Therapeutics Iii Exam 5- More Lipids (Risk)

Front 1

4 major drugs that cause dyslipidemia

Back 1

protease inhibitors
atypical antipsychotics (metabolic changes)
BBs
thiazides

Front 2

Drug interactions with cyclosporine (2)

Back 2

Cyclosporine + statin
also zetia

Front 3

safer statins to use concurrently with cyclosporine or PIs (2)

Back 3

fluva and pravastatin**- don't ahve same degree of CYP activity- better used with cyclosporine, etc

Front 4

cyclosporine effects in pt with dyslipidemia (2)

Back 4

Cylosporine increases LDL
interacts with statins (inhibits CYP? other routes of interference too like hepatic transport of statin)

Front 5

Protease inhibitors effects on lipid profile: Ritonavir

Back 5

increase TG

Front 6

Protease inhibitors effects on lipid profile: Atazanavir

Back 6

no effect

Front 7

Protease inhibitors effects on lipid profile: Indinavir

Back 7

increase in LDL

Front 8

drug interactions with PIs in pt with dyslipidemia treatment (2) which 2 drugs

Back 8

Possible interference with absorption of antiviral therapy in bile acid sequestrants

P450 interaction with statins- use pravastatin

Front 9

metabolic syndrome - cluster of risk factors that increase risk for CVD (4)

Back 9

Hypertension
Diabetes (pre-diabetes)
Dyslipidemia
Obesity

Front 10

Criteria for Metabolic Syndrome (5)

Back 10

3 out of 5:

Elevated Waist Circumference (inches)
Elevated Triglycerides (mg/dL)
Reduced HDL-C (mg/dL)
Elevated Blood Pressure (mm Hg)
Elevated Fasting Glucose (mg/dL)

Front 11

Atherogenic Dyslipidemia definition (2) disease states it is found in

Back 11

Characteristic lipids change found in:
Metabolic Syndrome
Diabetes (aka “diabetic dyslipidemia”)
(insulin resistance- results in increased TG- control these diseases first)

Front 12

atherogenic dyslipidemia characteristics (2)

Back 12

Elevated Triglycerides
Reduced HDL-C

BUT LDL IS STILL PRIMARY GOAL

Front 13

Treatment of Dyslipidemia in the Metabolic Syndrome: targets and goals (3 scenarios) goal LDL, etc

Back 13

LDL is still the primary target
LDL<100

When TG>200 mg/dL, non-HDL should be addressed with a target <130(LDL goal + 30)

Unless TG’s are >500 mg/dL
TG lowering becomes primary goal

Front 14

essential treatment to metabolic syndrome (3)

Back 14

Therapeutic Lifestyle Changes
(low fat, Exercise
Weight loss)

Front 15

drug tx for metabolic syndrome- preferred med

alternatives (2)

Back 15

Statins are preferred lipid-lowering meds
Fibrates and niacin are useful for lowering TG’s and raising HDL

Front 16

CARDS trial showed what?

Back 16

Suggests diabetics should have target LDL much lower than 100 mg/dL

Front 17

statins should be added to TLC without regard to baseline lipids (even if they are at goal) in what patients?( 2)

Back 17

diabetics with:

overt CVD. (A)

without CVD who are over the age of 40 years and who have one or more other CVD risk factors.

Front 18

Certain high-risk cases where CVD occurs in the 1st and 2nd decade: what pt population (for kids)

Back 18

Homozygous Familial Hyperlipidemia

Front 19

Children at Increased Risk for CVD/issues (6)

Back 19

Familial Hyperlipidemias
Type 1 & 2 Diabetes Mellitus
Kidney Disease-ESRD, nephrotic syn.
Metabolic Syndrome
Transplantation
Chronic Inflammatory Disease-SLE

Front 20

Screening of kids for dyslipidemia (2 steps)

Back 20

Selective screening:

If parent TC>240, check nonfasting TC

If kids TC>200, avg. >170, FHx. of early CVD, or FHx. of FH: then check fasting lipid profile

also pt at high/mod risk (homozygous familiarl) can take fasting lipid profile

Front 21

Children-Assessment risk: what puts kids at high tier 1 risk? (3)

Back 21

Tier 1 High Risk: HoFH, DM-1, CKD

Front 22

Children-Assessment risk: what puts kids at moderate tier 2 risk?

Back 22

HetFH, DM-2

Front 23

Children-Assessment risk: what puts kids at tier 3 risk? (3)

Back 23

Congenital heart disease, post-cancer treatment survivors, Kawasaki

Front 24

how to assess risk categories (4)

Back 24

high risk (tier 1)
tier 2- moderate risk
tier 3- at risk

if additional risk factors > 2 bump up a tier lvl

Front 25

other risk factors for kids (6)

Back 25

Smoking history (parents and kids>10 y.o.)
Family history of early CVD: Male <55; Female <65
BP interpreted for age/sex/height
BMI
Fasting glucose
Physical activity history

Front 26

Children-Treatment Goals based on tier of risk (3)

Back 26

Tier 1: High Risk
LDL <100 mg/dL
Tier 2: Moderate Risk
LDL <130 mg/dL
Tier 3: At risk
LDL <160 mg/dL

Front 27

for kids: when to consider drug therapy for LDL goals

Back 27

Consider drug therapy if >30 above goal or still above goal after 6 months of TLC

Front 28

Preferred initial treatment for kids and at what age

Back 28

statins
>=8 yo

Front 29

FDA approved statins for kids (4)

Back 29

simvastatin
lovastatin
artovastatin
pravastatin

Front 30

monitoring of statin therapy in kids (3)

Back 30

same as adults except...

