Dyslipidemia

Question 1

In what ways can cholesterol in the body be decreased?

Answer 1

reducing the formation
blocking the absorption
blocking enterohepatic recirculation of bile salts

Question 2

What does Non-HDL contribute to?

How does one calculate Non-HDL?

What level of TGs can cause acute pancreatitis?

Answer 2

Contributes to ASCVD risk (such as LDL, VLDL, Lipoprotein a)

Non-HDL = TC - HDL

TGs >= 500 mg/dL

Question 3

When are lipid panels best taken?

Why is this?

What is the friedewald equation?

When is this equation NOT used?

Answer 3

Best taken after a 9-12 hr fast

fasting primarily needed for TG; can be falsely elevated after eating

LDL = TC - HDL - (TG/5)

It should not be used when TG’s are > 400

Question 4

What’s a desirable value for Non-HDL?

for LDL?

What’s considered very high for LDL?

What’s desirable for HDL for men and women?

What are desirable TG levels?

Very high TG levels?

Answer 4

< 130

< 100

> =190

Men: >= 40
Women : >= 50

< 150

> = 500

Question 5

What factors are used to calculate the patients ASCVD risk? (12)

Answer 5

Age (20-79)
Sex
race
smoking status
TC
HDL
LDL
Whether statin is used
blood pressure
whether BP tx is used
Diabetes HX
ASA usage

Question 6

1. Which drugs can increase LDL AND TG? (5)
2. Which drugs incr LDL only? (2)
3. Which drugs incr TG only?
4. What conditions could also raise LDL/and or TG’s?

Answer 6

1. diuretics
   efavirenz
   immunosuppressants (cyclosporine and tacrolimus)
   atypical antipsychs
   protease inhibs
2. fibrates, fish oils
3. IV lipid emulsions
   propofol
   clevidipine
   bile acide sequestrants
4. Obesity, poor diet, AUD, hypothyroidism, smoking, diabetes, renal/liver disease, nephrotic syndrome

Question 7

You dont need to calc an ASCVD score for these subset of patients because they should alrdy be started on a statin ? (3)

Answer 7

Pt’s with clinical ASCVD

Diabetes

LDL >= 190 mg/dL

Question 8

Non Drug TX : Lifestyle Modifications

1. Diet to Maintain Healthy Weight (BMI 18.5-24.9)
   -What should this diet include?
2. Engaging in aerobic physical activity how many times a week and how long should these workouts last?
3. What should be avoided and limited?

Answer 8

1. Vegetables, fruits, whole grains and high fiber foods
   -healthy protein sources
   -limiting intake of saturated fat, trans fat, sweets, sugar sweetened beverages and red meat
2. 3-4x per week, lasting 40 mins/session
3. tobacco products and limiting alcohol usage

Question 9

Many cholesterol lowering drugs can cause _____.

these drugs should not be used if the AST or ALT is how many times the ULN?

Answer 9

liver damage

niacin, fibrates, potentially statins and zetia

> 3x ULN

Question 10

Which statins are considered high intensity?

Moderate?

Low?

Answer 10

1. lipitor 40-80 mg
   crestor 20-40 mg
2. lipitor 10-20 mg
   crestor 5-10 mg
   simvastatin 20-40 mg
   pravastatin 40-80 mg
   lovastatin 40 mg
   fluvastatin 40 mg BID/80XL
   Pitavastatin 1-4 mg
3. Simvastatin 10 mg
   pravastatin 10-20 mg
   lovastatin 20 mg
   fluvastatin 20-40 mg

Question 11

Statin Equivalent Doses:

Pitavastatin
Rosuvastatin
Atorvastatin
Simvastatin
Lovastatin
Pravastatin
Fluvastatin

Answer 11

2
5
10
20
40
40
80

Question 12

Most common adverse effect of statins?

How does it present?

Symptoms usually occur when?

Symptoms can present with varying severity such as: (explain)
Myalgia
Myopathy
Myositis
Rhabdomyolysis

Answer 12

Muscle damage

muscle soreness, tiredness or weakness that’s symmetrical on both sides of the body, in large muscle groups in legs, back, or arms

within 6 wks of starting treatment (but can develop anytime)

Myalgia: muscle soreness and tenderness

Myopathy: muscle weakness +/- cpk elevations

Myositis: muscle inflamm

Rhabdo: muscle sx’s with VERY HIGH CPK(>10k IU/L) plus muscle protein in urine (myoglobinuria) which can lead to acute renal failure

Question 13

Managing Myalgia:
1. Reducing risk by
-Avoiding ___
-DONT USE ___
-DONT USE ____ + ___

IF MYALGIA DOES OCCUR:

2. what should be done ?
3. IF MYALGIA RETURNS?
4. If pt unable to tolerate statin after at least 2 attempts… what should be done?

