Flashcards in Dyslipidemia-Cantrell Deck (70):
Compare the old and new cholesterol guidelines.
Old: based on risk, set goal
New: fixed dose, room for clinical judgment
Name the four groups eligible for pharmacotherapy to reduce the risk of ASCVD.
1. clinical ASCVD
2. LDL >190
3. patients with diabetes (40-75 years, LDL 70-189)
4. 10-year risk of ASCVD >7.5% (40-75 years, LDL 70-189)
In primary prevention, risk reduction is ____to LDL lowering.
in primary prevention, risk reduction is proportional to LDL lowering
What is the MOA of statins?
inhibition of 2-hydroxyl 3 methylglutaryl coenzyme A reductase, forms mevalonic acid, upregulates LDL receptors
Which cholesterol lowering class is considered first line in all patients?
What are 2 contraindications of statins?
acute liver disease and pregnancy/nursing
Which pregnancy category to statins belong to?
pregnancy category X (AKA don't use)
What is the definition of myalgia?
muscle pain/weakness (without CK elevations)
What is the definition of myopathy?
myalgias with CK >10 x ULN
What's the definition of rhabdomyolysis?
myopathy or weakness or CD >10,000 plus acute increase in serum creatinine or medical intervention with hydration treatment
What are the 4 main adverse effects of statins?
2. GI upset
3. increase in LFTs
4. eczema like rash with simvastatin
What 4 things need to be monitored at baseline in a patient starting on a statin?
1. lipid profile
3. Creatinine kinase
When do lipids need to be rechecked in a patient starting on a statin?
6-12 weeks after starting, the patient's lipid profile needs to be rechecked
Do LFT's need to be rechecked after starting a patient on a statin?
Do you need to repeat CK?
No, only need to recheck CK if patient develops myalgias
Should you track glucose levels after starting a patient on a statin?
What do you do in a patient who is asymptomatic, but has mild elevations in CK?
continue statin with careful monitoring
What do you do in a patient who is symptomatic (muscle soreness, tenderness, pain) but doesn't have CK elevation?
Continue statin, but if symptoms persist, change statin or reduce dose
What to do in a patient who has symptoms and has CK
stop statin, change statin after resolution
What to do in a patient with symptoms and CK >10?
recheck within one week
encourage PO fluids
may restart different statin after resolution
What to do in a patient with symptoms and CK >10,000?
recheck BUN, SrCR, electrolytes, UOP, and UA
Repeat within 24 hours
Admit for IV fluids
Who is at risk for muscle symptoms?
older, frail individual (esp. women)
those with impaired renal function
Which CYP metabolizes lovastatin?
Which CYP metabolizes Atorvastatin?
Which CYP metabolizes fluvastatin, rosuvastatin, and pitavastatin?
Simvastatin is contraindicated with which medications?
HIV/HepC PI gemifribrozil
Do not exceed 10mg of simvastatin with ___ and ____.
do not exceed 10mg of simvastatin (daily) with verapamil and diltiazem.
Do not exceed 20mg of simvastatin with___, ____, and _____.
do not exceed 20 mg of simvastatin with amiodarone, amlodipine, and ranolazine.
What is the high intensity dosing of atorvastatin?
40-80mg is the high-intensity dose of atorvastatin
What is the high-intensity dose of rosuvastatin?
20-40mg is the high-intensity dose for rosuvastatin
What is the moderate intensity dose of atorvastatin?
the moderate intensity dose of atorvastatin is 10-20mg
What is the moderate intensity dose of rosuvastatin?
5-10mg is the moderate-intensity dos of rosuvastatin
Who should be considered for non-statin therapy?
exhibit less than anticipated response
unable to tolerate a less than rec. dose of statin
completely statin intolerant
What does nicotinic acid (niacin) do?
decreases LDL by 20-25%
decreases TG's by 25-50%
increases HDL by 25-50%
What is niacin's MOA?
reduces hepatic production of VLDL
reduces clearance of HDL
What are 4 contraindications to niacin use?
peptic ulcer disease
What are some the adverse effects of nicotinic acid?
flushing, dry skin, itching, gastritis, hepatic toxicity, increased uric acid levels, hyperglycemia
What was the outcome of the ADMIT trial?
nicotinic acid (niacin) can be used safely in patients with diabetes
What are a few tips to improve tolerability of nicotinic acid (niacin)?
take niacin in evening with a low-fat snack
take 325mg asprin 30-60 min prior to taking niacin
do NOT take with a hot beverage
What four things need to be monitored for patients on niacin?
fasting lipid panel
uric acid level
What's the dosing of ER niacin (Niaspan)?
