Pharm Module 3

Front 1

What is the desired total cholesterol range?

Back 1

<200 mg/dl

Front 2

What is the desired LDL cholesterol range?

Back 2

<100-130 mg/dl

Front 3

What is the desired HDL cholesterol range?

Back 3

>60 mg/dl

Front 4

What is the desired triglycerides range?

Back 4

<150 mg/dl

Front 5

What is primary prevention in regards to CHD?

Back 5

The patient has never had a heart attack or issues, but risk factors are present.

Front 6

What is secondary prevention in regards to CHD?

Back 6

The patient has already had a heart attack or coronary event.

Front 7

What 4 things constitute clinical CHD?

Back 7

MI, Angina, Coronary angioplasty and/or stent placement, Prior unstable angina

Front 8

What 3 things constitute carotid artery disease?

Back 8

Stroke history, TIA, carotid stenosis (>50%)

Front 9

What are 3 other things that contribute to CHD risk equivalent?

Back 9

Peripheral arterial disease, Abdominal aortic aneurysm, Diabetes

Front 10

What is the LDL goal, LDL level to initiate lifestyle changes, and LDL level to consider drug therapy for someone with high risk CHD or CHD risk equiv (10 yr riks >20%)?

Back 10

Goal: <100mg/dl or <70.
Lifestyle change: >/= 100
Drug ther: >/=100, (<100 start to consider drug options)

Front 11

What is the LDL goal, level to initiate lifestyle change, drug therapy in a moderately high risk 2+ risk factors. (10 yr risk 10-20%)

Back 11

Goal: <130
Lifestyle change: >/=130
Drug ther: >=130 (100-129 consider drug options)

Front 12

What is the LDL goal, level to initiate lifestyle change, drug therapy in a Moderate risk 2+ risk factors. (10 yr risk <10%)

Back 12

Goal: <130
Lifestyle change: >=130
Drug ther: >=160

Front 13

What is the LDL goal, level to initiate lifestyle change, drug therapy in a Lower risk 0-1 risk factors

Back 13

Goal: <160
Lifestyle change: >=160
Drug ther: >=190 (160-189 consider drug options)

Front 14

What are the 6 risk factors of CHD besides LDL?

Back 14

Smoking, Hypertension, Low HDL, Fam hx of premature CHD, Age, Diabetes

Front 15

What Blood Pressure includes it as a risk for CHD?

Back 15

>140-90 or on BP meds

Front 16

What HDL level includes it as a risk for CHD?

Back 16

<40 mg/dl

Front 17

What family hx includes it as a risk for CHD?

Back 17

Premature CHD - first degree male <55yo, female <65yo

Front 18

What age includes it as a risk for CHD?

Back 18

Men >=45, Female >=55 or premature menopause w/out estrogen-replacement therapy

Front 19

What is considered a negative risk factor for CHD?

Back 19

HDL >60 mg/dl

Front 20

What diseases can induce hyperlipidemia? (7)

Back 20

Diabetes, Lipdystorphy, Chronic renal failure, Cirrhosis, Hypothyroidism, Obstructive liver disease, Cushing's syndrome

Front 21

What are 7 drugs that can induce hyperlipidemia?

Back 21

Alcohol, Progestins, Thiazide diuretics, beta blockers, steroids, cyclosporine, protease inhibitors

Front 22

How is Total cholesterol calculated?

Back 22

LDL + HDL + VLDL

Front 23

How is VLDL calculated?

Back 23

TG/5

Front 24

What is the recommended total fat intake as a therapeutic lifestyle change?

Back 24

25-35% of total calories

Front 25

What is the recommended saturated fat, polyunsaturated, and monounsaturated fat as a therapeutic lifestyle change?

Back 25

Sat: <7% of total calories
Polyunsaturated: up to 10%
Monounsaturated: up to 20%

Front 26

What is the recommended carbohydrate intake as a therapeutic lifestyle change?

Back 26

50-60% of total calories

Front 27

What is the recommended cholesterol intake as a therapeutic lifestyle change?

