Dyslipidemia Flashcards Preview

NAPLEX > Dyslipidemia > Flashcards

Flashcards in Dyslipidemia Deck (141):
0

What's a major risk factor for the development of coronary heart dx (CHD)?

Abnormalities of plasma lipoproteins resulting in predisposition to coronary, cerebrovascular, and peripheral arterial dx

1

Types of dyslipidemia?

Primary (familial)

Secondary (acquired)

2

List the secondary causes of hyperlipidemia

Diet - saturated or Trans fat

Drugs - diuretics, cyclosporine, Tacrolimus, glucocorticoids,
amiodarone

Diseases - biliary obstruction, nephrotic syndrome

Disordered & altered states of metabolism - hypothyroidism obesity etc

3

What's the formula to calculate LDL if pt didn't fast? When can't this formula be used?

Friedewald eqn: LDL = TC - HDL - (TG/5)


Can't be used when TG is > 400mg/dL

4

List natural pdts used for dyslipidemia

Red yeast rice

Garlic

OTC fish oils (used to lower TG when TG is >= 500)

Plant sterols/stanols

5

When is OTC fish oils used in dyslipidemia?

used to lower TG when TG is >= 500

6

What's the key point of the new ATP guidelines!

There's no evidence to support continued use of specific LDL or HDL tx targets.

Statins (primarily). Dosed at the appropriate intensity, are used in at-risk pts

7

When do u use nonstatin therapies in dyslipidemia?

When statins are NOT tolerated

8

What're the 4 key pt groups for statin benefit?

Clinical atherosclerotic cardiovascular dx (ASCVD), including coronary heart dx (ACS, S/P MI, stable or unstable angina, coronary or other arterial revascularization), stroke, TIA, or peripheral artery dx thot to be of atherosclerotic origin

Primary elevations of LDL >= 190mg/dL

Diabetes + 40-75 yrs of age + LDL btw 70-189 mg/dL

40-75 yrs + LDL btw 70-189 mg/dL + estimated 10-yr ASCVD risk of >= 7.5% (using global risk assessment)

9

In what dx states should statin therapy by initiated?

Clinical atherosclerotic cardiovascular dx (ASCVD), including coronary heart dx (ACS, S/P MI, stable or unstable angina, coronary or other arterial revascularization),

stroke,

TIA,

peripheral artery dx thot to be of atherosclerotic origin

10

Whats the value of LDL req to start statin therapy?

Primary elevations of LDL >= 190mg/dL

11

What's the other criteria that goes along with diabetes to start statin?

Diabetes
+
40-75 years
+
LDL btw 70-189mg/dL

12

What's the other criteria that goes along with 10yr ASCVD to start statin?

40-75 yrs
+
LDL btw 70-189 mg/.dL
+
Estimated 10-yr ASCVD risk >= 7.5% (using the global risk assessment tool)

13

Other factors may be useful in making a decision to start statin, if the 4 key factors results in inconclusive decision
Wrt LDL?

LDL >= 160mg/dL
Or
Other evidence of genetic hyperlipidemia

14

Other factors may be useful in making a decision to start statin, if the 4 key factors results in inconclusive decision
Wrt FH?

FH of premature ASCVD with onset
< 55 yrs in a first degree male relative
Or
< 65 yrs in first degree female relative

15

Other factors may be useful in making a decision to start statin, if the 4 key factors results in inconclusive decision
Wrt C-reactive protein?

High sensitivity C-reactive protein > 2 mg/dL

16

Other factors may be useful in making a decision to start statin, if the 4 key factors results in inconclusive decision
Wrt coronary artery Ca score?

Coronary artery Ca score >= 300 Agatston units
Or
>= 75 percentile for age, sex and ethnicity

17

Other factors may be useful in making a decision to start statin, if the 4 key factors results in inconclusive decision
Wrt Ankle Brachial index?

Ankle Brachial index < 0.9

18

What's the 10-yr ASCVD score that indicates statin therapy needs to be started?

>= 7.5%

19

What statin tx should be started in primary elevation of LDL >= 190mg/dL?

High-intensity statin

20

What statin tx should be started in Diabetes + 40-75yrs + LDL btw 70-189mg/dL + estimated 10-yr ASCVD risk < 7.5%?

