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Cardiology 2 > Pharm - dyslipidemia > Flashcards

Pharm - dyslipidemia Flashcards

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1
Q

What are 3 risk assessment tools that can be used to assess the risk for cardiovascular dz?

A
  • Framingham
  • ASCVD risk instrument
  • National lipid association risk stratification
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2
Q

major cardiovascular risk factors

A
  • age: male 45 or higher, female 55 or higher
  • family hx of early CHD (<55 in male first degree, <65 if female first degree relative)
  • current cig smoking
  • high BP (> or equal to 140/90, or on BP meds)
  • low HDL (<40 in men, <50 in women)
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3
Q

What 3 national organizations have published guidelines for the treatment of dyslipidemias?

A
  • national cholesterol education program(NCEP)
  • american college of cardiology (ACC) / american heart association (AHA)
  • national lipid association (NLA)
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4
Q

What 4 groups of people have demonstrated benefit of treating dyslipidemias?

A
  • pts w/ CHD, w/ or w/o hyperlipidemia
  • men w/ hyperlipidemia but no known CHD
  • men w/ HTN multiple cardiac risk factors but w/o hyperlipidemia
  • men and women w/ avg total and LDL levels and no known CHD
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5
Q

HMG-CoA reductase inhibitors, aka statins, MoA

A
  • statins inhibits HMG-CoA reductase
  • this enzyme catalyzes the rate-limiting step of cholesterol synthesis so the liver can’t make cholesterol
  • the liver therefore upregulates LDL receptors, and decreases production of VLDL, IDL, and LDL
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6
Q

What is the lipid lowering effect of statins on LDL?

A

decreased by 20-55%

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7
Q

What is the lipid lowering effect of statins on HDL?

A

increased by 2-10%

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8
Q

What is the lipid lowering effect of statins on triglycerides?

A

lowered 14-40%

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9
Q

What is the expected LDL lowering of a low intensity statin?

A

lowered by about <30%

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10
Q

What is the expected LDL lowering of a moderate intensity statin?

A

lowered by 30-50%

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11
Q

What is the expected LDL lowering of a high intensity statin?

A

lowered by about 50%

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12
Q

low intensity statin and dose

A

-Simvastatin: 10mg

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13
Q

moderate intensity statins and doses

A
  • Atorvastatin: 10-20mg

- Rosuvastatin: 5-10mg

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14
Q

high intensity statins and doses

A
  • atorvastatin: 40-80mg

- rosuvastatin: 20 mg

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15
Q

clinical endpoints demonstrated by statins

A
  • most studied drugs for dyslipidemia
  • they reduce all-cause mortality, cardiovascular mortality, stroke, angina, and need for revascularization procedures
  • also clear benefit in pts w/ DM
  • benefits are directly associated w/ percent LDL reduction
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16
Q

contraindications to statins

A
  • active liver dz
  • pregnancy or lactation (class X)
  • use low dose in transplant pts
  • contraindicated with use of certain drugs
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17
Q

drug interactions with simvastatin, in which they are completely contraindicated to prescribe

A
  • strong CYP3A4 drugs (statins are red flag drugs)
  • erythromycin, clarithromycin
  • gemfibrozil
  • azoles
  • HIV protease inhibitors
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18
Q

other drug interactions with simvastatin

A
  • amiodarone, amlodipine

- grapefruit juice

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19
Q

what is the prescribing recommendation for drug interactions with simvastatin that aren’t completely contraindicated?

