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88 Cards in this Set
- Front
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4 major drugs that cause dyslipidemia
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protease inhibitors
atypical antipsychotics (metabolic changes) BBs thiazides |
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Drug interactions with cyclosporine (2)
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Cyclosporine + statin
also zetia |
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safer statins to use concurrently with cyclosporine or PIs (2)
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fluva and pravastatin**- don't ahve same degree of CYP activity- better used with cyclosporine, etc
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cyclosporine effects in pt with dyslipidemia (2)
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Cylosporine increases LDL
interacts with statins (inhibits CYP? other routes of interference too like hepatic transport of statin) |
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Protease inhibitors effects on lipid profile: Ritonavir
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increase TG
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Protease inhibitors effects on lipid profile: Atazanavir
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no effect
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Protease inhibitors effects on lipid profile: Indinavir
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increase in LDL
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drug interactions with PIs in pt with dyslipidemia treatment (2) which 2 drugs
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Possible interference with absorption of antiviral therapy in bile acid sequestrants
P450 interaction with statins- use pravastatin |
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metabolic syndrome - cluster of risk factors that increase risk for CVD (4)
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Hypertension
Diabetes (pre-diabetes) Dyslipidemia Obesity |
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Criteria for Metabolic Syndrome (5)
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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) |
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Atherogenic Dyslipidemia definition (2) disease states it is found in
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Characteristic lipids change found in:
Metabolic Syndrome Diabetes (aka “diabetic dyslipidemia”) (insulin resistance- results in increased TG- control these diseases first) |
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atherogenic dyslipidemia characteristics (2)
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Elevated Triglycerides
Reduced HDL-C BUT LDL IS STILL PRIMARY GOAL |
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Treatment of Dyslipidemia in the Metabolic Syndrome: targets and goals (3 scenarios) goal LDL, etc
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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 |
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essential treatment to metabolic syndrome (3)
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Therapeutic Lifestyle Changes
(low fat, Exercise Weight loss) |
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drug tx for metabolic syndrome- preferred med
alternatives (2) |
Statins are preferred lipid-lowering meds
Fibrates and niacin are useful for lowering TG’s and raising HDL |
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CARDS trial showed what?
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Suggests diabetics should have target LDL much lower than 100 mg/dL
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statins should be added to TLC without regard to baseline lipids (even if they are at goal) in what patients?( 2)
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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. |
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Certain high-risk cases where CVD occurs in the 1st and 2nd decade: what pt population (for kids)
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Homozygous Familial Hyperlipidemia
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Children at Increased Risk for CVD/issues (6)
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Familial Hyperlipidemias
Type 1 & 2 Diabetes Mellitus Kidney Disease-ESRD, nephrotic syn. Metabolic Syndrome Transplantation Chronic Inflammatory Disease-SLE |
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Screening of kids for dyslipidemia (2 steps)
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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 |
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Children-Assessment risk: what puts kids at high tier 1 risk? (3)
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Tier 1 High Risk: HoFH, DM-1, CKD
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Children-Assessment risk: what puts kids at moderate tier 2 risk?
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HetFH, DM-2
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Children-Assessment risk: what puts kids at tier 3 risk? (3)
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Congenital heart disease, post-cancer treatment survivors, Kawasaki
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how to assess risk categories (4)
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high risk (tier 1)
tier 2- moderate risk tier 3- at risk if additional risk factors > 2 bump up a tier lvl |
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other risk factors for kids (6)
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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 |
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Children-Treatment Goals based on tier of risk (3)
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Tier 1: High Risk
LDL <100 mg/dL Tier 2: Moderate Risk LDL <130 mg/dL Tier 3: At risk LDL <160 mg/dL |
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for kids: when to consider drug therapy for LDL goals
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Consider drug therapy if >30 above goal or still above goal after 6 months of TLC
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Preferred initial treatment for kids and at what age
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statins
>=8 yo |
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FDA approved statins for kids (4)
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simvastatin
lovastatin artovastatin pravastatin |
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monitoring of statin therapy in kids (3)
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same as adults except...
Growth (age, height, BMI-normal growth chart) Sexual Maturation Development |
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know parameters for TMS
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--
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Kids and bile acid sequestrants (2)
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inital therapy for kids- a long time ago
been replaced with statins |
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Ezetimibe in kids (2)
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safe in kids > 10
can be used alone or in combo with statins |
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Niacin in children (2)
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may be considered if TG > 700 but not studied in people < 21 yo
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fibrates in children (2)
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may be considered if TG > 700 but not studied in ppl < 18
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CKD definition (2 defining parameters) also time duration
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as >3 months of either structural or functional abnormalities of the kidney or GFR <60 mL/min
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risk for people with CKD in regards to CVD (2)
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Patients with CKD are at increased for CVD
may present with various dyslipidemias |
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Chronic Kidney Disease Lipid Abnormalities trends
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those with nephrotic syndrome or diabetic CKD have the highest incidence of lipid abnormalities
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is CKD a risk equivalent
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yes
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management of lipids in CKD:
address what to do if LDL100-129, >130, and if non HDL>130 (TG > 200) |
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) |
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statins and proteinuria
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if starting statin- protein in urine goes up- statins can falsely elevate protein in urine (not kidney related)
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3 statins that require renal dose adjustments for CKD
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pitavastatin
rosuvastatin simvastatin |
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renal dosing for pitavastatin (3)
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GFR > 60 1-4 mg
GFR 15-59 1-2 mg GFR < 15 and on hemodialysis- 1-2 mg |
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renal dosing for rosuvastatin (2)
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5-10 mg for GFR 15-29
not studied in < 15 |
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renal dosing for simvastatin
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GFR <30 10-40 mg with starting dose of 5 mg
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drugs with no renal adjustments (2)
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ezetimibe
bile acid sequestrants (not absorbed) |
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preferred fibrate in CKD
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gemfibrozil
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fenofibrate renal dosing
avoid in what GFR? |
48 mg if GFR < 60
avoid in GFR < 15 |
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gemfibrozil renal dosing
avoid in what GFR |
600 mg QD (not BID) if GFR < 60
avoid in GFR < 15 |
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don't have to know exact dosing but know which drugs are preferred
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---
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look at renal dosing again...
