Dyslipidemia lecture

Question 1

The ASCVD-risk assessment evaluates a _______-year atherosclerotic cardiovascular disease incident

Answer 1

10

Question 2

List / describe 2 subtypes of dyslipidemias

Answer 2

1) Hypertriglyceridemia can lead to pancreatitis or eruptive xanthomas when very high TG levels (>500 mg/dL)
2) Low HDL-C
(also Diabetic dyslipidemia)

Question 3

According to AHA estimates, approximately 45% of American adults aged 20 or older have total cholesterol levels exceeding _________mg/dL

Answer 3

200

Question 4

Estimates from the National Cholesterol Education Program (NCEP) state that only ______% of patients have an optimal LDL-C (<100 mg/dL)

Answer 4

26%

Question 5

The underlying causes of dyslipidemias can be categorized into two types; what are these types?

Answer 5

primary or secondary

Question 6

List 3 etiologies of dyslipidemias

Answer 6

1) Familial
2) Primary
3) Secondary

Question 7

Primary Dyslipidemias: What are 2 types?

Answer 7

1) Homozygous familial hypercholesterolemia (HoFH) (rare)
2) Heterozygous familial hypercholesterolemia (HeFH)
(less rare; 1 case per 250 people)

Question 8

List drugs that can induce secondary or acquired dyslipidemias

Answer 8

1) Atypical antipsychotics & ritonavir
2) Diuretics, beta blockers, glucocorticoids, oral estrogen and progestin, tacrolimus, and cyclosporin can be associated with weight gain or hyperglycemia and cause dyslipidemias

Question 9

In the liver:
1) __________ is converted to pyruvate and then to acetyl-CoA
-Acetyl-CoA is eventually converted to HMG-CoA reductase
2) What is the target for statins?

Answer 9

1) Glucose
2) HMG-CoA reductase

Question 10

Only empty HDL and VLDL are made in the liver:
1) VLDL is transported across lipase, which changes the VLDL to IDL (aka _________________________)
2) IDL can then be converted to __________.

Answer 10

1) intermediate-density lipoproteins
2) LDL

Question 11

Familial hypercholesteremia:
Primary defect in familial hypercholesterolemia is the inability to bind ____________ to the _________ receptor (so stuck in bloodstream)

Answer 11

LDL to the LDL

Question 12

Many patients with dyslipidemia present with one or more of the following abnormalities; list them

Answer 12

Abdominal obesity
Atherogenic dyslipidemia
Increased blood pressure
Insulin resistance and/or glucose intolerance
Prothrombotic or proinflammatory state

Question 13

Patients with _________ or more of the abnormalities of dyslipidemia are considered to have metabolic syndrome

Answer 13

three

Question 14

1) Who should you recommend a heart-healthy lifestyle to?
2) What should you recommend for those very high risk for ASCVD?
3) What should you do for those age 75+ who aren’t very high risk?

Answer 14

1) Everyone
2) High intensity or max tolerated statin therapy
3) Moderate or high intensity statin therapy

Question 15

1) Define severe hypercholesterolemia
2) What diabetics should you initiate primary prevention for? What is this prevention?

Answer 15

1) LDL >/= 190 mg/ dL
2) Ages 40-75 and LDL of 70-189mg/dL (1.81-4.8 mmol/L):
Moderate-intensity statin therapy regardless of 10 yr ASCVD risk

Question 16

Nondiabetics
1) What nondiabetics should you initiate primary prevention for?
2) Based on 10 yr risk, what should you do for those high risk (>/=20%)?
3) What abt those with intermediate risk? (>/= 7.5% to <20%)
4) What abt low risk? (<5%)

Answer 16

1) 40-75 yrs and LDL of 70-189 mg/ dL (1.81-4.89 mmol/L)
2) Initiate high intensity statin therapy
3) If risk enhancers present, consider moderate intensity statin therapy
4) Emphasize heart-healthy lifestyle

Question 17

Describe primary prevention for those 20-39 y/o and LDL of 70-189 mg/ dL

Answer 17

Encourage lifestyle to reduce ASCVD risk

Question 18

1) Nonstatin lipid-lowering therapies (such as ezetimibe, bempedoic acid, and PCSK9 inhibitors) play a supportive role in the management of dyslipidemia and are primarily used in combination with what?
2) When are they used as monotherapy?