Growth (age, height, BMI-normal growth chart)
Sexual Maturation
Development

Front 31

know parameters for TMS

Back 31

--

Front 32

Kids and bile acid sequestrants (2)

Back 32

inital therapy for kids- a long time ago
been replaced with statins

Front 33

Ezetimibe in kids (2)

Back 33

safe in kids > 10
can be used alone or in combo with statins

Front 34

Niacin in children (2)

Back 34

may be considered if TG > 700 but not studied in people < 21 yo

Front 35

fibrates in children (2)

Back 35

may be considered if TG > 700 but not studied in ppl < 18

Front 36

CKD definition (2 defining parameters) also time duration

Back 36

as >3 months of either structural or functional abnormalities of the kidney or GFR <60 mL/min

Front 37

risk for people with CKD in regards to CVD (2)

Back 37

Patients with CKD are at increased for CVD

may present with various dyslipidemias

Front 38

Chronic Kidney Disease Lipid Abnormalities trends

Back 38

those with nephrotic syndrome or diabetic CKD have the highest incidence of lipid abnormalities

Front 39

is CKD a risk equivalent

Back 39

yes

Front 40

management of lipids in CKD:
address what to do if LDL100-129, >130, and if non HDL>130 (TG > 200)

Back 40

LDL 100-129- give low dose statin + TLC

>130 - may want to try low dose statin, or combo therapy high dose statin + zetia + TLC

if NON HDL > 130 and TG > 200- low dose statin + TLC OR high dose statin + zetia (or OM3, etc)

Front 41

statins and proteinuria

Back 41

if starting statin- protein in urine goes up- statins can falsely elevate protein in urine (not kidney related)

Front 42

3 statins that require renal dose adjustments for CKD

Back 42

pitavastatin
rosuvastatin
simvastatin

Front 43

renal dosing for pitavastatin (3)

Back 43

GFR > 60 1-4 mg
GFR 15-59 1-2 mg
GFR < 15 and on hemodialysis- 1-2 mg

Front 44

renal dosing for rosuvastatin (2)

Back 44

5-10 mg for GFR 15-29
not studied in < 15

Front 45

renal dosing for simvastatin

Back 45

GFR <30 10-40 mg with starting dose of 5 mg

Front 46

drugs with no renal adjustments (2)

Back 46

ezetimibe
bile acid sequestrants (not absorbed)

Front 47

preferred fibrate in CKD

Back 47

gemfibrozil

Front 48

fenofibrate renal dosing
avoid in what GFR?

Back 48

48 mg if GFR < 60
avoid in GFR < 15

Front 49

gemfibrozil renal dosing
avoid in what GFR

Back 49

600 mg QD (not BID) if GFR < 60
avoid in GFR < 15

Front 50

don't have to know exact dosing but know which drugs are preferred

Back 50

---

Front 51

look at renal dosing again...

Back 51

--- looks like they all can be used and atorvastatin doesn't have to be changed because it's CYP metabolized

Front 52

elderly "age"

Back 52

> 65

Front 53

elderly- risks compared to younger interms of CV/lipidemia (4)

Back 53

Absolute risk of increased cholesterol increases with age
Absolute risk of CHD mortality increases with age
Account for the majority of hospital admissions for acute MI

higher rates of death

Front 54

1%/2% rule for lipid lowering

Back 54

1% TC decrease = 2% CHD risk decrease

Front 55

LDL lowering in elderly- yes or no?

Back 55

Should not be excluded from the benefits of LDL lowering based on age alone

Front 56

elderly- things to consider (5)

Back 56

Increased risk for DDI’s
Adverse Effects
Decreased elimination
Cost
Overall risk:benefit in terms of life expectancy

Front 57

preferred treatment for dyslipidemia in elderly

Back 57

statins- most evidence

Front 58

bile acid sequestrants in elderly (2)

Back 58

problems with intolerance and DDI’s

Front 59

fibrates in elderly- (2) things to know

Back 59

Dose adjustment in CKD and may increase risk of gallstones in elderly

Front 60

drug that is good for use in CKD (2)

Back 60

atorvastatin- no dose adjustments
pravastatin

Front 61

ezetimibe in elderly

Back 61

well tolerated and just as effective as in younglings

Front 62

advanced age (>70)- and statins- is there any issue here in terms of AE?

Back 62

Advanced age (>70) is a risk factor for myopathy with statins.

Front 63

emerging (new) risk factors for poor outcomes in dyslipidemia (5)

Back 63

hs-CRP
ApoB
Lipoprotein A: Lp(a)
Fibrinogen
Homocysteine

Front 64

hs-CRP what's it stand for

what is it?

what do abnormal lvls suggest?