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--- looks like they all can be used and atorvastatin doesn't have to be changed because it's CYP metabolized
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elderly "age"
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> 65
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elderly- risks compared to younger interms of CV/lipidemia (4)
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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 |
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1%/2% rule for lipid lowering
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1% TC decrease = 2% CHD risk decrease
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LDL lowering in elderly- yes or no?
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Should not be excluded from the benefits of LDL lowering based on age alone
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elderly- things to consider (5)
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Increased risk for DDI’s
Adverse Effects Decreased elimination Cost Overall risk:benefit in terms of life expectancy |
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preferred treatment for dyslipidemia in elderly
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statins- most evidence
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bile acid sequestrants in elderly (2)
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problems with intolerance and DDI’s
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fibrates in elderly- (2) things to know
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Dose adjustment in CKD and may increase risk of gallstones in elderly
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drug that is good for use in CKD (2)
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atorvastatin- no dose adjustments
pravastatin |
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ezetimibe in elderly
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well tolerated and just as effective as in younglings
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advanced age (>70)- and statins- is there any issue here in terms of AE?
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Advanced age (>70) is a risk factor for myopathy with statins.
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emerging (new) risk factors for poor outcomes in dyslipidemia (5)
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hs-CRP
ApoB Lipoprotein A: Lp(a) Fibrinogen Homocysteine |
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hs-CRP what's it stand for
what is it? what do abnormal lvls suggest? |
high sensitivity c reactive protein
inflammatory marker in blood elevated lvls suggested increase increased risk of CVD |
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lipophilic statins- that may have higher risk of myopathies (3)
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liphophilic
atorvastatin lovastatin simvastatin hydrophilic- pravastatin, rosuvastatin |
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hs-CRP most useful for what population?
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most useful in intermediate risk (FRS 10-20%) patients in whom therapy is being considered
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levels of hs CRP as related to risk (3)
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<1 mg/L: lower risk
1-3 mg/L: intermediate risk >3 mg/L: higher risk |
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hs CRP vs CRP
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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 |
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JUPITER trial- what did it look at
primary endpoint |
rosuvastatin to prevent vascular events in men/women with elevated CRP (in low risk)
Occurrence of 1st major CVD event |
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results of JUPITER trial (2)
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rosuvastatin group had a significant reduction of primary outcome
and mortality but ARR wasn't very huge |
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Ways to lower hs-CRP (5)
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similar to how to lower LDL
Weight loss, diet and exercise Statins (more potent LDL lowering=more potent hs-CRP lowering) Fibrates Ezetimibe Aspirin |
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unknowns with hs CRP test (2)
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Target level to treat to?
who do we screen? we can't tell who has high hs CRP? |
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Apo B lvl - what does it tell you
levels are determined largely by what? |
Measure of all non-HDL lipoproteins (attached to all of them)
Largely determined by number of LDL particles |
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downside to Apo B (when are results vague?)
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disproportionately higher when TG’s are high
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benefit of Apo B (2)
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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) |
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what do ATPIII guidelines say about Apo B? (3) (how to use, whether to use...treatment)
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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 |
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ADA and ACC 2008 Consensus Conference Report: who was it addressed to? (regarding other lipids in measuring athergenic risk) (2)
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Specific to patients with cardiometabolic risk (htn, syndrome X, obesty...)
Specific to patients with cardiometabolic risk |
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Suggested treatment goals in patients with Cardiometabolic Risk (Apo B)
(highest and high- define each) |
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 |
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drugs that lower Apo B (4)
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statins- lower ApoB
fibrates- lower ApoB niacin- " BAS- " |
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Mipomersen- what is it
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Antisense oligonucleotide directed at human apo B100
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first document that recommended targeting ApoB
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ADA/ACC 2008 conference guidelines report
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mipomersen- efficacy and AE (general- are there any)
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Good LDL lowering but AE noted
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Challenges regarding Apo B (5)
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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 |
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Lipoprotein (A)- benefits to lower it?
2 drugs that can lower it |
Unknown whether benefits to lowering
Niacin, Estrogen help lower |
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Fibrinogen - what elevates its levels (2)
what decreases it (2) more FYI |
Increased by smoking, inflammation
Decreased by exercise, avoiding smoking, niacin, fibrates |
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Homocysteine - more FYI
what lowers it (2) |
Unknown whether benefits to lowering
Folic acid, vitamins B6/B12 help lower |
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The Pharmacist's role- (2)
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Adherence- is really shitty in most pt- and CVD risk reduction is directly related to patient adherence
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4 ways to improve pt adherence
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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 |