex
69
How do PCSK9i effect cholesterol?
Decrease LDL 60%
70
What is the MOA of bile acid sequestrants?
bind and form complex with bile acids that is excreted in the feces
71
What are CIs with bile acid sequestrants?
1. Cholestyramine: complete biliary obstruction 2. Colesevelam: Bowel obstruction, TG>500, TG induced pancreatitis
72
What are warnings with bile acid sequestrants?
1. Some formulations contain phenylalanine; do not use in PKU 2. Increased bleeding risk due to Vit K deficiency
73
What are SEs with bile acid sequestrants?
1. Constipation (reduce dose or laxative) 2. Abdominal pain 3. Cramping 4. Bloating 5. Gas/ Dyspepsia 6. Elevated TGs 7. nausea 8. esophageal obstruction 9. teeth discoloration/erosion of enamel/decay (cholestyramine packet)
74
How are cholestyramine packets administered?
1. Mix powder in 2-6oz water/non-carbonated liquid 2. Do not sip or hold the resin in the mouth for prolonged periods 3. Take with a meal and liquid
75
How are Colesevelam packets/tablets administered?
1. Empty 1 packet into a glass; add 8oz water, fruit juice, or diet soft drink and mix well 2. Take with meal and a liquid
76
How are Colestipol packets administered?
Empty 1 packet into 3oz of liquid and store until mixed
77
How do bile acid sequestrants effect cholesterol?
1. Dcrease LDL 10-30% 2. Raise HDL 3. May increase TG; do not start if TG>300
78
What bile acid sequestrant is safe in pregnancy?
Colesvelam
79
What bile acid sequestrant is also used as an antihyperglycemic?
Colesvelam
80
Colesvelam
Welchol
81
Cholestyramine
Prevalite
82
Colestipol
Colestid
83
What are DIs with bilie acid sequestrants?
1. Separate drugs by 1-4 hours before and 4-6 hours after 2. monitor INR 3. decrease absorption of ADEK 4. increase metformin ER
84
Ezetimibe + bempidoic acid
Nexlizet
85
What drugs should be taken 4 hours prior to Welchol?
1. cyclosporine 2. SU 3. Levothyroxine 4. olmesartan 5. phenytoin 6. oral contraceptives
86
What is the MOA of fibrates?
PPAR alpha agonists; increase lipoprotein lipase activity and catabolism of VLDL particles decreasing TGs
87
What are CIs with fibrates?
1. Severe liver disease (including primary biliary cirrhosis) 2. Gallbladder disease 3. severe renal disease (CrCl≤30) 4. breastfeeding 5. use with repaglinide/simvastatin (gemfibrozil)
88
What are the warnings with fibrates?
1. Myopathy (Increased risk with a statin in older adults, diabetes, hypothyroidism, renal failure) 2. cholelithiasis 3. transient reversible elevated SCr >2
89
What are SEs with fibrates?
1. Dyspepsia (gemfibrozil) 2. Elevated LFTs (dose-related) 3. abdominal pain 4. elevated CPK 5. URTIs
90
What is monitored with fibrates?
1. LFTs 2. renal function
91
How is fenofibrate renally dosed?
Reduce dose of CrCl 31-80
92
Which fenofibrates are taken with meals?
Fenoglide Lipofen
93
How is gemfibrozil administered?
600mg BID 30 min before breakfast and dinner
94
How do fibrates effect cholesterol?
1. Decrease TGs 20-50% 2. Can increase LDL when TGs are high (usually lowers LDL)
95
What drugs interact with fibrates?
1. Do not use gemfibrozil with statins/zetia 2. Inrease effects of SUs and warfarin 3. Chochicine can increase myopathy
96
Fenofibrate/ Fenofibric Acid
1. Tricor 2. Trilipix 3. Fenoglinide 4. Fibricor 5. Lipofen
97
Gemfibrozil
Lopid
98
What is the MOA of Niacin?
Decreases the rate of hepatic synthesis of VLDL (TG) and LDL
99
What are CIs with niacin?
