Therapeutics - Dyslipidemia Part 2

Question 1

patient on a statin is not reaching LDL goal

what do we do next

Answer 1

1st - assess adherence!

if they are adherent, add ezetimibe. could add bile acid sequesterant, but prolly not

Question 2

if patient is still not at LDL goal with statin + zetia (or bile acid resin)

what do we do next? what if this doesnt work?

Answer 2

could add PCSK9 inhibitor, bempedoic acid (nexletol), or inclisiran (leqvio)

if this doesnt work – refer to lipid specialist – may need MAB (Evkeeza/evinacumab) - HOWEVER, this is very expensive and very last line

Question 3

true or false

zetia cannot be combined with bempedoic acid

Answer 3

FALSE - it can

Question 4

true or false

ezetimibe is not recommended to be used alone

Answer 4

TRUE

it’s well tolerated, but not very effective by itself

typically added to statin therapy

Question 5

true or false

ezetimibe must be taken with food

Answer 5

false - doesnt matter

Question 6

counseling point if patient is on ezetimibe and a bile acid sequesterant

Answer 6

take the zetia either 2 hours before or 4 hours after

Question 7

3 available bile acid sequestrants

which comes as a tab in which the patient has to take 3 tabs BID (VERY INCONVENIENT)

Answer 7

colesevelam (lot of tabs)
cholestyramine
colestipol

Question 8

should cholestyramine be taken with food

Answer 8

yes

Question 9

true or false

bile acid sequestrants are not recommended to be used alone

Answer 9

TRUE - dont do too much alone

Question 10

can bile acid sequestrants be combined with statins

Answer 10

yes - just cant take at same time

Question 11

why are bile acid sequestrants not really used

Answer 11

no CV outcome trials, and there’s a lot of AE

Question 12

if patient can’t take zetia for some reason, would a PCKS9 inhibitor or a bile acid sequestrant make more sense

Answer 12

typically PCKS9 inhibitor, unless cost is an issue

Question 13

name some AE of bile acid sequestrants in general

Answer 13

constipation, nausea, dyspepsia

increased triglycerides!

Question 14

true or false

bile acid sequestrants increase triglycerides

Answer 14

true

Question 15

name 3 DDI of colesevelam with other drugs

Answer 15

-decreased phenytoin levels (increased seizures)

-decreased INR for warfarin (bleed)

-increased TSH in patients getting thyroid HRT

Question 16

name 2 PCSK9 inhibitors

both can be given Q2 weeks

which can be given only Q month?

Answer 16

alirocumab ( praluent)
evolocumab (repatha)

repatha

Question 17

name some AE of the PCSK9 inhibitors

Answer 17

not many - just miled injection site reactions, myalgia

however, no long term safety data - potential cognitive effects

Question 18

repatha + efgartigimod interaction

Answer 18

decreased repatha levels

Question 19

MOA bempedoic acid (nexletol)

how is the MOA an advantage?

Answer 19

ATP citrate lyase inhibitor

may be used in patients who get myalgia from statins

Question 20

true or false

nexletol does not have significant LDL reduction on its own

Answer 20

TRUE

like ezetimibe, really only useful with statin, or all 3 can even be used together

Question 21

true or false

nexletol is not as good as statins and PCSK9 inhibitors at reducing CV outcomes

Answer 21

TRUE

PCKS9 inhibitors are definitely a better option if the patient is statin intolerant

Question 22

name some AE of bempedoic acid (nexletol) and who we definitely do not wawnt to give this drug to

Answer 22

increases uric acid - (by inhib OAT 2) so definitely dont give to gout patients!!!!

also risk of gallstones
increased SCr and LFT
tendon rupture

lot of SE

Question 23

true or false

bempedoic acid should not be considered 1st line, but is a possible option in shared decision making

Answer 23

true

Question 24

molecular wise, what is Inclisiran (Leqvio)

Answer 24

a siRNA (small interfering ribonucleic agent)

Question 25

how is inclisiran adminsitered

Answer 25

subQ injection given by HC provider

Question 26

true or false there is no long term safety data available yet for inclisiran (leqvio)

Answer 26

true

Question 27

only indication for evinacumab (Evkeeza)

Answer 27

familial hypercholesteremia (decreases LDL by 47%)

Question 28

why is Evkeeza (evinacumab) considered very last line

Answer 28

its very expensive, and is an IV hour long infusion every 4 weeks

Question 29

general MOA of evkeeza

Answer 29

angiopoietin-like 3 inhibitor

Question 30

2 potential natural alternative therapies for LDL lowering

Answer 30

red yeast rice garlic

Question 31

counseling points if a patient wants to use red yeast rice to lower their cholesterol