500mg daily of Niaspan for 30 days, increased to 1000mg for 30 days, then to 1500 mg (can titrate up to 2500mg)
IR does of Niacin. What to know about them?
quickly absorbed (smaller doses)
more flushing, itching associated with IR dosage forms of niacin
SR doses of Niacin. What to know?
SR absorbed over 12-24 hours
SR doses have an increased risk for hepatotoxicity
ER doses of Niacin. What to know?
ER doses absorbed over 8 hours.
The ER doses of niacin (Niaspan) are the best therapeuitc option.
What is the problem with flush free formulations of niacin?
no flushing, but these formulations don't have effects on lipids
niacin ER+ simvastatin vs. simvastatin alone.
ER niacin offered no reduction of CV events
What are the advantages of ezetimibe (Zetia)?
there's little/no risk of myopathy or LFT increase
zetia has a predictable response and convenient dosing
seldomly does it need to be renal/hepatic dose adjusted
What are the disadvantages of ezetimibe?
ezetimibe only affects LDL
can't/shouldn't be used as monotherapy
What's the role of Zetia in therapy?
Zetia should be used as adjunctive therapy to statin or other for LDL reduction
What's the main take away message of the IMPROVE IT trial?
simvastatin vs simvastatin + ezetimibe
first major trial to show additional benefit when adjunctive therapy is added to statin
Which three drugs are considered fibric acid derivatives?
Whats the MOA of fibric acid derivatives?
fibric acid derivatives activate peroxisome proliferation activating factor and increase lipoprotein lipase activity
What do fibric acid derivatives do?
fibric acid derivatives
decrease LDL 10-20%
decrease TG up to 50%
increase HDL 10%
When should fibric acid derivatives be used?
when TG's are above 500
What are contraindications to fibric acid derivative use?
severe renal dysfunciton
What side effects are caused by fibric acid derivatives?
GI side effects
rash (from fenofibrate)
What drug interactions occur with fibric acid derivatives?
gemfibrozil interacts with statins
warfarin interacts with gemifibrozil
cyclosporine interacts with fenofibrate
Describe the interaction between gemfibrozil and statins.
gemfibrozil inhibits statin glucuronidation-->increases cmax of statins 2-3 fold
38% of rhabdomyolysis cases involve statin-fibrate
(fenofibrate is a safer option when using with statin)
What's the dosing of gemifibrozil?
600mg BID prior to meals
safer agent in patients with renal dysfunction(if CrCl
Whats the dosing of fenofibrate?
Note: less risk of statin interaction than gemfibrozil
What three drugs are considered bile acid sequestrants?
colesavalem, cholestryramine, colestipol
What's the MOA of bile acid sequestrants?
binds bile acids in small intestine interrupting enterohepatic circulation
LDL's are cleared at a higher rate from plasma
and it causes an increase in VLDL secretion
What are the adverse effects of bile acid sequestrants?
bile acid sequestrants cause constipation, bloating, and heartburn.
colesevelam is better tolerated
Which medications do bile acid sequestrants interact with?
statins, levothyroxine, warfarin, digoxin, V/M are have decreased absorption when patient is on a bile acid sequestrant
Contraindications to bile acid sequestrant use?
What are the treatment options of choice for elevated TG's?
fibrates, niacin, O3FA
Non pharm: review for secondary causes
What's the MOA of O3FA?
O3FA inhibits secretion of VLDL
20-50% reduction in TG
can increase LDL
Adverse effects of fish oil?
poor taste (refridgerate and don't take with carbonated beverages)
What to monitor in patients taking fish oil?
fasting lipid panel, LFT, CK, TSH, A1C
do follow-up lipid panel 4-12 weeks after initiation