Back 64

high sensitivity c reactive protein

inflammatory marker in blood

elevated lvls suggested increase increased risk of CVD

Front 65

lipophilic statins- that may have higher risk of myopathies (3)

Back 65

liphophilic

atorvastatin
lovastatin
simvastatin

hydrophilic- pravastatin, rosuvastatin

Front 66

hs-CRP most useful for what population?

Back 66

most useful in intermediate risk (FRS 10-20%) patients in whom therapy is being considered

Front 67

levels of hs CRP as related to risk (3)

Back 67

<1 mg/L: lower risk
1-3 mg/L: intermediate risk
>3 mg/L: higher risk

Front 68

hs CRP vs CRP

Back 68

hs-CRP just be ordered specifically and correct unit of measurement is mg/L!!!

Regular CRP is not applicable and is measured in mg/dL

Front 69

JUPITER trial- what did it look at

primary endpoint

Back 69

rosuvastatin to prevent vascular events in men/women with elevated CRP (in low risk)

Occurrence of 1st major CVD event

Front 70

results of JUPITER trial (2)

Back 70

rosuvastatin group had a significant reduction of primary outcome
and mortality

but ARR wasn't very huge

Front 71

Ways to lower hs-CRP (5)

Back 71

similar to how to lower LDL

Weight loss, diet and exercise
Statins (more potent LDL lowering=more potent hs-CRP lowering)
Fibrates
Ezetimibe
Aspirin

Front 72

unknowns with hs CRP test (2)

Back 72

Target level to treat to?

who do we screen? we can't tell who has high hs CRP?

Front 73

Apo B lvl - what does it tell you

levels are determined largely by what?

Back 73

Measure of all non-HDL lipoproteins (attached to all of them)

Largely determined by number of LDL particles

Front 74

downside to Apo B (when are results vague?)

Back 74

disproportionately higher when TG’s are high

Front 75

benefit of Apo B (2)

Back 75

May be a better measure of lipoprotein-associated atherosclerotic risk than LDL (higher Apo B indicates smaller, more dense LDL which is more atherogenic- you can measure this with a ratio of LDL to Apo B)

Can be measured directly or estimated via non-HDL cholesterol (TC minus HDL) in patients with elevated TG’s (which would normally throw off LDL calculations)

Front 76

what do ATPIII guidelines say about Apo B? (3) (how to use, whether to use...treatment)

Back 76

Recognizes the significance of Apo B as an independent risk factor and that it may be superior to LDL in risk prediction

Questionable whether ApoB is preferred as a target of therapy

Recommend utilization of non-HDL as a secondary target in patients with elevated TG’s given it is considered a surrogate for Apo B

Front 77

ADA and ACC 2008 Consensus Conference Report: who was it addressed to? (regarding other lipids in measuring athergenic risk) (2)

Back 77

Specific to patients with cardiometabolic risk (htn, syndrome X, obesty...)

Specific to patients with cardiometabolic risk

Front 78

Suggested treatment goals in patients with Cardiometabolic Risk (Apo B)
(highest and high- define each)

Back 78

highest risk (those with est. CVD or diabetes + 1 or more RF): Apo B < 80 (LDL < 70 derp)

high risk (2+ RF, diabetes with no RF)-
Apo B < 90

Front 79

drugs that lower Apo B (4)

Back 79

statins- lower ApoB
fibrates- lower ApoB
niacin- "
BAS- "

Front 80

Mipomersen- what is it

Back 80

Antisense oligonucleotide directed at human apo B100

Front 81

first document that recommended targeting ApoB

Back 81

ADA/ACC 2008 conference guidelines report

Front 82

mipomersen- efficacy and AE (general- are there any)

Back 82

Good LDL lowering but AE noted

Front 83

Challenges regarding Apo B (5)

Back 83

Studies regarding risk prediction are conflicting

Apo B might be more useful in high-risk patients or patients on treatment versus low-risk patients

no one is sure how to assess Apo B in the best way (ratio of Apo B:A1- the protein on HDL? or just Apo B?

Testing is not as widely available-$$$
Lack of familiarity and consensus

Front 84

Lipoprotein (A)- benefits to lower it?
2 drugs that can lower it

Back 84

Unknown whether benefits to lowering
Niacin, Estrogen help lower

Front 85

Fibrinogen - what elevates its levels (2)
what decreases it (2)
more FYI

Back 85

Increased by smoking, inflammation
Decreased by exercise, avoiding smoking, niacin, fibrates

Front 86

Homocysteine - more FYI
what lowers it (2)

Back 86

Unknown whether benefits to lowering
Folic acid, vitamins B6/B12 help lower

Front 87

The Pharmacist's role- (2)

Back 87

Adherence- is really shitty in most pt- and CVD risk reduction is directly related to patient adherence

Front 88

4 ways to improve pt adherence

Back 88

Assess adherence at each encounter

Simplify medication regimens

Provide good counseling techniques: Adjust approach based on patient understanding and abilities* (literacy)

Encourage use of prompts to remember medications/refill reminders