Dyslipidemia- PNN

LDL goal for patients with clinical ASCVD (MI, stroke, TIA, PAD)

LDL goal <70; put on high intensity statin

LDL goal for patients with familial hypercholesterolemia, LDL >190

LDL goal <100; put on high-intensity statin

True or false: patients age 40-75 with DM and LDL >70 should be on at least moderate intensity statin

true; may need high intensity if have other risk factors

At which PREVENT risk score should moderate intensity statin be initiated?

7.5% of greater

What are some examples of risk-enhancing factors that favor statin therapy initiation?

-Apolipoprotein B>130

-Lipoprotein(a) >30

-Hs-C reactive protein >2

-LDL>160

What medications can increase cholesterol?

-thiazides

-loop diuretics

-beta-blockers

-protease inhibitors

-antipsychotics

-SGLT2 inhibitors

HMG-CoA reductase inhibitors ________ (increase/decrease) high-sensitivity C-reactive protein (hsCRP)

decrease

Altoprev generic

Lovastatin

Vytorin generic

ezetimibe/simvastatin

Lescol generic

fluvastatin

What are the two brand names of pitavastatin?

Livalo and Zypitamag (magnesium salt form)

How does rifampin effect Livalo concentrations?

although rifampin is an inducer, it actually INCREASES pitavastatin concentrations, so limit Livalo dose to 2mg QD when given with rifampin

Max dose of rosuvastatin if CrCl<30 and/or the patient is on gemfibrozil (Lopid)

10mg/day

True or false: Crestor should only be initiated for cholesterol management

false; can also be started for patients with hs-CRP >2 and at least one more CV risk factor, regardless of LDL

Caduet generic

amlodipine/atorvastatin

Which statins should not be given with strong CYP3A4 inhibitors?

Zocor and Altoprev

Max dose of simvastatin with verapamil/diltiazem? Max dose of simvastatin with amiodarone, amiodarone, ranolazine?

-10mg/d

-20mg/d

Max dose of lovastatin with verapamil, diltiazem, dronedarone? Max dose of lovastatin with amiodarone?

-20mg/d

-40mg/d

What is the max dose of Crestor in Asians?

20mg/day

Which statin must be taken with food?

Altoprev (lovastatin)

Dose equivalent for LDL reduction

Please Remember All Statins Lower Pretty Flexibly

Pitavastatin- 2mg

Rosuvastatin- 5mg

Atorvastatin- 10mg

Simvastatin- 20mg

Lovastatin- 40mg

Pravastatin- 40mg

Fluvastatin- 80mg

Which statins are given at night?

Fluvastatin (IR), Lovastatin (IR), and Simvastatin

"FLoS at night"

Which medications may increase the muscle toxicity of statins via additive effects?

daptomycin, zidovudine, raltegravir, colchicine, pregabalin

Side effects of statins

-myopathy

-hepatotoxicity

-increase glucose

-upper respiratory infections

-reversible memory loss (rare)

True or false: statins may decrease INR, increasing the risk of clots in patients on warfarin

false: statins can increase INR (thus bleeding) on warfarin

Zetia MOA

inhibits absorption of cholesterol at the brush border of the small intestine

PCSK9 inhibitors (include brand)

-alirocumab (Praluent)

-evolucumab (Repatha)

How often is alirocumab vs evolucumab dosed?

-Praluent: SQ q2w

-Repatha: SQ q2w OR once monthly

A common adverse effect of niacin is flushing and itching. What are some ways to mitigate that side effect?

-titrate slowly

-take after meals

-take 325mg ASA 30-60 min prior

Adverse effects of niacin (6)

-flushing

-itching

-GI distress

-hyperuricemia

-hyperglycemia

-hepatoxicity

Which formulation of niacin is associated with more hepatoxicity?

IR

True or false: bile acid sequestrants can be used as adjunct for uncontrolled hypertriglyceridemia after first and second line monotherapy

false; bile acid sequestrants increase triglycerides

It is recommended to separate bile acid sequestrants ____ hours before or ____ hours after a dose of other medications

1-2 hours before or 4-6 hours after

Side effects of bile acid sequestrants

constipation, bloating, nausea, and flatulence

Fibric acid derivatives MOA

PPAR-alpha agonist which increases clearance of TGs by increasing lipoprotein lipase activity

Gemfibrozil is CYP inhibitor. What are some of its drug interactions?

-increase effects of warfarin

-increase myopathy with statins

-increased risk of hypoglycemia with repaglinide

Adverse effects of fibric acid derivatives

-cholelithiasis (gallstones)

-may decrease Hg, Hct, and WBC

-myopathy

-associated with VTE

-may lower HDL

When are omega-3 fatty acids recommended?

when TGs are VERY high (>500)

_______ is the only omega-3 fatty acid that includes ONLY EPA and has CV risk reduction

Vascepa; by it only having EPA, it has also less effect on increasing LDL

Omega-3 fatty acids may ______ (increase/decrease) bleeding

increase

True or false: garlic does not help lower cholesterol

true

Bempedoic acid brand and MOA

Nexletol; ACL inhibitor

Which cholesterol medications increase uric acid? (2)

niacin and bempedoic acid

Adverse effects of bempedoic acid

-hyperuricemia

-tendon rupture

-increased chance of infection

-muscle pain

Nexlizet generic

bempedoic acid/ezetimibe

What is the new medication for dyslipidemia that inhibits angiotensin-like protein 3? How is it given?

Evinacumab (Evkeeza) given IV