Dyslipidemia

Question 1

Total Cholesterol Goals

Answer 1

Less than 200mg/dl Optimal
200-240 Borderline High
>240 mg/dl High

*Not a target for therapy

Question 2

Triglyceride Goals & Lifestyle Modifications

Answer 2

Less than 150mg/dl.

Treatment: Diet, exercise, weight loss of BMI >25, smoking cessation.

Question 3

HDL Goals

Answer 3

Goals:

> 40mg/dl- Low
60 mg/dl- High
No specific goals for raising HDL-C

Question 4

LDL Goals & Treatment

Answer 4

Primary Target.

Goals: Less than two risk factors 160 mg/dl, 2 or more risk factors (Framingham score 10-20%) goal less than 130mg/dl. Frammingham 20% or CHD risk equivalents 25), Pharmacotherapy (i.e. statins, niacin, ezetimibe, bile acid sequestrants)

Question 5

Non-HDL-C

Answer 5

Total-HDL =non-HDL

Goal is 30 points higher than LDL-C goal.

Question 6

Statins

Answer 6

MOA reduces hepatic cholesterol synthesis and lowers intracellular cholesterol which stimulates the up-regulation of the LDL-C receptor and increases the uptake of non-HDL-C particles from systemic circulation.

Pleiotropic effects: improves endothelial function, inhibit platelet aggreation, decrease LDL oxidation, reduce vascular inflammation, stabilize plaques.

Rosuvastatin
Atorvastatin
SImvastatin*
Pravastatin
Lovastatin*
Fluvastatin
Pitavastatin

*the most drug interactions.

Monitoring check baseline lipids and again in 608 weeks. Periodically thereafter.

FDA removed LFT monitoring from statin labels in Feb 2012.

Question 7

Niacin

Answer 7

MOA: Inhibits the hepatic production of VLDL and consequently it’s metabolite LDL-C

Role in therapy: consider adding onto a statin for LDL-C lowering.

Contraindications: 1)Active hepatic dz, 2) Active peptic ulcer dz

ADRs

1. Flushing, can take ASA 30 min before
2. Elevated LFTs
3. Increased glucose levels
4. Induce hyperuricemia (avoid in gout pts)
5. Myopathy

Question 8

Ezetimibe

Answer 8

MOA: Selective inhibitor of dietary and biliary cholesterol absorption

Only evidence showing outcomes was in a trial of CKD patients 17% reduction in major atherosclerotic events when COMBINED with simvastatin. Never alone has sone any benefit in real outcomes other than LDL lowering!

Use in therapy: third line agent.

Question 9

Bile Acid Sequestrants

Answer 9

MOA: bind bile acide in intestines, decreasing biliary cholesterol absorption.

Contraindication: Complete biliary obstruction

ADRs, GI constipation, obstruction, etc.

Drug Interactions: can bind many drugs, decreasing absorption.

Question 10

Fibrates

Answer 10

Fenofibrate, Gemfibrozil

MOA: PPR-alpha activation, reduced hepatic secretion of VLDL, induction of lipoprotein lipase-mediated lipolysis and clearance of TG.

Clinical use: reserve for patients with high TG >400mg/dl. Clinical evidence for cardiac events seems stronger in Gemfibrozil group.

Contraindications:
Sifnificant renal or hepatic dysfunction
Gallbladder Dz
Biliary cirrhosis

Important ADRS
In general well tolerated, most common ADR is GI upset.

*Renally CL–> needs dose adjustments!

Question 11

Omega-3 Fatty acids

Answer 11

DHA and EPA- inhibit hepatic secretion of TG and promote metabolism of TG

Literature supports use of 3-15 g/day. Can initiate DHA and EPA at 1g/day to see TG lowering.

ADRs:
Fishy taste/burpting
Antiplatelet effects

Question 12

Risk Factors for Calculating LDL-C goal

Answer 12

Cigarette smoking
HTN >140/90 or on therapy
Low HDL-C 60 serves as negative risk
Family Hx of premature CHD, first degree relative, male 45 male, >55 female

Question 13

CHD Risk Equivalents

Answer 13

DM, PVD, AAA, CAD (TIA Or Stoke), Frammingham >20%

Question 14

When to initiate drug therapy for dyslipidemia?

Answer 14

High Risk CHD: >100mg/dl
Moderately high risk: 2+ risk factors, frammingham 10-20%, >130mg/dl
Moderate risk, 2+ risk factors, frammingham 190 mg/dl.

Question 15

Statin Drug Interactions

Answer 15

Cyclosporine: use pravastatin or rosuvastatin (5 mg/dl)

HIV Protease Inhibitors & HCV protease inhibitors- CI with simva or lovastatin
Preferred prava, pitava, or rosuvastatin (10mg/day limit)

Azole antifungals, Clarithromycing, Erythromycin- discontinue statin while on AF therapy or convert to pravastatin or rosuvastatin

Nefazodone: preferred pravastatin or rosuvastatin

Amiodarone: Limit statin doses, Lovastatin 40 mg/day, Simvastatin 20mg/dl or concert o prava or rosuvastatin.

Diltiazem/Verapamil: limite lova to 20mg, simvastatin to 10mg or convert to prava or rosuva

Grapefruit Juice: Limit to less than 1 quart daily. Assess for muscle pain.

Question 16

Other Medical Causes for Hyperlipidemia

Answer 16

DM, Hypothyroidism, Alcoholism,

Recent cardiac event will falsely lower lipids up to 12 weeks after.