Back 27

<200 mg/day

Front 28

What is the recommended dietary fiber intake as a therapeutic lifestyle change?

Back 28

20-30g/day

Front 29

What is the recommended plant sterols as a therapeutic lifestyle change?

Back 29

2g/day

Front 30

What is the recommended protein intake as a therapeutic lifestyle change?

Back 30

15% of total calories

Front 31

What is the most frequently prescribed cholesterol medication?

Back 31

Statins (HMG CoA reductase inhibitors)

Front 32

How do statins work?

Back 32

Inhibit the conversion of HMG CoA to mevalonate by inhibition of HMG CoA reductase. Mevalonate is an early precursor to the synthetic pathway for endogenous cholesterol production in the liver, also upreg of liver LDL receptors -->removal of LDL from blood. Also, plaque stabilizing properties.

Front 33

How do statins effect LDL, TG and HDL?

Back 33

Reduce LDL 18-55%,
Reduce TG 7-30%
Raise HDL 5-15%

Front 34

What are 3 major side effects of statins?

Back 34

Myopathy and increased CK, Increased liver enzymes (mostly ALT), GI upset

Front 35

What are 3 things to know about myopathy and increased CK as a side effect of statins?

Back 35

Dose related, drug interactions increase risk, baseline CK should be tested. If CK is increased 3-10x above baseline, can keep pt on drug, but if >10x - discontinue

Front 36

What are 3 things to know about increased liver enzymes as a side effect of statins?

Back 36

Monitor baseline, at 12 weeks then annually, discontinue if >3x upper limit of normal, counsel pts on etoh intake and increased risk.

Front 37

What are the contraindications of statins? Absolute and relative.

Back 37

Absolute: acute or chronic liver disease, pregnancy.
Relative: large etoh intake

Front 38

What dose of Atorvastatin (Lipitor) is needed to reach a 39% LDL reduction?

Back 38

10 mg

Front 39

What dose of Lovastatin (Mevacor) is needed to reach a 31% LDL reduction?

Back 39

40 mg

Front 40

What dose of Pravastatin (Pravacol) is needed to reach a 34% LDL reduction?

Back 40

40 mg

Front 41

What dose of Simvastatin (Zocor) is needed to reach a 35-41% LDL reduction?

Back 41

20-40 mg

Front 42

What dose of Fluvastatin (Lescol) is needed to reach a 25-35% LDL reduction?

Back 42

40-80 mg

Front 43

What dose of Rosuvastatin (Crestor) is needed to reach a 39-45% LDL reduction?

Back 43

5-10 mg

Front 44

What drugs can cause an increase in levels of lovastatin (mevacor), simvastatin (Zocor), and Atorvastatin (Lipitor)?

Back 44

Inhibitors of 3A4 (ketoconazole, fluconazole, grapefruit juice, cimetidine, clarithromycin and erythromycin)

Front 45

What drugs can increase levels of fluvastatin (Lescol) and Rosuvastatin (Crestor)?

Back 45

Inhibitors of 2C9 (fluconazole, isoniazid and zafirlukast)

Front 46

What statins do not have any drug interactions?

Back 46

Pravastatin (Pravacol)

Front 47

Which 2 statins have no interaction with grapefruit juice?

Back 47

Pravastatin (Pravacol) and Rosuvastatin (Crestor)

Front 48

What is the relationship between statins and Coenzyme Q10?

Back 48

High doses of statins can cause a decrease in coenzyme Q10

Front 49

Which two statins are necessary to take at bedtime? And why?

Back 49

Simvastatin (Zocor) and Lovastatin (Mevacor)
When you sleep you make the most cholesterol and these 2 have a short half life so their best effect is seen at night.

Front 50

How do bile acid sequestrants work to lower cholesterol?

Back 50

After oral administration, they form a non-absorbable complex w/ bile acids in the gut -->removes the cholesterol-rich bile acids from enterohepatic circulation. This increases LDL catabolism in the liver leading to increase numbers of hepatic LDL receptors resulting in decreased LDL.

Front 51

How do Bile acid sequestrants effect LDL, HDL and TG?