A
  • with amiodarone/amlodipine, limit simvastatin to 20 mg

- avoid grapefruit juice

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20
Q

interacting drugs with rosuvastatin

A

-gemfibrozil

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21
Q

prescribing recommendation for drug interactions with rosuvastatin

A

-if using with gemfibrozil, limit rosuvastatin dose to 10 mg daily

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22
Q

drug interactions w/ atorvastatin

A

-clarithromycin

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23
Q

prescribing recommendation for atorvastatin/clarithromycin drug interaction

A

-limit atorvastatin to 20 mg daily

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24
Q

adverse effects of statins

A
  • myopathy
  • myalgia
  • liver enzyme elevation
  • rhabdomyolysis
  • cognitive decline
  • DM
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25
patient risk factors for developing rhabdomyolysis secondary to a statin
- renal insufficiency - age > 65 - concurrent admin of gemfibrozil, niacin or a drug that interacts w/ a statin resulting in statin accumulation
26
monitoring parameters for efficacy of statin therapy
- lipid profile 6 wks following initiation | - lipid profile eval 2-3 times per year once goals have been met
27
monitoring parameters for safety of statin therapy
- liver function tests - baseline and then as clinically indicated - CPK: baseline (optional) and repeat w/ myalgia
28
What is the best time of day to take a statin?
in the evening as that is when the most cholesterol is produced
29
lipid lowering effects of niacin on LDL
decrease 5-25%
30
lipid lowering effects of niacin on HDL
increase of 15-35%
31
lipid lowering effects of niacin on TGs
decrease 20-50%
32
contraindications of niacin
- liver dz - severe gout - active peptic ulcer - arterial bleeding
33
drug interactions of niacin
- statins: this is a caution | - antihyperglycemic agents (DM meds)
34
monitoring parameters for efficacy of niacin
-fasting lipids q 4-6 weeks during dose titration then q 4-6 mos
35
monitoring parameters for safety of niacin
- LFTs at baseline, q 6-12 weeks X 1yr, then periodically - blood glucose in DM - CPK baseline and w/ muscle sx if on statin - uric acid
36
lipid lowering effects of fibric acid derivatives (aka fibrates) on LDL
- variable - in many pts: decrease of 5-20% - usually LDL increases in pts w/ very high TGs
37
lipid lowering effects of fibric acid derivatives on HDL
-increase 10-35%
38
lipid lowering effects of fibric acid derivatives on TGs
decrease 20-50%
39
contraindications of fibric acid derivatives
- pre-existing gallbladder dz - hepatic dysfunction - severe renal impairment
40
drug interactinos of fibrates
- statins - avoid gemfibrozil in combo w/ statins, fenofibrate can be used if needed. - exetimibe - cholelithiasis risk
41
monitoring parameters for efficacy in fibric acid therapy
- these drugs take 3 mos to see full effect | - fasting lipids q 4-6 mos
42
monitoring parameters for safety in fibric acid therapy
-LFTs at baseline then periodically
43
MoA of ezetimibe
- cholesterol absorption inhibitor - inhibits cholesterol absorption at the brush border of the small intestine from bile and dietary intake - results in reduced hepatic cholesterol stores and increases cholesterol clearance in the blood
44
lipid lowering effects of ezetimibe on LDL
-decrease of 20%
45
lipid lowering effects of exetimibe on HDL and TGs
- negligible - HDL increased 0-5% - TG decreased 5-11%
46
MoA of bile acid sequestrants (BAS)
- bile acids are normally reabsorbed in the jejunum and ileum then return to cholesterol cycle - BASs are resins that complex w/ the bile acids preventing reabsorption - liver recognizes the reduction and increases hepatic uptake and catabolism of LDL
47
lipid lowering effects of BAS on LDL
-15-30% (modest at best)
48
lipid lowering effects of BAS on HDL
3-5%
49
lipid lowering effects of BAS on TG
-they actually can increase the TGs 0-10%
50
contraindications to using BASs
- bowel obstruction - complete biliary obstruction - hypersensitivity
51
precautions to using BASs
- malabsorptions disorders - chronic constipation - TGs > 200 mg/dL
52
drug interactions with BASs
- they bind many drugs (too many to list) and impair absorption to varying degrees - most clinically relevent to drugs w/ narrow therapeutic window (warfarin) - separate the doses of BASs from other drugs (1 hr before or 4-6 hrs after)
53
ADRs of BASs
- contipiation/flatulence/bloating - steatorrhea - increased TG concentration - malabsorption of fat soluble vitamins
54
long-chain omega-3 FAs
- EPA - DHA - essential - sources: anchovy, halibut, herring, kipper, mackerel, mullet, salmon, sardine, sturgeon, trout, tuna
55
ADRs of omega-3 FAs
fishy aftertaste - fishy burp -use enteric coated or refrigerate capsules
56
lipid lowering effects of fish oil on LDL
-can see an increase by 40% when TGs >500
57
lipid lowering effects of fish oil on TGs
-20-50% (similar to fibrates)
58
The AHA recommends eating how much fatty fish?
-two servings per week
59
dosing of fish oil for hypertriglyceridemia
2.0 - 4.0 gm of DHA plus EPA daily
60
dosing of fish oil for very high triglycerides
Lovaza 4 gm daily or 2.0 gm BID
61
NLA recommendations for LDL goals
<70 or 100 mg/dL
62
NLA recommendations for non-HDL goals
<130 or 100 mg/dl

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