Answer 13

1. drug interactions, including OTC products

-simvastatin 80 mg/day

• gemfibrozil + statin

2. Hold statin, check CPK, see if other causes

-after 2-4 wks, re challenge w/same statin at same or decr dose.

3. Discontinue the statin. once muscle sx’s resolve, use low dose of a diff statin; gradually increase the dose
4. Non statin tx may be considered

Question 14

STATINS:

1. Atorvastatin
   -Brand name?
   -Dosing?
   -name when combined with amlodipine?
2. Fluvastatin
   -Dosing
   -How should the IR be taken?
   -whats brand name of XR version and how should it be dosed?
3. Lovastatin
   -Brand Name
   -Dosing?
   -IR take with ?
   -XR (altoprev) taken at ___
4. Pitavastatin brand name and dosing ?
5. Pravastatin brand name and dosing?
6. Rosuvastatin
   -brand names
   -dosing
   -may need to lower dosing in which pt’s?
7. Simvastatin
   -brand names
   -Name of simva+zetia
   -dosing specifics
   -Do not use which dose and why?

Answer 14

1. Lipitor
   -10-80 mg daily
   -Caduet
2. 20-80 mg
   - take daily in evening
   -Lescol XL , taken daily
3. Altoprev (Mevacor)
   - 20-80 mg
   - evening meal
   -take at bedtime
4. Livalo or Zypitamag
   - 1-4 mg daily
5. Pravachol
   -10-80 mg daily
6. Crestor, Ezallor Sprinkle
   -5-40 mg daily
   -asian pt’s due to 2x higher exposure
7. Zocor, FloLipid
   - Vytorin
   -10-40 mg daily in the EVENING
   -dose of 80 mg due to incr risk of myopathy

Question 15

STATINS:
1. CIs?
2. Warnings?
3. Can you use during pregnancy?
4. For diabetic pt’s… what can statins do?
5. what can it do to LFTs?
6. Rosuvastatin specific warning?
7. Lipitor specific warning?
8. AE’s ?
9. Monitoring?

Answer 15

1. breastfeeding , liver disease, concurrent use of strong CYP3a4 inhibs (with simvastatin + lovastatin), concurrent use of cyclosporine (w/pitavastatin)
2. muscle damage
3. DO NOT use during pregnancy
4. Increase A1C/fasting glucose but the benefits of statins outweigh the risk
5. incr LFTS = Hepatotoxicity
6. Proteinuria, hematuria (transient)
7. Hemorrhagic stroke (if recent stroke or TIA) benefits outweigh risks
8. Myalgia/Myopathy
9. Lipid panel at baseline, 4-12 wks after starting or adjusting. Then every 3-12 months usually annually

LFTS at baseline and if sx’s of hepatotoxicity occur

Myalgia /myopathy/rhabdo

Question 16

For CrCL< 30, use lower starting doses of what?

For eGFR < 60 use lower starting dose of?

How much can statins lower LDL, incr HDL and decr TG?

Answer 16

1. lovastatin, simvastatin, rosuvastatin
2. pitavastatin
3. ~20-55%
   5-15%
   10-30%

Question 17

Statins and DDI’s:
1. In general which statins have less ddi’s?
2. Which ones r cyp3a4 substrates?
3. which drugs can incr risk of myopathy and shouldnt be used with statins?
4. Which drug increases the concentrations of ator, simva, and lova? whats the max dose of simva if you’re also concurrently on this specific medication?

Answer 17

1. rosuvastatin + pravastatin
2. lipitor, lovastatin, simvastatin
3. Fibrates (especially gemfibrozil) and niacin
   -DO NOT USE STATINS WITH GEMFIBROZIL
4. Amlodipine
   -20 mg/day

Question 18

Significant Drug Interactions: G <3 PACMAN

(Name the drugs in the acronym)

1. Which statins cannot be used with G <3 PACM
2. if using cyclosporine and crestor, whats max dose of crestor allowed?
3. if using cobicistat with lipitor, whats max dose of lipitor?
4. Max daily doses of simva and lovastatin with amio?
5. max daily doses of simva and lova on non-dhp ccbs?

