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Flashcards in Dyslipidemia meds Deck (86):
1

What synthesizes cholesterol?

The liver

2

Where do we get additional cholesterol?

From our diets

3

Give two features about cholesterol

It has a membrane structure
It is a precursor to steroid hormones

4

What is the formula for total cholesterol (endogenous and dietary)?

Total-C = (LDL + HDL + VLDL)

5

What is your bad cholesterol? What is the shorthand for this?

Low density lipoproteins
LDL

6

What is your good cholesterol? What is the shorthand for this?

High density lipoproteins
HDL

7

What is the shorthand for triglycerides?

VLDL

8

What is the optimal LDL measurement?

< 100 mg/dL

9

What LDL measure is classified as high?

160-180 mg/dL

10

What are the 2018 ACC/AHA adult recommendations

See slide 10

11

What are some causes of secondary dyslipidemia?

Diabetes
Hypothyroidism
Obstructive liver disease
Chronic renal failure
Drugs

12

List some lifestyle changes that can lower LDL

TLC diet (reduced intake of cholesterol-raising nutrients and LDL lowering therapeutic options)
Weight reduction
Increased physical activity

13

Choice of lipid lowering drugs

See slide 17

14

What are the most commonly prescribed drugs for increased cholesterol?

HMG CoA Reductase Inhibitors
AKA statins

15

By what % do statins tend to reduce LDL and TG by?

18-55% (LDL)
7-30% (TG)

16

By what % do statins increase HDL?

5-15%

17

What are some major side effects of statins?

Myopathy (increased CK)
Increased liver enzymes (increased AST/ALT)

18

What are some contraindications for statins?

Absolute: liver disease
Relative: use with certain drugs

19

Give some examples of things that statins have demonstrated therapeutic benefits for.

Reduced major coronary events
Reduce CHD mortality
Reduce stroke

20

What is the MOA of statins?

Block rate -> limiting step in cholesterol synthesis

21

When do we see statin induced myopathy?

Serum CK >10x ULN with unexplained muscle pain

22

When do we see statin induced rhabdomyalysis?

Serum CK > 40x ULN with unexplained muscle pain or weakness

23

When do pts at risk of statin induced myopathy tend to present?

In the first 12 months

24

Which statin poses the highest risk for induced myopathy?

High dose simvastatin

25

What internal element causes simvastatin to pose the risk for induced cardiomyopathy?

CYP3A4

26

What should you do if pts experiences SEs on a statin?

Try a different one

27

Give two examples of statins?

Atorvastatin
Rosuvastatin

28

What is an issue with pitavastatin?

Its very expensive and not generically available as of 2/11/19

29

By what percent does rosuvastatin lower LDL??

63%

30

By what percent does atorvastatin lower LDL?

57%

31

By what percent does simvastatin lower LDL?

46%

32

How many high dose pts developed myopathy while on simvastatin?

52

33

How many low dose pts developed myopathy while on simvastatin?

22

34

How many high dose pts developed rhabdo while on simvastatin?

22

35

How many low dose pts developed rhabdo while on simvastatin?

0

36

What is the FDA simvastatin black-box warning?

Restricting dosing of 80 mg of simvastain

37

When can pts be put on 80 mg of simvastatin?

When they have been taking it for >12 months

38

What should pts on an 80 mg dose w/o adverse effects do when they need to take a contraindicated drug?

They should switch to another statin

39

What should pts who's LDL goal cannot be reached on the 40 mg dose of simvastatin?

They should be switched to a statin w/ less risk of cardiomyopathy

40

List some drugs that are contraindicated with simvastatin

Itraconazole
Eythromycin
HIV protease inhbitors
Nefazodone
Gemfibrozil
Cyclosporin
Danazol

41

With what drugs should we not exceed 10 mg simvastatin with?

Amiodarone
Verapamil
Diltiazem

42

With what drugs should we not exceed 20 mg simvastatin daily?

Amlodipine
Ranolazine

43

What is an odd contradiction with simvastatin?

Not ingesting > 1 quart of grapefruit juice daily

44

Are elevated transaminases on statins a reason to dc?

No

45

Are statin side effects agent specific or class specific?

Agent specific

46

What should you do with unexplained myalgias w/o CK elevation?

Try a different statin

47

How many pts receive new scripts for simvastatin?

Very few

48

What is the MOA of bile acid sequestrants?

Bind dietary cholesterol

49

What are the major actions of bile acid sequestrants (BAS)?

Reduce LDL 20-25%
Raise HDL 3-5%
May increase TG

50

What are some SEs of BAS?

GI distress/constipation, diarrhea, bloating
Decreased absorption of other drugs

51

When are BAS agents contraindicated?

Severe hepatic impairment
Raise TG (esp > 400 mg/dL)

52

Give some examples of BAS

Cholestyramine
Colestipol
Colesevelam

53

What is an issue with colesevelam?

Its very exepnsive ($561)

54

When do we usually give BAS?

As add on therapy to max dose statins

55

What are the major actions if Niacin?

Lowers LDL by 5-25%
Raises HDL by 15-35%
Lowers TG by 10-50%

56

What is a major SE of niacin?

Flushing

57

How do we minimize flushing with Niacin?

Pretreatment with NSAIDS 30-60 minutes prior to ingestion

58

When is niacin usually used?

As add on therapy
Not monotherapy
Not often used

59

What was needed to prove the efficacy of niacin?

A new large trial

60

What did the niacin trial show?

Niacin did not reduce incidence of primary composite endpoint (??)

61

What happened with the niacin trial?

Trial was stopped early

62

What was an unexpected increase in the niacin trial?

Strokes increased

63

What was the basic conclusion of the niacin trial?

Niacin doesnt reduce CVA risk but does increase risk CVA risk so its little used

64

How much do fibric acids decrease TG and VDL by?

25-50%

65

How much do fibric acids lower LDL?

5-20%

66

Might fibric acids raise LDL?

Yes, with high TG

67

How much might fibric acids raise HDL by?

10-20%

68

What are two fibric acids?

Gemfibrozil
Fenofibrate

69

What class is ezetimibe a part of?

A drug of a new class that inhibits intestinal absorption of cholesterol

70

How much does ezetimibe lower LDL?

2-25%

71

What is the effect of ezetimibe with statins?

Increases effects of statin by 10-15% w/o side effects

72

When is ezetimibe well tolerated?

At 10 mg/d

73

What is vytorin?

Exetimibe + simvastatin

74

What are PCSK9 inhibitors?

New class of monoclonal antibodies

75

What do PCSK9 inhibitors do when they are added to statins?

Reduce LDL by 50-60%

76

How do you administer PCSK9 inhibitors?

SC injection q2-4 weeks

77

What place do PCSK9 inhbitors have in therapy?

Add on to max dose statins

78

What is a new class of drug not yet FDA approved?

Bempedoic acid
FDA labeling requested in Feb 2019

79

How often do you give bempedoic acid?

Daily

80

What is the MOA of bempedoic acid?

Inhibits ATP citrate lyase (key enzyme in chol synthesis)

81

What is the PO dose of bempedoic acid?

180 mg once daily

82

Did bempedoic acid show a decrease in LDL?

Yes

83

Did bempedoic acid decrease non-HDL?

Yes

84

Did TC decrease on bempedoic acid?

Yes

85

What are two other things that bempedoic acid decrease?

Apolipoprotein B
High-sensitivity CRP

86

Fixed dose statin therapies

See slide 46