Answer 18

1) Statins
2) In patients unable to tolerate the recommended dose of a statin

Question 19

Although the _______________-style diet has no consistent effect on LDL-C levels, it has been shown to reduce major cardiovascular events among persons at high cardiovascular risk when compared to a control diet

Answer 19

Mediterranean

Question 20

List 2 dietary supplements that reduce LDL by binding cholesterol

Answer 20

Soluble fiber and psyllium

Question 21

Dietary supplements:
1) Describe Eicosapentaenoic acid (EPA) and docosahexaenoic acid (DHA)
2) What is important to know abt red yeast rice?

Answer 21

1) Omega-3 fish oil
Reduces triglycerides and VLDL-C
Anti-inflammatory properties
2) Avoid concurrent use with prescription statins
Recommend a brand with the USP seal of approval

Question 22

True or false: Phytosterols are an OTC that reduces LDL

Answer 22

True

Question 23

Familial hypercholesterolemia: List 2 orphan drugs used for it

Answer 23

1) Mipomersen (Kynamro)
2) Lomitapide (Juxtapid)

Question 24

Familial hypercholesterolemia
1) How is Mipomersen (Kynamro) administered?
2) How is Lomitapide (Juxtapid) given?
3) What do both of these have in common?

Answer 24

1) SubQ
2) PO
3) BBW for hepatotoxicity & are orphan drugs

Question 25

Besides route of administration, what differentiates Mipomersen (Kynamro) from Lomitapide (Juxtapid)?

Answer 25

1) Mipomersen (Kynamro): Reduces LDL-C levels by ∼25% 2) Lomitapide (Juxtapid): Reduces LDL-C levels by ∼40%

Question 26

Statin therapy should be generally discontinued in who?

Answer 26

Patients with intolerable symptoms

Question 27

HMG-CoA reductase inhibitors (Statins): ____________, ____________, and sometimes __________ are associated with more significant drug–drug interactions since they are predominantly metabolized by CYP3A4

Answer 27

Lovastatin, simvastatin, atorvastatin

Question 28

Cholesterol absorption inhibitors 1) What is the minor side effect (although it's generally well-tolerated)? 2) Concomitant use with ___________ can lead to increased exposure to both ezetimibe and __________

Answer 28

1) Minor GI side effects/ diarrhea 2) cyclosporine; cyclosporine

Question 29

Cholesterol absorption inhibitors: 1) _______________ comes as tablets 2) What 2 kinds come as powder?

Answer 29

1) Colesevelam 2) Colestipol and cholestyramine

Question 30

Proprotein convertase subtilisin/kexin type 9 (PCSK9) inhibitors: 1) Both alirocumab and evolocumab are fully human monoclonal antibodies to PCSK9 and were approved by the FDA in _________. 2) What are some adverse effects? 3) What is a downside of these?

Answer 30

1) 2015 2) Injection site reactions, allergic reactions, infections, and post shot “flu-like” symptoms 3) Expensive $$$

Question 31

Proprotein convertase subtilisin/kexin type 9 (PCSK9) inhibitors: List 2 of them and their initial doses

Answer 31

1) Alirocumab (Praluent): 75 mg SUBQ every two weeks or 300 mg SUBQ every month 2) Evolocumab (Repatha): 140 mg SUBQ every two weeks or 420 mg SUBQ every month

Question 32

What may amplify the flushing and itching assoc. with Niacin (Vitamin B3)? What helps?

Answer 32

1) Concomitant alcohol and hot beverages may magnify flushing and pruritus with niacin 2) Extended-release products associated with decreased risk compared to instant release products

Question 33

Niacin modestly increases __________________ and HbA1c levels (so don't use in people with diabetes)

Answer 33

fasting plasma glucose

Question 34

Can you use statins in patients with kidney disease?

Answer 34

Yes, just reduce the dose