Answer 18

Grapefruit
Protease inhibs
Azole antifungals
Cyclosporine + Cobicistat
Macrolides (except azithro)
Amiodarone
Non-DHP CCBS

1. simvastatin and lovastatin
2. 5 mg/day
3. 20 mg/day
4. Simva = 20 mg/day
   Lova= 40 mg/day
5. Simva = 10 mg/day
   Lova = 20 mg/day

Question 19

MOA of Ezetimibe?

Brand Name?

Name when combo with Simvastatin?

name when combo with bempedoic acid?

Dosing?

if eGFR < 60 and using vytorin? (simva + zetia)

Answer 19

inhibits absorption of cholesterol in the small intestine

Zetia

Vytorin

Nexlizet

10 mg daily

dont exceed simvastatin 20 mg/day

Question 20

Ezetimibe:

1. Warnings:
   Avoid use in ____ or __

Skeletal muscle ae’s risk incr when combined with ___

Pregnancy?

Breastfeeding??

2. AE’s such as
   M___, A__, pain in extremities, D, U, S
3. Monitoring?
4. How does zetia monotherapy improve the following : LDL, HDL, TG

Answer 20

1. Moderate, severe hepatic impairment

statins

risks to fetus unknown

generally not recc

2. myalgia, arthralgias, diarrhea, URTIs, sinusitis
3. LFTS at baseline and whenever clinically indicated afterwards
4. LDL lowers 18-23%, HDL incr 1-3%, lower TG by 5-10%

Question 21

Zetia DDI’s:

1. Cyclosporine, wat happens and what should u monitor ?
2. Concurrent BA sequestrants do what to zetia? how should u dose the drugs?
3. Zetia can incr the risk of cholelithiasis when used with __ and __. What should you do in this case?

Answer 21

1. concentration of both drugs incr. monitor levels of cyclosporine
2. decr zetia. give zetia 2 hrs before or 4 hours after BA sequestrants
3. Fenofibrate, Gemfibrozil

-DONT USE WITH GEMFIBROZIL

Question 22

Whats the MOA of PCSK9 mAB?

1. Alirocumab
   -Brand name?
   -How supplied?
   -Dosing?
2. Evolocumab
   -brand name?
   -How supplied?
   -Dosing?

Answer 22

blocks the ability of PCSK9 to bind to the LDL receptor

1. praluent
   -75 mg/mL and 150 mg/mL prefilled syringes or prefilled pen
   -75-150 mg SQ once every 2 weeks or 300 mg SQ monthly
2. Repatha SureClick or Pushtronex
   -140 mg/mL prefilled syringe or autoinjector
   420 mg/3.5 mL prefilled cartridge

140 mg SQ once every 2 wks or 240 mg monthly

Question 23

PCSK9I: Safety

1. Warnings?
2. Side effects? (I, N, I, U, U, B, L)
3. Monitoring?
4. Store in ___ but can be kept at room temp for up to ___ days and then must be discarded
5. Prior to admin, allow the prefilled pen to do what? Inspect for particulate matter
6. How does PCSK9I lower LDL, non HDL and apoB and TC?

Answer 23

1. Allergic rxns
2. inj site rxns, nasopharyngitis, influenza, urti’s, UTI, back pain (evolocumab), incr LFTS with alirocumab
3. LDL at baseline and at 4-8 wks to assess response
4. fridge, 30
5. allow prefilled pen to warm to room temp (30 mins)
6. lowers LDL by 60%, non-HDL by 35%, apoB by 50%, TC by 36%

Question 24

How do Bile Sequestrants work?

Answer 24

They bind bile acids in the intestine, forms a complex that’s excreted in feces. This results in partial removal of bile acids from enterohepatic circulation, preventing their reabsorption.

Question 25

Determining the need for add on tx (preferred tx add on would be zetia or PCSK9I) : State LDL threshold 1. Clinical ASCVD + very high risk 2. Clinical ASCVD NOT very high risk 3. Clinical ASCVD and baseline LDL >= 190 4. No clinical ASCVD with diabetes and/or 10 year ASCVD risk >=20% 5.No clinical ASCVD with baseline LDL >=190

Answer 25

1. LDL >= 55 2 and 3. LDL >= 70 4. LDL >= 70 5. LDL >= 100

Question 26

BA Sequestrants: 1. Colesevelam -Brand name? -How supplied -Also approved for? -Dosing? 2. Cholestyramine -brand name -Also approved for? -how supplied? -Initial dosing? -Maintenance dosing? 3. Colestipol -Brand name -How supplied? -Dosing for tabs -Dosing for packet/granules

