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What does high intensity statins do?

lower LDL by >/= 50%

What are high intensity statins?

atorvastatin 40-80 mg and rosuvastatin 20-40 mg

What does moderate intensity statins do?

lower LDL by 30-49%

What are moderate intensity statins?

atorvastatin 10-20 mg, rosuvastatin 5-10 mg, simvastatin 20-40 mg, pravastatin 40-80 mg, lovastatin 40 mg, fluvastatin 40 mg BID, fluvastatin XL 80 mg, and pitavastatin 2-4 mg

What are the categories for patients to receive statins?

patients with clinical ASCVD, familial hypercholesterolemia with LDL > 190, adult with DM, primary prevention with no ASCVD or DM

What kind of statin is given for patients with clinical ASCVD?

high intensity statin with LDL goal < 70

What kind of statin is given for patients with familial hypercholesterolemia with LDL > 190?

high intensity statin with LDL goal < 100

What kind of patients with DM are considered for statin?

40-75 y/o with LDL >/= 70

What kind of statin is given for patients with DM 40-75 y/o with LDL >/= 70?

moderate intensity and consider high intensity if multiple risk factors

What kind of patients are considered for primary prevention with no ASCVD or DM?

adults 40-75 y/o

What is done for primary prevention?

calculate 10 year risk of ASCVD, risk factors, risk enhancing factors, patient's preference, and coronary artery calcium (CAC) scores

What drugs are added for high intensity statin treatment groups if LDL goal is not met?

add ezetimibe to high intensity statin and add PCSK9 inhibitor if LDL is still high

What is low risk of 10 year risk?

< 5%

What is borderline risk of 10 year risk?

5-7.5%

What is intermediate risk of 10 year risk?

7.5-19.9%

What is high risk of 10 year risk?

/= 20%

What are risk enhancing factors?

FH of premature ASCVD, LDL >/= 160, metabolic syndrome, CKD, inflammatory dx like RA/psriasis/HIV, history of preeclampsia/premature menopause with age < 40, high risk ethnic groups like south asian, Hs-C reactive protein >/= 2.0, apolipoprotein B >/= 130, ankle-brachial index < 0.9, lipoprotein >/= 50

What kind of healthy adult is considered moderate intensity statin?

age 40-75 y/o, LDL >/= 70, 10 year risk score >/= 7.5%

What are scores of coronary artery calcium score?

score 0, 1-99, an > 100

What is score of 0 for coronary artery calcium score?

delay statins except if major risk factors

What is score of 1-99 for coronary artery calcium score?

favor statin especially if age >/= 55 y/o

What is score > 100 for coronary artery calcium scores?

statins indicated

When is cholesterol monitored after starting statins?

4-12 weeks after

What is LDL goal for healthy patients?

< 100

What is LDL goal for high risk patients?

< 70

What is HDL goal for men?

40

What is HDL goal for women?

50

What is normal triglyceride?

< 150

What is borderline triglyceride?

150-199

What is high triglyceride?

200

What is desirable total cholesterol?

< 200

What is borderline total cholesterol?

200-239

What is high total cholesterol?

240

When is cholesterol screening needed?

testing kids as young as 2 if FH, and people > 20 y/o with no cardiovascular dx should have risk assessment every 4-6 yrs

What is very high risk of non-HDL-C?

< 100

What is very high risk of LDL-C?

< 70

How is total cholesterol calculated?

LDL + HDL + (TG/5)

How is non-HDL cholesterol calculated?

TC - HDL = LDL + (TG/5)

What is cholesterol/HDL ratio?

TC/HDL

What is cholesterol/HDL ratio goal?

< 5.0 and ideally < 3.5

What drugs can inc cholesterol?

thiazide diuretics, loop, beta blockers, protease inhibitors, anitpsychotics like olanzapine, and SGLT2 blockers

What classes of drugs are used for dyslipidemia?

statins, cholesterol absorption inhibitor, PCSK9 blockers, niacin, bile acid sequestrants, fibric acid derivatives, and omega 3 fatty acids

What does statins do?

dec LDL, dec CRP, and used for mixed hyperlipidemia

What does cholesterol absorption inhibitor do?

dec LDL

What does PSCK9 inhibitor do?

dec LDL

What does niacin do?

dec LDL and triglyceride, inc HDL, and used of mixed hyperlipidemia

What does bile acid sequestrants do?

inc triglyceride

What does fibric acid derivatives do?

dec triglyceride and inc HDL

What does omega 3 fatty acid do?

dec triglyceride

What is blocked by statins?

HMG-CoA

What are drugs for statins?

pitavastatin, rosuvastatin, atorvastatin, simvastatin, lovastatin, pravastatin, and fluvastatin

What drugs interact with pitavastatin?

erythromycin (limit Livalo to 1 mg once daily), rifampin (limit Livalo to 2 mg once daily), fibrates cause inc risk of myopathy

What is Zypitamag?

magnesium salt form of pitavastatin

What are drug interactions with rosuvastatin?

separate aluminum and magnesium antacids, inc effects of warfarin

What are drug interactions of atorvastatin?

substrate of CYP3A4 and dec by inhibitors, fibric acid agents or niacin can inc myopathy, and separate dose from colestipol or cholestyramine

What happen if simvastatin 40 mg is not lowering LDL?

change to atorvastatin 40 mg

What is drug interaction for simvastatin?

avoid with CYP3A4 inhibitors like azoles/macrolides/HIV protease inhibitors/nefazodone/gemfibrozil/cyclosporine/danazol, use max of 10 mg/day with verapamil/diltiazem, use max of 20 mg/day with amiodarone/amlodipine/ranolazine, and avoid grapefruit juice if > 1 quart daily

What are drug interactions with lovastatin?

avoid use with inhibitors like ketoconazole/erythromycin/clarithromycin/protease inhibitors (ritonavir)/cobicistat, don't use over 20 mg/day with verapamil/diltiazem, don't go over 40 mg/day with amiodarone/dronedarone, and use other statins with amiodarone like fluvastatin/prvastatin/pitavastatin

What are drug interactions with pravastatin?

minor CYP3A4 substrate and less potential for drug interactions, inc risk of myopathy with fibric acid, and separate with colestipol and cholestyramine

What are drug interactions with fluvastatin?

