Hyperlipidemia- Madras

Names of the 3 Bile Acid Sequestrants and their MOA:

• Colestipol, Cholestyramine, Colesevelam

• MOA: bind to bile acids in intestine

What are the main effects of Bile Acid Sequestrants? (like LDLs, VLDLs, TGs, HDLs)

• know

• decrease LDLs

• CAN INCREASE TGs

Which bile acid sequestrant is indicated in diabetes?

• know

Colesevelam

What is a main counseling point with Cholestyramine?

• know

• for Cholestyramine suspension do NOT sip or keep in your mouth!!!

  • can cause enamel/tooth decay

What is a general side effect of Bile acid sequestrants and how do we avoid them?

• know

GI ADRs

• start on low dose

Bile acid sequestrants can decrease absorption of some meds, so make sure to administer those meds ____-____ hrs before or ____-_____ hrs after.

1-4 hrs before or 4-6 hrs after

All statins are lipophilic except for…

• Pravastatin

• Rosuvastatin

Which Statins are CYP3A4?

• Atorvastatin

• Simvastatin

• Lovastatin

Which Statins are CYP2C9?

• Fluvastatin

• Rosuvastatin

• Pitavastatin

Which Statin is not metabolized by any CYP?

• Pravastatin

MOA of Statins and their main effects on LDLs and TG:

MOA: Inhibit HMG CoA Reductase

Effects: decreases LDLs and TGs

Never start what dose of Simvastatin?

• know

80 mg

What statin should be taken in the evening with food?

• know

Lovastatin IR

What statin should be taken before bedtime?

• know

Lovastatin ER

Hallmark symptom of Rhabdomyolysis:

• know

coke colored urine

In Statins the main ADR is…

muscle ADRs (myopathy/myalgia/Rhabdomyolysis)

If you have myopathy associated w/ statins, what happens to CK levels?

increase

If you have myalgia associated w/statins, what happens to CK levels?

no increase in CK

With what statin, is there no evidence of reducing CV morbidity/mortality?

• know

Pitavastatin

After starting a statin, when do you get a lipid panel?

• know

4-12 weeks

If you double the dose of a statin, does it double the LDL decrease?

no!!

• FYI only see a 6-7% more decrease

If a pt was Asian, what Statin and dose would be recommended?

Rosuvastatin 5 mg

With hydrophilic Statins they can potentially reduce the risk of ____________.

myalgia

Max effect of statins seen in about ___ weeks.

6

What supplement is not recommended for routine use if taking a statin or have muscle symptoms?

• know

CoQ10

What fruit should be avoided on statins?

grapefruit/ grapefruit juice

What are some drug interactions w/ CYP3A4 inhibitors/substrates and Simvastatin?

• there’s a lot listed, but I selected the ones that Madras put emphasis on

• azole antifungals

• macrolide antibiotics

• gemfibrozil

• cyclosporine

• non-DHPs- reduce dose

With what conditions should statins be stopped/held off?

• FYI

• rhabdomyolysis

• major surgery

• hypotension

• dehydration

Statin contraindications:

• liver disease

• elevated LFTs

• lactating/pregnant

Brand name and dosage form of Bempedoic acid:

• know

• Nexletol

• oral

Bempedoic acid works as a _______ inhibitor and decreases ______ in the liver.

• know

• ACL inhibitor

• decreases LDL

Major ADRs of Bempedoic Acid:

• know

• hyperuricemia

• increase LFTs

• tendon rupture

Are statins and fibrates recommended to take together?

• know

NO

Brand/Generic names of fibrates:

Gemfibrozil

• Lopid

Fenofibrate

• tricor, triglide, antara, lofibra, trilipix, lipofen, fibricor, fenoglide

Have fibrates shown to reduce CV mortality?

• know

no

What are the effects of fibrates on lipoproteins? (Ex: LDL, HDL, VLDL, TG)

• decrease TG

• increase HDL

What are the contraindications of Fibrates?

• know

• gallbladder disease

  • bc ADR of fibrates is gallstones

• hepatic disease

• renal disease

Brand name and dosage form of Ezetimibe:

• know

• Zetia

• oral

Ezetimibe works by decreasing what lipoprotein?

• know

• decrease LDL

Do not use Gemfibrozil with ________________.

• know

Ezetimibe

Ezetimibe is contraindicated in…

• know

liver disease

ADRs of Ezetimibe:

• know

• gallstones

• increase LFTs

For nicotinic acid, there is an IR, SR, and ER version. Which is recommended?

• know

ER- aka Niaspan

IR nicotonic acid increases which ADR?

• know

flushing

SR nicotinic acid increases which ADR?

increases hepatotoxicity

Effects of Nicotinic acid/Niaspan on lipoproteins:

(VLDLs, TGs, HDLs, LDLs)

• know

• decrease VLDLs, LDLs, TGs

• increase HDL

ADRs of Nicotinic Acid:

• know

• flushing

• hyperglycemia

• peptic ulcer

• hyperuricemia

• hepatotoxicity

How do we avoid flushing with Nicotinic Acid?

• know

• take aspirin

• take with food

• take at bedtime

• avoid anything HOT

  • eating, drinking, showers, etc.

Generic name and dosage form of Lomitapide:

• know

• Juxtapid

• oral

Boxed warning of Lomitapide:

• know

• increase liver transaminases

• hepatotoxicity

Lomitapide decreases what lipoprotein?

LDLs

What type of inhibitor is Lomitapide?

• know

TG transfer protein inhibitor

Contraindications of Lomitapide:

• know

• pregnancy

• Use with CYP3A4 inhibitors

Alirocumab brand name and dosage form:

• know

• Praluent

• Sub-Q

Alirocumab and Evolocumab have an indication for reducing the risk of

MI, Stroke, angina requiring hospitalization in adults w/ CVD

• basically know these have a CV indication

Alirocumab and Evolocumab are what type of inhibitors?

PCSK9 Inhibitors

Evolocumab brand name and dosage form:

• know

• Repatha

• Sub-Q

Inclisiran is what type of inhibitor and is what type of administration?

• PCSK9 inhibitor

• Sub-Q

What two vitamins should we not take while doing lipid lowering therapy?

• vitamin E or C

The main effect of fish oil is to decrease _______ and has ____ and _____ side effects.

The main effect of fish oil is to decrease TGs and has GI and bleeding side effects.

Can Vascepa decrease CV events?

yes

What is the equation for calculating LDL?

You cannot calculate LDL values if your TGs are >_______.

400

High, Moderate, and Low intensity statins each lower LDL by what %?

High ≥50%

Moderate 30-49%

Low <30%

What are the high intensity statins and their dosing?

• Atorvastatin

  • 40-80 mg

• Rosuvastatin

  • 20, 40 mg

What are the moderate intensity statins and their dosing?

What are the low intensity statins and their dosing?

• Simvastatin

  • 10 mg

• Pravastatin

  • 10-20 mg

• Lovastatin

  • 20 mg

• Fluvastatin

  • 20-40 mg

• Pitavastatin

  • 1 mg

What are the 4 statin groups?

1. Secondary ASCVD prevention

2. Severe hypercholesterolemia (LDL ≥190 mg/dL)

3. Primary Prevention: Adults 40-75 YO w/ DM and NO ASCVD and LDL ≥70 mg/dL

4. Primary Prevention: Adults 40-75 YO w/ NO DM and NO ASCVD and ≥7.5% 10-year ASCVD risk and LDL 70-189 mg/dL

For which Statin group do you need to calculate a ASCVD 10-year risk score?

group 4