Answer 31

no known effects on CV outcomes also, if not fermented right, can cause kidney failure by containing citrinin (also - would need so much of it. structurally similar to lovastatin, but need 1800mg of rice to equal effect of 5mg lovastatin)

Question 32

counseling points if a patient wants to use garlic to lower LDL

Answer 32

conflicting data can potentiall decrease LDL and increase HDL, but no effect on TG also, formulation may be important to potentially see outcomes bad breath and might smell bad

Question 33

hypertriglyceridemia is most common in which gender and ethnicity

Answer 33

mexican male americans

Question 34

what kind of diet/lifestyle can cause hypertriglyceridemia

Answer 34

lot of alcogol, high saturated fats, sugars, sedentary lifestyle

Question 35

true or false TPN with lipid emulsions can lead to high triglycerides

Answer 35

true

Question 36

concerns with high triglycerides ALONE

Answer 36

alone, really no CV effect biggest concern is pancreatitis

Question 37

patient has TG over 500 what to do?

Answer 37

need both lifestyle modification AND statin

Question 38

a low ___ and high ___ diet is best for lowering triglycerides

Answer 38

low carbs and high protein

Question 39

if TG is between 150 and 500, what to do?

Answer 39

change diet, increase activity, stop smoking give fish oil! (omega 3)

Question 40

what 2 PARTICULAR foods are good to eat to lower TG

Answer 40

salmon, tuna

Question 41

if patients TG is over 1000, what meds to give?

Answer 41

either fibrate therapy or omega 3

Question 42

patient's TG is 544. already on atorvastatin what to do?

Answer 42

emphasize lifestyle modification and give fibrate therapy or omega-3

Question 43

true or false weight loss cannot reduce TG significantly

Answer 43

FALSE - it can (up to 70% reduction!)

Question 44

foods that have omega-3 fatty acids who should they be recommended to?

Answer 44

fish (salmon, tuna, herring, sardines, mackerel, anchovies) seeds, cod liver oil, avacado, walnuts, soybeans recommend to patients with high TG

Question 45

is OTC omega-3 supplementation recommended?

Answer 45

not really efficacy isnt verifies, may have inconsistent contents. also AE of burping, fishy taste, dyspepsia

Question 46

what is the prescription fish oil? can it be combined with a statin

Answer 46

vascepa/icosapent ethyl yes - better effects when combined with statin

Question 47

vascepa has shown a reduction in CV events and death when added to a statin however, what is a big concern with vascepa

Answer 47

can cause afib

Question 48

true or false gemfibrozil should be taken with a meal

Answer 48

true - 30 mins before meal

Question 49

which fibrate is preferred and why - fenofibrate or gemfibrozil

Answer 49

fenofibrate bc it's shown to have somehwat better outcomes, better tolerated, and has less DDI gemfibrozil has a higher risk of myopathy with statins also, fenofibrate is QD and gemfibrozil is BID

Question 50

ADR of gemfibrozil

Answer 50

dyspepsia abdominal pain gallstones

Question 51

true or false fenofibrate must be taken with food

Answer 51

false - doesnt matter

Question 52

if a statin is needed with fenofibrate, what statin dose should be used?

Answer 52

low-moderate intensity (bc myopathy risk)

Question 53

true or false both fibrates need dose adjustment in renal insufficiency

Answer 53

true

Question 54

true or false fenofibrate can be dicontinued after 2-3 months of therapy if the pt isnt responding

Answer 54

true

Question 55

3 CI to fenofibrate

Answer 55

pregnant/breastfeeding gallbladder disease active liver disease

Question 56

name some ADR of fenofibrate

Answer 56

increased LFT (with statin) myopathy (with statin) gallstones pancreatitis (only if TG continues to be high) increased BUN/SCr

Question 57

true or false niacin is highly recommended to be given with a statin to decrease TG

Answer 57

FALSE - no benefit, and actually potential increase in ischemic stroke

Question 58

Which form of niacin is really only used for supplementation in cases of deficiency, and which formulation is used to lower cholesterol/TG (BUT NOT RECOMMENDED)

Answer 58

supplementation - IR ER - for cholesterol/TG but not rec SR is not used

Question 59

AE of niacin

Answer 59

flushing, hives, hyperglycemia, hyperuricemia (gout) NOT RECOMMENDED

Question 60

in terms of pregnancy, at what time point should lipid lowering agents be discontinued?

Answer 60

1-3 months before attempting conception

Question 61

which class of lipid lowering agents is pregnancy category C, meaning that there are no studies in pregnant women, but may be safe

Answer 61

bile acid sequestrants may potentially be safe bc not systemically absorbed - but still not really recommended

Question 62

if a patient has been on a statin and stops bc they want to get pregnant, when can they restart the statin again?

Answer 62

only after they're done breastfeeding