CYP2C9 inducers like rifampin dec fluvastatin levels and inc risk of myopathy with fibric acid or niacin

Which statins are given at bedtime?

fluvastatin IR, lovastatin IR, and simvastatin IR

Which statin is most potent?

rosuvastatin

Which statins are given regardless of time of day?

rosuvastatin, atorvastatin, pravastatin

What are side effects of statins?

myopathy, severe muscle sx/fatigue, mild to moderate muscle sx rhabdomyolysis with gemfibrozil/niacin, hepatotoxicity, inc glucose, GI distress, headache, upper respiratory infections, and reversible memory loss

How is severe muscle sx or fatigue handled when using statin?

d/c statin, evaluate CPK/creatine/urinalysis

What statins are less likely to cause muscle sx?

pravastatin, fluvastatin, low dose rosuvastatin

What drugs inc skeletal muscle toxicity with statin?

daptomycin, zidovudine, raltegravir, and colchicine

What are contraindication of statin?

liver disease, alcoholism, pregnancy, and breastfeeding

What needs to be monitored with statin?

LFT at baseline, lipid panel at baseline and then 4-12 weeks after starting and then every 3-12 months, CPK for muscle aches

What statins interact with CYP3A4 inhibitors?

lovastatin, atorvastatin, simvastatin dec by inhibitors and cause inc statin levels and toxicity, inc risk of myopathy and rhabdomyolysis

What happens to statin with red yeast rice?

red yeast rice act similar to lovastatin so when used together it cause inc toxic effects

What statins interact with warfarin?

lovastatin, atorvastatin, rosuvastatin, and simvastatin inc bleeding with warfarin

What statins don't interact with warfarin?

pravastatin, pitavastatin, fluvastatin

What are drug for cholesterol absorption inhibitor?

ezetimibe

When is ezetimibe used?

used alone or together with statin to dec LDL

What needs to be monitored for ezetimibe?

monitor LFT if used with statins

What are side effects of ezetimibe?

back pain, arthralgia, diarrhea, sinusitis, abdominal pain

What are drugs for PSCK9 inhibitors?

alirocumab and evolocumab

What is MOA of PCSK9 inhibitors?

human monoclonal antibodies that block binding of PCSK9 to LDL receptors to dec LDL

When is PCSK9 inhibitors used?

adjunct to diet and max tolerated statin and for patients that need additional dec of LDL

What needs to be monitored for alirocumab?

LDL within 4-8 weeks of starting and hypersensitivity

What are side effects of niacin?

flushing, itching, GI distress (take with food), hepatoxicity, hyperglycemia, and hyperuricemia

How is flushing and itching avoided when using niacin?

titrate slowly, take after meals, and take 325 mg of aspirin 30-60 min before to dec flushing

What needs to be monitored for niacin?

lipids, LFT, glucose, and uric acid

What drugs interact with niacin?

statins inc risk of myopathy

What are drugs for bile acid sequestrants?

cholestyramine colestipol, and colesevelam

When is bile acid sequestrants not used?

not used with triglyceride >/= 300 and discontinue if triglyceride > 300

What are side effects of bile acid sequestrants?

constipation, bloating, nausea, flatulence, and impaired absorption of fat soluble vitamins like A/D/E/K and folate

Which bile acid sequestrants have less GI side effects?

colesevelam

What are drug interactions for bile acid sequestrants?

impair drug absorption of digoxin, levothyroxine, warfarin, thiazide, oral contraceptives, tricyclic antidepressants, and others, and bile acid sequestrants like cholestyramine bind to other drugs so separate 1-2 hr before or 4-6 hr after dose of other drugs

When is cholestyramine discontinued?

if triglyceride > 400 mg/dL

What are drugs for fibric acid derivatives?

gemfibrizol and fenofibrate

What does fibric acid derivates do?

stimulate enzyme lipoprotein lipase and dec triglyceride, inc HDL, and can inc LDL if triglyceride is high

What are drug interactions with gemfibrizol?

if used with statins then inc risk of myopathy, inc effects of warfarin so monitor INR, and repaglinide inc risk of hypoglycemia

What are side effects of fibric acid derivatives?

cholelithiasis, dec HDL with fenofibrate, VTE, inc risk of myopathy with gemfibrozil with statin

When is fenofibrate not used?

if CrCl </= 30 and hepatic impairment

When is omega 3 fatty acid used?

if triglyceride > 500

What are drugs for omega 3 fatty acid?

omega 3 acid, icosapent ethyl, and omega 3 carboxylic acids

What is affected by omega 3 acid (Lovaza)?

EPA and DHA

What is affected by icosapent ethyl (Vascepa)?

EPA