Moderate-Intensity statin

21

What statin tx should be started in 40-75yrs + LDL btw 70-189mg/dL + estimated 10-yr ASCVD risk < 7.5%?

Consider risk benefit

22

What statin tx should be started in 40-75yrs + LDL btw 70-189mg/dL + estimated 10-yr ASCVD risk >= 7.5%?

Moderate-to-high intensity

23

What statin tx should be started in Clinical atherosclerotic cardiovascular dx ASCVD risk < = 75yrs?

High-intensity statin

24

What statin tx should be started in Clinical atherosclerotic cardiovascular dx ASCVD risk > 75yrs?

Moderate-intensity statin

25

List conditions that req High-intensity statin

Primary elevation of LDL > 190mg/dL

Diabetes + 40-75yrs + LDL btw 70-189mg/dL + estimated 10-yr ASCVD risk >= 7.5%

Clinical atherosclerotic cardiovascular dx ASCVD risk < = 75yrs (2nd prevention)



26

What statin tx should be started in Diabetes + 40-75yrs + LDL btw 70-189mg/dL + estimated 10-yr ASCVD risk >= 7.5%?

High-intensity

27

List conditions that req Moderate-to-High intensity statin

40-75yrs + LDL btw 70-189mg/dL + estimated 10-yr ASCVD risk >= 7.5%

28

List conditions that req Moderate-intensity statin

Diabetes + 40-75yrs + LDL btw 70-189mg/dL + estimated 10-yr ASCVD risk < 7.5%

Clinical atherosclerotic cardiovascular dx ASCVD risk > 75yrs

29

List high-intensity statins

Atorvastatin (Lipitor) 40-80 mg daily

Rosuvastatin (Crestor) 20-40 mg daily

30

Effect of high-intensity statins (Atorvastatin (Lipitor) 40-80 mg/d and Rosuvastatin (Crestor) 20-40 mg/d) on LDL?

Reduces LDL >= 50%

31

List moderate-intensity statins

Atorvastatin (Lipitor) 10-20 mg/d
Rosuvastatin (Crestor) 5-10 mg/d
Simvastatin 20-40 mg/d
Pravastatin 40-80 mg/d
Lovastatin 40 mg/d
Fluvastatin XL 80 mg/d
Fluvastatin 40 mg bid
Pitavastatin 2-4 mg/d

32

Effect on moderate-intensity statin on LDL?

Daily dose reduces LDL 30-40%

33

List low-intensity statins

Simvastatin 10 mg/d
Pravastatin 10-20 mg/d
Lovastatin 20 mg/d
Fluvastatin 20-40 mg/d
Pitavastatin 1mg/d

34

What criteria is needed to use non-pharmacologic therapy?

Adults < 80yrs +/- CVD

35

Increase Vegs, fruits, and whole grains

True

36

Calories from saturated fat (non-pharmacologic therapy)?

5-6% of calories from saturated fat

Reduce % of calories from Trans fat

37

Aerobic activity (non-pharmacologic therapy)?

3-4 session/wk; lasting 40 mins/session + moderate-to-vigorous intensity

38

Effect of increased physical activity on LDL?

Can reduce LDL 3-6 mg/dL

39

Preferred BMI (non-pharmacologic therapy)?

18.5 - 24.9 kg/m2

40

Tobacco pdt (non-pharmacologic therapy)?

Avoid tobacco pdts

41

What's the drug of choice in treating elevated LDL?

Statins

42

What's used to determine appropriate statin intensity chosen?

Pts level of risk

43

What SE is common to many of the drugs used in dyslipidemia?

Potentially hepatotoxic

T4 liver enzymes should be monitored

44

When should dyslipidemia therapy be d/c?

AST (8-48 units/L)
Or
ALT (7-55 units/L)

Become > 3 times the upper limit of normal

45

Mgt of mild-to-moderate muscle sx associated with statin use?

D/c statin and evaluate sx

Check for other conditions/ meds that can cause muscle damage

Restart, if sx resolves

46

MOA of statins?

Inhibit the enzyme 3-hydroxy-3-methylglutaryly coenzyme (HMG-CoA) reductase

Thus prevention conversion of HMG-CoA to mevalonate

47

What's the rate-limiting step in cholesterol synthesis?

