Hyperlipidemia

Question 1

What are the 5 major risk factors for CVD?

Answer 1

smoking
hypertension (>140/90 or on meds)
low HDL (45, women >55)
Fam hx of early CHD
Age (men >45, women >55)

Question 2

LDL goal - “high risk” (CHD)

Answer 2

<70)

Question 3

LDL goal - “moderately high risk” (2+ risk factors)

Answer 3

<130

Question 4

LDL goal - “moderate risk” (2 risk factors)

Answer 4

<130

Question 5

LDL goal - “lower risk” (0-1 risk factors)

Answer 5

<160

Question 6

Risks factors for metabolic syndrome

Answer 6

3 or more:
abdominal obesity (men >40, women >35)
tg >150
low HDL (men 130/>85)
fasting glucose >110

Question 7

What is the treatment approach for hyperlipidemia?

Answer 7

1. initiate TLCs
2. Treat secondary causes (DM, meds, etc.)
3. Treat LDL to goal
4. When LDL is to goal, treat high tg (>200)
5. Attempt to increase HDL if <40

Question 8

What are the TLCs (therapeutic lifestyle changes) for LDL lowering?

Answer 8

1. TLC diet (low fat, low cholesterol), plant stanols/sterols, fiber
2. weight reduction
3. increased physical activity

Question 9

*What part of the cholesterol panel do statins mostly act on?

Answer 9

LDL reduction

Question 10

*What part of the cholesterol panel do bile-acid resins mostly act on?

Answer 10

LDL reduction

Question 11

*What part of the cholesterol panel do fibric acid derivatives mostly act on?

Answer 11

decrease triglycerides

Question 12

*What part of the cholesterol panel do omega-3 fatty acids mostly work on?

Answer 12

decrease triglycerides

Question 13

*Statins - MOA

Answer 13

inhibit HMG CoA reductase –> decrease in cholesterol production (up regulation of LDL receptors and enhanced clearance)
*only works if receptors are not defective

Question 14

Statins - time of day to administer

Answer 14

usually at night so it peaks when cholesterol synthesis is the highest (2-4am)

Question 15

Side effects are low with statins but include:

Answer 15

elevated liver enzymes
myopathy
rabdomyolysis

Question 16

DDI - Statins (because of CYP450)

Answer 16

gembibrozil
Protease inhibitors
itraconazole/ketoconazole/voriconazole
emycin/clarithromycin

Question 17

Which 2 statins reduce LDL the most?

Answer 17

Atorvastatin (Lipitor) 60%

Rosuvastatin (Crestor) 60+%

Question 18

What level are we getting under control first in drug therapy for high cholesterol?

Answer 18

LDL

Question 19

What level do we treat next after lowering LDL?

Answer 19

Triglycerides

Question 20

What drug can reduce total cholesterol/LDL, Apo B, non-HDL or TG and increase HDL in patients where mono therapy is not adequate?

Answer 20

Niacin extended release/Simvastatin (Simcor)

Question 21

As you increase the dose of statin, you increase the risk of _______.

Answer 21

Myopathy

Question 22

What level is considered very high LDL?

Answer 22

> 190mg/dl

Question 23

What can be added to statins for very high LDL?

Answer 23

ezetimibe +/- nicotinic acid

bile acid sequestrates +/- nicotinic acid

Question 24

What class are: cholestyramine (Questran), colestipol (Colestid) and Colesevelam (Welchol)?

Answer 24

bile acid binding resins

Question 25

What time of day are bile acid binding resins given?

Answer 25

with meals (acts on bile acid that is present during digestion)

Question 26

*Bile acid binding resins - side effects

Answer 26

GI (bloating, constipation, gas), increase in liver enzymes, increase in TG *hard to tolerate*

Question 27

Bile acid binding resins - DDI

Answer 27

fat soluble vitamins (binds) | give 1 hr before or 4 hrs after meal

Question 28

What is the selective cholesterol absorption inhibitor?

Answer 28

Ezetimibe (Zetia) | combo agent simvastatin + ezetimibe (Vytorin)

Question 29

What is the nicotinic acid derivative used for hyperlipidemia?

Answer 29

``` ER Niacin (Niaspan) IR Niacin (available OTC) ```

Question 30

Nicotinic acid derivative dosing considerations

Answer 30

``` start out low and titrate b/c of side effects effective range 1500-2000 mg/day take at night (b/c of flushing) take ASA or NSAID 30 min before avoid ETOH ```

Question 31

*Nicotinic acid - side effects

Answer 31

``` flushing hepatotoxicity (esp. at higher doses) glucose homeostasis/insulin resistance blurry vision gout ```

Question 32

Classification of serum TG

Answer 32

normal <150 borderline high 150-199 high 200-499 very high 500+

Question 33

What is the secondary target of therapy for hyperlipidemia?

Answer 33

non-HDL (VLDL + LDL)

Question 34

At what level do you treat TG?

Answer 34

>200

Question 35

Treatment of triglycerides

Answer 35

1. treat underlying factors 2. niacin 3. fibric acid derivative "fibrates" 4. fish oil 5. therapeutic phlebotomy

Question 36

What are the underlying factors for elevated triglycerides?

Answer 36

diet, ETOH, DM, hypothyroidism, antiretrovirals, steroids,

Question 37

What is the treatment goal for very high triglycerides (>500)?

Answer 37

prevent acute pancreatitis

Question 38

*What are the two formulations for fibrates?

Answer 38

Fenofibrates and Gemfibrozil | *Fenofibrates are favored b/c of dosing (no restriction with food timing)

Question 39

*Fibrates - clinical issues

Answer 39

gall stones | Gemfibrozil can increase LDL and fenofibrates can decrease LDL

Question 40

Fibrates - DDI

Answer 40

protein bound so can displace other meds: warfarin, ASA, glyburide, statins, niacin

Question 41

Fibrates - ADE

Answer 41

contraindication: hepatic or renal dysfunction and preexisting gall bladder disease

Question 42

How much fish oil is needed/day to reduce TG?

Answer 42

2-4 grams

Question 43

Fish oils should be discontinued if what occurs?

Answer 43

acute bleeding episode such as hemorrhagic stroke

Question 44

Causes of low HDL (<40 mg/d)

Answer 44

physical inactivity type 2 diabetes smoking genetic

Question 45

What med is the DOC for low HDL treatment?

Answer 45

Niacin

Question 46

Red yeast rice - active ingredient

Answer 46

``` Monacolin K (comparable to Lovastatin) can lower cholesterol ```

Question 47

Red yeast rice - dosage

Answer 47

600 mg po bid

Question 48

Risk factors for statin induced myopathy

Answer 48

female 65+ kidney disease hypothyroidism

Question 49

Red yeast rice - effects on levels

Answer 49

lowers TC, TG and LDL | increases HDL

Question 50

Ezetimibe (Zetia) - MOA

Answer 50

(selective cholesterol absorption inhibitor) | blocks niemann Pick C1 like 1 peptide (NPC1L1) in the small intestine

Question 51

At what level should triglycerides be treated before LDL?

Answer 51

>500