Back 51

Reduce LDL 15-30%
Raise HDL 3-5%
May increase TG! (drawback!)
Not as potent as statins

Front 52

What are the adverse effects of bile acid sequestrants?

Back 52

GI distress/ constipation/ bloating (usually worse 1st 3 weeks), decreased absorption of other drugs

Front 53

What drugs may have decreased absorption due to bile acid sequestrants? What can be done to avoid this?

Back 53

Warfarin, digoxin, amioderone, thyroid preparations.
Give these drugs 1 hr before or 6 hrs after the bile acid seq.

Front 54

What are contraindications of bile acid sequestrants? Absolute and relative

Back 54

Absolute: dysbetalipoproteinemia (familial disease w/ increased tg and chol), raised TG (espec if >400 mg/dl)
Relative: TG >200 mg/dl

Front 55

What are the 3 main bile acid sequestrants?

Back 55

Cholestyramine (Questran), Colestipol (Colestid), Colesevelam (Welchol)

Front 56

What is the dose range for Cholestyramine (Questran)?

Back 56

4-16 g

Front 57

What is the dose range for Colestipol (Colestid)?

Back 57

5-20 g

Front 58

What is the dose range for Colesevelam (Welchol)?

Back 58

2.6-3.8 g

Front 59

What does Nicotinic Acid do?

Back 59

Niacin is a B-vit sold OTC that decreases VLDL production from liver --> decreasing LDL. Also, increases lipoprotein activity --> reduction of TGs

Front 60

How does Nicotinic Acid effect LDL, TG and HDL?

Back 60

Reduce LDL 5-25%
Reduce TG 20-50%
Raise HDL 15-35%

Front 61

What doses of Nicotinic acid are needed to lower tg and ldl?

Back 61

Niacin >1000 mg work on lowering TG and doses >1500 mg lower LDL also

Front 62

What are the 5 main adverse effects of nicotinic acid?

Back 62

Flushing/itching, Hyperglycemia, Hyperuricemia, Upper GI distress, Hepatotoxicity

Front 63

How does flushing/itching occur as a side effect to nicotinic acid?

Back 63

Prostaglandin mediated, usually seen w/ initiation of therapy or dose increase but tolerance does develop. Aspirin 30 min before helps. Alcohol/ hot drinks make worse.

Front 64

How would one minimize hyperglycemia as an adverse effect of nicotinic acid?

Back 64

Start low and titrate dose slowly or use sustained-release product

Front 65

What occurs w/ hyperuricemia as an adverse effect of nicotinic acid?

Back 65

Possible gout attack

Front 66

What should you know about hepatotoxicity as an adverse effect of nicotinic acid?

Back 66

Most common w/ sustained release preparations, Niaspan (extended release product) may have least toxicity, dose related, <3 g/day helps minimize toxicity.

Front 67

What are the contraindications of Nicotinic acid? Absolute, relative

Back 67

Absolute: Active liver disease, Severe gout
Relative: DM, Hyperuricemia, PUD

Front 68

What are the 3 main nicotinic acid drugs?

Back 68

Immediate release (Crystalline), Extended release (Niaspan), Sustained release

Front 69

What is the dose range for immediate release nicotinic acid (Crystalline)?

Back 69

1.5-3 g

Front 70

What is the dose range for extended release nicotinic acid (Niaspan)?

Back 70

1-2 g

Front 71

What is the dose range for sustained release nicotinic acid?

Back 71

1-2 g

Front 72

What do Fibric Acids do?

Back 72

Decrease plasma TG levels by increasing VLDL catabolism via increasing activity of the degrading enzyme, lipoprotein lipase

Front 73

How do Fibric Acids effect LDL, TG and HDL?

Back 73

Lower LDL 5-20% (w/ normal TG)
May raise LDL w/ high TG
Lower TG 20-50%
Raise HDL 10-20%
Often used in combo w/ statins

Front 74

What are the adverse effects of Fibric Acids?