Conversion of HMG-CoA to mevalonate (which is the step prevented by statins)

48

List main statins

Atorvastatin (Lipitor)

Simvastatin (zocor)

Rosuvastatin (Crestor)

Pravastatin (Pravachol)

Lovastatin (Mevacor, Altoprev)

Fluvastatin (Lescol, Lescol XL)

Pitavastatin (Livalo)

49

What's the brand name of Atorvastatin?

Lipitor

50

What's the brand name of Simvastatin + Ezetimibe?

Vytorin

51

Whats the brand name of Rosuvastatin?

Crestor

52

What's the equivalent dose of Atorvastatin (Lipitor)?

10mg

53

What's the equivalent dose of Simvastatin (Zocor)?

20mg

54

What's the equivalent dose of Rosuvastatin (Crestor)?

Equiv dose = 5 mg

55

What's the equivalent dose of Lovastatin and Pravastatin?

40 mg

56

What's the equivalent dose of Fluvastatin?

80mg

57

What's the equivalent dose of Pitavastatin?

2

58

Which statin is used in the evening?

Simvastatin

Mevacor (Lovastatin immediate release)

59

Which statin is used at bedtime?

Fluvastatin (Lescol)

Altoprev (Lovastatin ext-release)

60

CI to statin use?

Active liver dx (including any unexplained elevations in hepatic Transaminases)

Pregnancy

61

Warnings associated with statin use?

Skeletal muscle effects (e.g. Myopathy, including risk of rhabdomyolysis)

62

Factors that increase risk of Skeletal muscle effects (e.g. Myopathy, including risk of rhabdomyolysis)?

Higher doses of statins

Concomitant use of certain medicines

>= 65 yrs

Female

Uncontrolled hypothyroidism

Renal impairment

63

Effect of statin on A1C?

Statin can cause an increase in A1C and FBG

But benefits of statin therapy far outweigh the risk of hyperglycemia

64

SEs of statins?

Myalgia

Arthralgias

Myopathy

Diarrhea

Increased CPK

Rhabdomyolysis (increase risk with higher dose)

Cognitive impairment (memory loss, confusion - reversible)

Increased BG

Increased A1c

Possible increase risk of cataracts

Increase LFTs

65

Monitoring of statins?

LFTs at baseline and as clinically indicated thereafter

Lipid panel 4-12 wks after initiation or up titration, then Q 3-12 months thereafter

66

What's the preg cat of statin?

X

67

Which statins can be taken anytime of the day?

Crestor (Rosuvastatin)

Lipitor (Atorvastatin)

Livalo (Pitavastatin)

Lescol XL (Fluvastatin)

Pravachol (Pravastatin)

68

Which statins don't need renal dose adjustment?

Lescol (Fluvastatin)

Lipitor (atorvastatin)

69

Which statin do u dose adjust when CrCl is < 60 ml/min

Livalo (Pitavastatin)

70

Which other dyslipidemia agent use is CI with statin?

Fibrates esp, Gemfibrozil

71

Effect of niacin pdt containing >= 1gm and statin? (And statin + colchine)

Increase risk of myopathies

72

Are Lovastatin, simvastatin and atorvastatin 3A4 inducers, inhibitors, substrates?

3A4 substrates

73

Effect of Lovastatin, simvastatin and atorvastatin being 3A4 substrates?

LAS, undergo extensive first-pass metabolism by CYP 3A4

74

What dose of simvastatin should a pt not be started on? (Pts that are currently on this dose, may continue)

80mg / day

75

What meds should u not exceed simvastatin 10mg/day with?

Verapamil

Diltiazem

Dronedarone

76

What meds should u not exceed simvastatin 20mg/day with?

Amiodarone

Amlodipine

Ranolazine

77

If pt is on Verapamil/ Diltiazem/ Dronedarone, what dose of simvastatin may also be used in this pt?

No more than 10mg/ day of simvastatin

78

If pt is on amiodarone/ amlodipine/ Ranolazine, what dose of simvastatin may also be used in this pt?

No more than 20mg/ day of simvastatin

79

What meds should u not exceed lovastatin 20mg/day with?

Danazol

Diltiazem

Dronedarone

Verapamil

80

What meds should u not exceed lovastatin 40mg/day with?

Amiodarone

81

If pt is on amiodarone, what dose of lovastatin may also be used in this pt?