Answer 26

1. Welchol -625 mg tab or 3.75 g granule packet -glycemic control in t2dm, can lower A1C 0.5% -3.75 grams daily or in divided doses w/meal and liquid 2. Prevalite -pruritis due to incr levels of bile acids -4 g powder packet -4 grams daily or BID -8-16 g/day divided BID w/meals (max 24 g/day) 3. Colestid - 1 gram tab, 5 g packet/granules - 2 g daily or BID (max 16 g/day) -5 g daily or BID (max 30 g/day)

Question 27

1. Cholestyramine CI? 2. Colesevelam CI? 3. Warnings? -Some forms contain ___ and shouldnt be used in pt's with ___ -Incr ___ due to vit K deficiency 4. AE's such as -C___ -A -C -B -G -Incr ___ -D or N 5. When are BA's not reccomended? 6. What should pt's consider when using the cholestyramine packet? 7. Which is a treatment option for pregnant pt's? 8. How good can it lower LDL, incr HDL and whats the effect on TG?

Answer 27

1. complete biliary obstruction 2. bowel obstruction, TG> 500, hx of hypertriglyceridemia induced pancreatitis 3. phenylalanine, PKU -bleeding tendency 4. Constipation abdominal pain cramping bloating gas TG's dyspepsia nausea 5. When TG are >= 300 6. Sipping or holding the resin suspension in mouth for prolonged periods can change surface of teeth resulting in discoloration, erosion of enamel or decay so use GOOD ORAL HYGIENE 7. Colesevelam 8. LDL lower 10-30% -HDL incr 3-5% -No change or TG incr 5%

Question 28

BA Sequestrants and DDI's: 1. For cholestyramine or colestipol, how should you separate them from other drugs? 2. Which one has fewer DDI's? 3. Colesevelam can incr levels of? 4. Which meds should be taken 4 hours prior to colesevelam? (6) 5. BA sequestrants can do what to fat soluble vitamins, folate, and iron? -What may be needed due to this?

Answer 28

1. Take all other drugs at least 1-4 hours before or 4-6 hours after the BA sequestrant 2. Colesevelam 3. metformin ER 4. Cyclosporine SU's levothyroxine olmesartan phenytoin oral contraceptives containing ethinyl estradiol & norethindrone 5. decr absorption! -MVI, but separate admin from the BA sequestrant

Question 29

How do fibrates work?

Answer 29

PPARalpha agonists which upregulate the expression of apoC-2 and apoA-I. ApoC-2 incr lipoprotein lipase activity leading to incr catabolism of VLDL particles which decr TG.

Question 30

1. Fenofibrate, Fenofibric acid -Brand names? 2. Dosing for Fenofibrate 3. Dosing for Trillipix 4. Gemfibrozil -brand name? -Dosing?

Answer 30

1. tricor, Trillipix 2. 43-130 mg daily 3. 45-135 mg daily 4. Lopid -600 mg BID, 30 mins before breakfast and dinner

Question 31

1. Fibrates CI -Severe ____ including ___ -Severe ____ disease with CrCL<= ___ -G -B -Concurrent use with __ or ___ (gemfibrozil only) 2. Fibrates Warnings: -M____ incr risk when coadministered with ____(in older adults, diabetes, renal failure, hypothyroidism) -C -Reversible incr to ___ 3. AE's? -D with Gemfibrozil -INCR ___ -A -Incr ___ -U 4. Monitoring (2)? 5. Reduce the dose if CrCL = ____ 6. How much does it reduce TG's? -Incr HDL? Lowers LDL? -What can it do to LDL when TG are high?

Answer 31

-liver disease, primary billiary cirrhosis -renal, 30 -gallbladder disease -breastfeeding - repaglinide, simvastatin 2. Myopathy statins -Cholelithiasis -SCr 3. Dyspepsia -lfts (dose related) -abdominal pain CPK URTI's 4. LFTS and renal function 5. 31-80 6. 20-50% !!!!!! -15% -5-20% -Can incr LDL when TG are high

Question 32

Fibrate DDI's : 1. Fibrates (especially gemfib) can incr risk of myopathy and rhabdo... it shouldnt be used with __ or ___ 2. what other drug could incr risk of myopathy when given with fenofibrate? 3. Which drug is CI with gemfibrozil? 4. Fibrates can incr the effects of which drugs?

