Which drug class is thought to work by either decreasing hepatic circulation or decreasing TG synthesis
Omega 3
What is the major side effect of Omega 3’s?
Fishy burp
indigestion
altered taste
What are the medications included in Omega 3?
Fish oil supplements
Fatty fish’s
Lovaza
When are Omega 3’s given and what is the desired effect?
When TG are greater than 500 mg/dL
Desired effect: Decrease TG by 60%
Which medication’s MOA is a decrease in intestinal absorption of dietary and biliary cholesterol?
Cholesterol Absorption inhibitors
What are some of the major side effects of ezetimibe? (and what class is it?)
Cholesterol absorption inhibitors
Diarrhea and musculoskeletal
(also sinusitis and infections)
What class are the drugs Gemfibrozil and Fenofibrate in?
Fibrates
Which of the fibrates is easier to tolerate for the pt in that it is only dosed QD for the most part as opposed to it’s sister medication
Fenofibrate is given QD
Gemfibrozil is given BID *so you would probably chose fenofibrate.
When are fibrates used?
2nd line for selected pt’s (those who can’t take statins)
and when TG is greater than 500mg/dL
What medications are considered Nicotinic Acids?
Nicotinic acid
Niacinamide
Niacin
What is the Mechanism of action for fibrates?
Activate PPAR-alpha which modulates metabolism and catabolism of lipids (works on the genes)
What drug is assumed to work in adipose tissue and decreases TG syntesis
Nicotinic acid
Which drug class is known for causing flushing?
Nicotinic acid
How can you minimize the effects of flushing when taking a drug in the class nicotinic acid?
Full dose of ASA (325mg) along with
or
switching to extended release NA
When are Nicotinic acids used
when TG is greater than 500mg/dL
What 2 medication classes are second lines for those with hyperlipidemia who cannot tolerate statis?
Bile Acid Sequestrants
Fibrates ** (MC used)
What medication works in the GI tract to exchange resins that bind to bile acids
Bile acid sequestrants
What medications are considered bile acid sequestrants?
Chelestyramine
Colestipol
Colesevelam
What is good to know when prescribing a pt a BAS (bile acid sequestrant)
Cholestyramine comes only in powder form the other 2 BAS come in table form
PT’s will probably prefer to take the tablet
What medication may cause extreme constipation, flatulence, nausea, vomitting thus making the action in the GI the rate limiting step for these pt’s.
BAS
What is the mechanism of action of Statins?
Inhibit CoA reductase
Which statins are the highest potency?
Atorvastatin(lipitor)
Rosuvastatin(crestor)
What are the names of the statins?
Fluvastatin (Lescol) Pravastatin (Pravachol) Lovastatin (Mevacor) Simvastatin (Zocor) Atorvastatin (Lipitor) Rosuvastatin (Crestor)
Which statin is best for use in those who might be at risk of other drug interactions. This drug has a lower risk of mypotahy and other comorbidies.
Pravastatin (Pravachol)
What characteristic makes Pravastatin a good choice for a person who is at risk of drug interactions?
It is metabolized by sulfation (the rest go through different CYP systems).
T/F Pravastatin is a good high potency choice for patients requiring a statin.
False-Pravastatin is a low potency med.
What Statins are low potency statins?
Pravastatin
Lovastatin
Which statins are moderate potency statins?
Atorva Rosuva Simva Prava Lova Fluva
Which statins are high-intensity statins?
Atorva
Rosuva
What is the expected % LDL decrease of High-intesity statins?
50% or more
What is the expected % LDL decrease of moderate intensity statins?
30-50%
What is the expected % LDL decrease of low-intensity statins?
Less than 30%
What are the recommended time guidelines for exercise weekly?
3-4 sessions per week
40 minutes per session
Moderate to vigorous intensity
What factors put a patient at risk of developing dyslipidemia?
Diet
Drugs
Diseases
Altered metabolism
What factors have been proven to predispose an individual to complications from dyslipidemia?
Age Gender Race Systolic BP Smoking DM HDL Total cholesterol Meds for BP
What factors have been proven to predispose an individual to adverse events while on a statin?
Multiple comorbidities
Hx of previous statin intolerance or muscle d/o
Unexplained ALT elevations greater than 3x ULN
Drug interactions
Age over 75yo
What labs should be ordered at baseline in patient who are considering taking a statin?
Fasting lipid panel
ALT
CK
A1C
What labs should be ordered at baseline if prescribing a class of drugs for hyperlipidemia that is NOT a statin?
Uric acid
Triglycerides (can’t use BAS if TG are high)
sCr/GFR (fibrates)
What is the ASCVD cutoff for starting a statin?
7.5%
What is the cutoff for starting meds for elevated TG?
1,000 mg/dL (reasonable to start at 500mg/dL as well)
If headaches, dizziness or stomach upset occur while on statin patient may take it ________ to decrease symptoms. If these symptoms occur they will probably improve _______.
At night
With time
If the patient is unable to tolerate the statin it is ok to start first by trying to ______?
Lower the dose
Patients should be instructed to report directly to the ER and stop taking their statin immediately if they notice ________?
Change in urine color to dark brown.
What should be monitored (and how often) to determine the efficacy of a newly initiated statin?
Signs and symptoms of heart disease:
Check Lipid panel (should start to decrease) 6-8wks after starting.
when is it reasonable to decrease level of statin intensity in follow up with a patient?
If LDL goes below 40mg/dL
In regards to safety what levels should we monitor as needed?
AST, ALT for signs of liver disease
Ask pt about signs of myalgia (check CK if suspect)
CK greater than 10x ULN-d/c immediately
CK 3-10x ULN - d/c and switch pt to a different statin or a lower dosage.
If you have a pt with a hx of cardiac event/stroke what intensity statin should this pt take?
High intensity
For pt’s with LDL greater than 190mg/dL and age of 21+ years what intensity statins should this pt be started on?
High intensity
Pt’s who have diabetes and are between 40-75 with a ASCVD risk of 7% what intensity statin should this pt be started on?
Moderate
For a patient with DM aged 40-75 who has an ASCVD risk of 7.5% what intensity statin should this pt be started on?
High
For a pt with a ASCVD risk of 7.5% and is age 40-75 what intensity statin should this pt be started at?
Moderate-high