No more than Lovastatin (Mevacor) 40mg/d

82

If pt is on danazol/ Dronedarone/ Diltazem/ verapamil, what dose of lovastatin may also be used in this pt?

No more than Lovastatin (Mevacor) 20mg/d

83

What meds should be avoided with Atorvastatin (Lipitor)?

Cyclosporine

Tipranivir + Ritonavir or Telaprevir

84

What meds should u not exceed atorvastatin 20mg/day with?

Clarithromycin

Itraconazole

Lopinavir + Ritonavir

Darunavir + Ritonavir

Fosamprenavir +/- Ritonavir

85

What meds should u not exceed atorvastatin 40mg/day with?

Nelfinavir

Boceprevir

86

What types of meds are to be avoided with simvastatin and Lovastatin (Mevacor)?

Itraconazole, Ketoconazole, Posaconazole, Voriconazole

Erythromycin, Clarithromycin, Telithromycin

HIV protease Inhibitors

Boceprevir, Telaprevir

Nefazodone

Cyclosporine

Gemfibrozil

Danazol (with simvastatin)

Grapefruit juice

87

Sx of liver damage from statin use?

Brown or dark colored urine

Pale stools

Feel more tired than usual

Skin and/or whites of eyes become yellow

88

Sx of muscle damage from statin use?

Muscle weakness, tenderness, aching, cramps, stiffness or pain that happens without a good reason, esp if u also have a fever or feel more tired than usual

89

MOA of Ezetimibe?

Inh absorption of cholesterol at the brush border of small intestine

90

Brand name of Ezetimibe?

Zetia

91

Brand name of Ezetimibe + Simvastatin?

Vytorin

92

Preg category of Ezetimibe (Zetia)?

C

93

How do u dose bile acid resins with Ezetimibe (Zetia)?

Give Ezetimibe (Zetia) 2 hrs before

OR

4 hrs after bile acid resin

94

What's the concern with Vytorin (Ezetimibe + Simvastatin)?

Increased muscle damage

95

MOA of bile acid sequestrants/ bile acid binding resins?

Binds Bile acids in intestine forming a complex excreted in feces

T4 preventing re-absorption

96

List bile acid sequestrants/ bile acid binding resins agents

Cholestyramine (Questran, Prevalite)

Colesevelam (Welchol)

Colestipol (Colestid)

97

What's the grand name of Colesevelam (bile acid sequestrants/ bile acid binding resins)?

Welchol

98

How do u take Cholestyramine?

Comes in powder

Mix with water or non-carbonated liq

99

How do u take Colesevelam (Welchol)?

With a meal + liquid

100

SEs of bile acid sequestrants/ bile acid binding resins?

Constipation (may need dose reduction or laxative)

Abdominal pain

Cramping

Gas

Bloating

Hypertriglyceridemia

101

When does ATP IV guidelines not recommend the use of bile acid sequestrants/ bile acid binding resins (Cholestyramine, Colesevelam (Welchol), and Colestipol)?

TGs >= 300mg/dL

102

Why does ATP IV guidelines not recommend the use of bile acid sequestrants/ bile acid binding resins (Cholestyramine, Colesevelam (Welchol), and Colestipol)?

Bcuz they have NO effect on TGs and may even increase TGs in some cases

103

Possible SE of cholestyramine (Questran, Prevalite)?

Teeth discoloration, erosion of enamel/ decay

Sipping or holding the suspension in mouth for prolonged periods

104

Which bile acid sequestrants/ bile acid binding resins (Cholestyramine, Colesevelam (Welchol), and Colestipol) is considered safest?

Colesevelam (Welchol)

Still consider separating other drugs by 1-4 hrs

105

Whys the use of concurrent multivitamin recommended with the use of bile acid sequestrants/ bile acid binding resins (Cholestyramine, Colesevelam (Welchol), and Colestipol)?

They may reduce absorption of fat-soluble vits (A, D, E, K)

106

MOA of fibrates?

Fibrates are peroxisome proliferator receptor alpha (PPARalphasign) activators

Resulting in enhanced elimination and reduce synthesis of VLDL (lower TGs) and higher LDL

107

What's the caveat to reducing TGs?

When TGs are high, reducing TGs may result in HIGHER LDL

T4 be careful to monitor LDL, when reducing TGs

108

Results of ACCORD lipid study wrt fenofibrate use?