Back 74

Dyspepsia (3-5%)
Gallstones (clofibrate 4.7% and gemfibrozil)
Myopathy (especially when given in combo w/ statins)

Front 75

What are the contraindications of Fibric Acid?

Back 75

Severe renal or hepatic disease

Front 76

What are the drug interactions associated w/ Fibric Acid?

Back 76

Gemfibrozil w/ statins or niacin may increase incidence of hepatotoxicity or myositis

Front 77

What are the 4 main Fibric Acids?

Back 77

Fenofibric (TriLipix), Gemfibrozil (Lopid), Fenofibrate (TriCor), Clofibrate (Atromid - S)

Front 78

What is the dosage range for Fenofibric (Trilipix)?

Back 78

45-135 mg daily

Front 79

What is the dosage range for Gemfibrozil (Lopid)?

Back 79

600 mg bid

Front 80

What is the dosage range for Fenofibrate (TriCor)?

Back 80

200 mg daily

Front 81

What is the dosage range for Clofibrate (Atromid - S)?

Back 81

1000 mg bid

Front 82

What does Zetia (ezetimibe) do?

Back 82

Inhibits intestinal absorption of cholesterol. Can be used as monotherapy or in combo w/ statins

Front 83

What to Zetia do as a combination?

Back 83

Decreases LDL by 12-20% more than monotherapy w/ statin

Front 84

What is the combo drug of Zetia (ezetimibe) and a statin?

Back 84

Vytorin which is a combo w/ simvastatin.
10-40mg simvistatin + 10mg ezetimbe

Front 85

What might be a good reason for giving Zetia (ezetimibe)?

Back 85

Zetia is not as potent as a statin. Might be good to use in combo for patients maxed out on statins.

Front 86

What are the side effects of Zetia (ezetimibe)?

Back 86

Back pain, arthralgia (no increased risk of myopathy)

Front 87

What are the contraindications of Zetia (ezetimibe)?

Back 87

Moderate to severe liver failure, pregnancy

Front 88

What is a drug interaction of Zetia (ezetimibe)?

Back 88

Decreases bioavailability of gemfibrozil (fibric acid)

Front 89

What does Omega 3 Polyunsaturated fatty acids (fish oil) do to total cholesterol, tg, ldl and hdl?

Back 89

Reduces cholesterol (27-45%), reduces TG (64-79%), reduces LDL and increases HDL.

Front 90

What is the FDA approved product of omega 3 polyunsaturated fatty acids?

Back 90

Lovaza - contains omega 3 ethyl esters 4 grams per day

Front 91

Fatty fish like mackerel, lake trout, herring, sardines, albacore tuna, and salmon are high in which 2 kinds of omega 3 fatty acids?

Back 91

Eicosapentaenoic acid (EPA) and docosahexaenoic acid (DHA)

Front 92

What are a few adverse effects of Omega 3 fatty acids?

Back 92

Increase bleeding risk - be careful if on blood thinners!
Nausea, fishy after taste

Front 93

What do plant sterols do to LDL?

Back 93

2-3 g/day reduces LDL 6-15%

Front 94

Where do plant sterols come from?

Back 94

Soybean or tall pine tree oils

Front 95

What is a butter-like spread that contains plant sterols?

Back 95

Benecol

Front 96

How do you determine risk assessment for CHD?

Back 96

Count risk factors: smoking, HTN, low HDL, fam hx of premature CHD, age
2+ risk factors = high risk

Front 97

What should you do for patients with 2+ risk factors for CHD?

Back 97

Perform 10 yr risk assessment based on Framingham criteria. If greater than 20%, pt is at CHD risk equivalent.

Front 98

What should you do for patients with 0-1 risk factors?

Back 98

10 year risk assessment not required. Most pts have a 10 yr risk <10%

Front 99

What is the LDL goal for a pt with CHD or CHD risk equivalents?

Back 99

<100, but optimal is <70

Front 100

What is the LDL goal for a pt w/ 2+ risk factors for CHD?

Back 100

<130, but optimal is <100

Front 101

What is the LDL goal for a patient w/ 0-1 risk factors for CHD?

Back 101

<160