1. acute liver disease 2. active PUD 3. arterial bleeding
100
What are warnings with niacin?
1. Rhabdomyolysis with doses ≥1g/d when combined with statins 2. Hepatotoxicity (CR worst) 3. Elevated BG and uric acid 4. low phosphate 5. caution in unstable angina/ acute phase of MI
101
What are SEs with niacin?
1. Flushing 2. Puritis 3. Vomiting/nausea 4. Diarrhea 5. Elevated BG 6. Hyperuricemia/Gout 7. cough 8. orthostatic hypotension 9. low platelets 10. hypophosphatemia
102
What should be monitored with niacin?
1. LFTs (baseline, every 6-12 weeks for first year, then every 6 months) 2. BG (DM) 3. uric acid (gout hx) 4. INR (warfarin) 5. lipids
103
How can flushing with niacin be reduced?
1. ER formulation (less flushing/hepatotoxicity) 2. Aspirin 325mg/ ibuprofen 200mg 30-60min before dose 3. Take with food (NOT spicy food, alcohol, hot beverages)
104
How is niacin dosed?
250mg-3000 titrated slowly; Take with food
105
How is Niacin administered?
IR: 3 divided doses with food ER: at bedtime after a low-fat snack CR/SR: QD with food
106
How does niacin affect cholesterol?
1. Increased HDL 15-30% 2. Decrease TG 20-30% 3. Decrease LDL 5-25%
107
What are DIs with niacin?
Take niacin 4-6 h after bile acid sequestrants
108
What fish oil is approved for ASCVD risk reduction when TGs are 135-499 and using statin?
Icosapent ethyl (Vascepa)
109
When are fish oils indicated?
Adjunct to diet when TGs ≥500
110
What are warnings with fish oils?
1. HSR to fish/shellfish 2. Monitor LFTs with hepatic impairment and LDL 3. Can increase LDL levels; possible association with frequent recurrence of Afib/flutter in patients with afib in the first months of initiation (Lovaza) 4. Stop prior to elective surgeries due to bleeding risk
111
What are SEs with fish oils?
1. Eructation (burping) 2. Dyspepsia 3. Taste perversion (Lovaza) 4. arthalgia (Vascepa)
112
How do fish oils affect cholesterol?
1. Decrease TG 45% 2. Can Increase LDL 44% (Lovaza)
113
Omega-3 Acid Ethyl Esters (EPA/DHA)
Lovaza
114
Icosapent ethyl (ethyl ester of EPA)
Vascepa
115
How is Vascepa administered?
2g BID with food
116
What are DIs with fish oils?
Prolong bleeding time; monitor INR with warfarin
117
What is the MOA if bempidoic acid?
inhibits cholesterol synthesis in the liver upstream of HMGCoA
118
What are SEs with bempidoic acid?
1. hyperuricemia 2. tendon rupture
119
When is bempidoic acid apporived?
As an add on in HeFH or ASCVD in combinaion with a statin
120
Bempidoic Acid
Nexletol
121
What is the MOA of Inclisiran?
Inhibits intracellular production of PCSK9
122
What is Inclisiran used for?
Add on for HeFH or primary hyperlipidemia with a statin DO NOT use with PCSK9 mab due to over lapping MOA
123
What are SEs with Inclisiran?
1. Injection site reaction (SC) 2. arthalgia
124
Inclisiran
Leqvio
125
What are SEs with lomitapide (Juxtapid)?
Hepatotoxicity (BBW with REMS program)
126
What are CIs with Juxtapid?
1. active liver disease 2. pregnancy 3. use of mod-strong CYP3A4 inhibitors
127
What is the MOA of Juxtapid?
prevents assembly of apoB containing lipoprotein by inhibiting TG transfer protein
128
Lomitapide
Juxtapid
129
Evinacumab
Evkeeza
130
What is the MOA of evinacumab?
monocloal antibody inhibits angiopoietin like 3 resulting in increased lipid metabolism
131
What are SEs with evinacumab?
1. HSR (IV administration) 2. Anaphylaxis

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