Answer 32

1. statins, zetia 2. colchicine 3. Repaglinide as it can incr hypoglycemic effects 3. Warfarin and SU's

Question 33

Niacin: 1. MOA? 2. niacin is also known as ? (2) 3. How is niacin supplied? (3) 4. How should Niacin be titrated? 5. Dosing for IR? 6. Dosing for ER? 7. Dosing for CR or SR?

Answer 33

1. decr the rate of hepatic synthesis of VLDL (decr TG) and LDL. 2. Nicotinic acid or vitamin B3 3. IR (Niacor), ER , CR/SR (Slo Niacin , OTC) 4. SLOWLY 5. 250-3000 mg in 3 divided doses with food! 6. 500-2000 mg at bedtime after a low fat snack!!! 7. 250-750 mg daily with food!

Question 34

NIACIN : 1. CI? 2. Warnings: R, H, Incr __ and __ and decr ___ 3. AE's -F, P, V, D, Incr __, H (or gout), decr __ 4. Monitoring of ___ at baseline, every ___ of the first yr and then every ___ 5. Which formulation is the preferred and why? 6. how can pt's lessen the flushing? 7. Are niacin formulations interchangeable? 8. How does Niacin affect the HDL? 9. Niacin with BA sequestrants.. how should u separate it out?

Answer 34

1. active liver disease, active peptic ulcer disease or arterial bleeding 2. Rhabdo, hepatotoxic, BG, uric acid, phosphate 3. flushing, pruritis, vomiting , diarrhea, incr bg, hyperuricemia, platelets 4. lfts, 6-12 weeks, 6 months 5. ER form, less flushing and hepatotoxicity (most $$$$$$ tho) 6. Take ASA 325mg or ibu 200 mg 30-60 mins before the dose; take w/food but avoid spicy food, alc and hot bevs 7. no 8. It increases by 15-35%! 9. take niacin 4-6 hrs after BA sequestrants

Question 35

1. When are fish oils indicated? 2. Icosapent ethyl (vascepa) is recc for ____ in select pt's (clinical ascvd or t2dm w/additional risk factors) when TG's are ___ despite use of max tolerated statin 3. Omega 3 Acid Ethyl Esters -Brand name ? -1 gram capsule contains ___ and ___ -Dosing? 4. Icosapent Ethyl -Brand name -Contains __ or __ of icosapent ethyl, an ethyl ester of EPA -Dosing

Answer 35

1. Theyre indicated as an adjunct to diet when TG >= 500 2. ascvd risk reduction , 135-499 3. Lovaza -465 mg EPA, 375 mg DHA - 4 caps daily or 2 caps BID 4. Vascepa - 0.5, 1 g -Dosing is 2 g BID with food!!!

Question 36

Fish Oils: 1. Warnings -Use caution in pt's with known ____ -Monitor ___ in pt's with hepatic impairment and LDL periodically -What can lovaza do to LDL levels? 2. AE's -E, D, T and A 3. What are the main lipid effects it has? 4. Omega 3 fatty acids can ___, so monitor ___ in pt's taking __

Answer 36

1. hypersensitivity to fish and /or shellfish - LFTS -Lovaza can incr LDL levels and have some association with more frequent recurrences of AFib or AFlutter in pt's with AF. 2. Eructation (burping), dyspepsia, taste perversions (lovaza), arthalgia (vascepa) 3. Decr TG up to 45%!! Can incr LDL up to 44% with lovaza, but not seen with vascepa 4. prolong bleeding time -INR, warfarin

Question 37

Other Drugs: 1. Bempedoic Acid -brand name? -+zetia brand name? -MOA? -Approved for? -AE's 2. Inclisiran -Brand Name -How supplied? -MOA? -Approved for? -DO NOT USE with ____ -AE's

Answer 37

1. Nexletol -Nexlizet - Inhibs cholesterol synthesis in liver by inhib ACL, which is an enzyme upstream of HMG COA reductase in cholesterol synthesis -HeFH or ASCVD in combination w/statin (add on tx) in pt's who require additional lowering of LDL -Hyperuricemia (and gout), tendon rupture 2. Leqvio -SQ injection -Inhibs intracellular production of PCSK9 via RNA interference -Approved for HeFH or primary hyperlipidemia in combo with a statin (add on tx) in patients who require additional LDL lowering. -PCSK9 mAB due to overlapping moa -Inj site rxns, arthralgia