Study showed no significant difference in experiencing a major cardiac event btw using fenofibrate + simvastatin and fenofibrate alone.

But, it found that using the combo of fenofibrate + simvastatin caused worsening of renal fxn

109

List agents under fibrates

Fenofibrate, Fenofibric Acid (TriCor, Trilipix)

Gemfibrozil (Lopid)

110

What's the most common brand names of Fenofibrate, Fenofibric acid?

TriCor

Trilipix

111

What's the brand name of Gemfibrozil (fibrate)?

Lopid

112

What's the caveat to consider when using fibrates (fenofibrate/ Gemfibrozil) in a pt with high TGs?

Can increase LDL when TGs are high

113

Which fibrate is the ONLY one with an indication to use with a statin?

Trilipix

114

MOA of niacin?

Decreases rate of hepatic synthesis of VLDL (lowers TGs) and LDL

115

What's niacin also known as?

Nicotinic acid

Or

Vitamin B3 (although doses for cholesterol reduction are much higher than those found in multivitamin pdts)

116

List agents under Niacin

Immediate-Release (crystalline) niacin (Niacor) - OTC

Extended-Release Niacin (Niaspan)

Controlled-(or sustained) Release Niacin (Slo-Niacin) - OTC

117

What's the brand name of Extended-Release Niacin?

Niaspan

118

In what strength do Extended-Release Niacin (Niaspan) come in?

500mg

750mg

1000mg

119

SE of Niacin use

Flushing

Pruritus (itching)

Nausea/ vomiting

Diarrhea

GI distress

Hyperglycemia

Hyperuricemia (or gout)

Increased cough

Hepatotoxicity

Orthostatic hypotension

Hypophosphatemia

120

Monitoring parameters of Niacin use?

Check LFTs (at start of baseline; Q 6-12wks for first yr)

BG (if diabetic)

Uric gout (if gout)

INR (if on warfarin)

121

Which formulation of Niacin has less flushing and less hepatotoxicity? T4 best clinical choice from Niacin Grp?

Niaspan (but, it's most expensive)

122

Are formulations of Niacin interchangeable?

No! (Applicable to regular release v. Extended release)

123

How should u use Niacin in combo with statins?

Stick to lower statin doses

124

How should u use Niacin and Bile acid Sequestrants (Colevelesam (Welchol))?

Take Niacin 4-6 hrs AFTER bile acid sequestrants

125

Use of fish oils?

Adjunct to diet in pts with TGs >= 500mg/dL

126

List agents under fish oil

Omega-3 acid Ethyl Esters (Lovaza)

Icosapent ethyl (Vascepa)

127

What's the brand name of Omega-3 Acid Ethyl Esters?

Lovaza

128

SEs of fish oils?

Eructation (burping)

Dyspepsia

Taste perversions (Lovaza)
Arthralgias (Vascepa)

129

Which fish oil can increase LDL by up to 44%?

Lovaza ONLY

No such increase seen with Vascepa

130

Effect of omega-3-acids (fish oil) on bleeding out?

Lovaza and Vascepa may prolong bleeding time

131

List new agents used for Homozygous Familial Hypercholesterolemia (HoFH)

Lomitapid

Mipomersen

132

MOA of Lomitapide?

Lomitapide binds to and inhibits microsomal TG transfer protein (MTP) in the endoplasmic reticulum

133

What's the brand name of Lomitapide?

Juxtapid

134

Pregnancy category of Lomitapide (Juxtapid)?

X

135

MOA of Mipomersen?

Mipomersen is an oligonucleotide inhibitor of apo B-100 synthesis.

ApoB is the main component of LDL and VLDL, which is a precursor to LDL

136

What's the brand name of Mipomersen?

Kynamro

137

What's the CI to Mipomersen (Kynamro) use?

Liver dx (including unexplained elevations in hepatic Transaminases)

138

Due to risk of hepatotoxicity, howz Mipomersen (Kynamro) made available?

Only available through a Kynamro Risk Evaluation and Mitigation Strategy (REMS) program

139

What med can be used as a pre-tx to prevent flushing caused by Niacin agents?

325mg aspirin (or 200mg of ibuprofen) 30-60 mins before dose (for a few weeks)

140

List drugs that significantly reduce TGs by > 10%?

Fibrates

Fish oils

Niacin

Decks in NAPLEX Class (73):