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54 Cards in this Set
- Front
- Back
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When should LDL lowering drug be used in a CHD risk equivalents pt?
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>130 mg/dL
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when should LDL lowering drug be used in a 10-year risk <10% patient?
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>160 mg/dL
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when should LDL lowering drug be used in a 10-year risk 10 - 20% patient?
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>130
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when should LDL lowering drug be used in a 0-1 risk factor for CHD patient?
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>190 mg/dL
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What are 3 therapeutic lifestyle changes?
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diet
wt reduction increased physical activity |
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when do provider assess response to LDL lowering drug?
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6 weeks
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if goal is not achieved, what is the next step?
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intensify dose of statin; or combine statin with bile acid sequestrant or niacin
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What is primary prevention and secondary prevention?
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primary: have not have an CV event
secondary: have CV event and trying to prevent another |
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MOA of statins
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inhibition of HMG-CoA reductase
inhibit LDL biosynthesis increase LDL receptors decrease TG |
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Which 2 statins has longest t1/2?
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atorvastatin and rosuvastatin
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statins adverse effects?
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myalgia, liver damge due to inhibitors of 3A4. Lova, Simva, Atorva
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Statins drug interaction class:
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warfarin
gemfibrozil cyclosporine |
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how often do we monitor LFT?
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baseline, 3 months, biannually
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Creatine Kinase measurement: what for, and when?
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enzyme used as a marker of muscle injury; check when myalgia
Significant when >10x ULN |
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statins adverse reactions:
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myopathy
hepatotoxicity neuropathies GI disturbances rash |
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Risk factors for rhabdomyolysis:
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age, body size, gender, renal function, concomitant meds (Amiodarone, Azole Antifungals, Macrolide antibiotics (clarithromycin, erythromycin), Gemfibrozil, Diltiazem, Verapamil
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should we d/c statins if transaminase elevation > 2x ULN
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no, >3x ULN
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MOA of Bile Acid Resins
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increase cholesterol 7-alpha-hydroxylase
increase conversion of chol to bile acid increase bile acid secretion therefore: increase LDL receptors, VLDL and LDL removal; net effect is decrease LDL-C |
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Bile acid resins effect on LDL
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decrease 15-30%
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adverse effects of bile acid resins
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rare systemic toxicities
GI (60%), minimized by stool softeners (psyllium) |
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bile acid resins is contraindicated in pt that:
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biliary or intestinal obstruction, TG>500
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Drug interactions of bile acid resins
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bind to many drugs (dose other med 1 hr ac or 4-6 hours after BAR
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Monitor for bile acid resins
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monitor severe constipation, CBC yearly for anemia
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Dosing Bile acid resins
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take with food, start low, titrate slow due to GI effects
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Niacin is water-soluble ___ vitamin
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vitamin B; found in meat, fish, cereals, roasted coffee
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MOA of niacin
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decrease hepatic production of VLDL and of apoB
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What drug class is best to increase HDL and do everything we want to the lipid panel
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Niacin
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T/F: extended release niacin have lower risk of causing hepatotoxicity then sustain release
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True
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adverse effects of niacin
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flushing: but niaspan reduce 78%
GI irritation hyperglycemia hyperuricemia eczema, psoriasis |
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Niacin drug interactions
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antihypertensives: orthostatic hypotension
antagonize gout therapy antagonize diabetic therapy |
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Niacin contraindications
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liver disease, PUD, precautions in uncontrolled diabetes and gout
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Niacin counseling points
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titrate slowly
take with food to minimize GI upset avoid hot liquid caution with alcohol aspirin 30-60 prior dose |
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MOA of fibrates
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PPARalpha agonist
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This class is a good choice for elevated TG > 500
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fibrates
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fibrates adverse effects
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GI (most common)
rash gallstone formation leukopenia accumulation of renal dysfunction myositis |
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finofibrates can be used with statins safely but not gemfibrozil. T/F
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Yep
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What effects does fish oil has?
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low TG, no change in LDL and HDL; antiarrhythmic
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fish oil is shown to reduce:
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incidence of CHD
nonfatal MI sudden death possibly Alzheimer's disease |
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Fish oil cardioprotective dose
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1-2 grams/day
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Fish oil effects on lipid panel:
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TG: decrease 25-30%
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Min dose for therapeutic effect in hypertriglyceridemia of fish oil
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4g/day
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MOA ezetimibe
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selectively inhibits intestinal cholesterol absorption
-decrease intestinal delivery of cholesterol -decrease cholesterol stores -increase clearance of cholesterol from the blood |
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ezetimibe is a prodrug. T/F
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True; its active glucuronide metabolite circulate enterohepatically
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Ezetimibe effect on lipid panel:
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decrease LDL 18%
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Indications of Ezetimibe
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adjunctive therapy to diet
in combination with statin and diet |
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Ezetimibe contraindications
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active liver disease
unexplained elevated serum transminasaes |
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T/F: ezetimibe and fibrates are great combo
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No, not recommended
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combo ezetimibe with simvastatin is significantly better than simvastatin alone.
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False, no significant
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Statins is for LDL as bile acid sequestrants is for ______, niacin for _______, fibrates for ________, ezetimibe for ________, fish oil for ________
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statins - LDL
bile acid - LDL niacin - HDL fibrates - TG Fish oil - TG |
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after 2 visits and pt LDL goal is not achieved, what is the next step?
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treat other lipid risk factors
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What are possible combination therapy?
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statin-niacin
statin-ezetimibe statin-fibrate add fish oil or BAR to any regimen |
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what do you think about statin-gemfibrozil therapy?
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bad, increase risk of CK --> myopathy and rhabdomyolysis; renal failure due to its inhibition of P450/glucuronidation
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Tx of metabolic syndrome
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get LDL to goal
wt reduction physical activity treat associated risk factors: htn, asa for pt with CHD, elvated TG, low HDL |
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Management of low HDL
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1. achieve LDL goal
2. if TG > 200 mg/dL: achieve non-HDL goal by increase LDL-lowering therapy add niacin or fibrate 3. If TG < 200 mg/dL: consider drugs for raising HDL (fibrates, niacin) |
