Lipids 1

Fridegwald equation

TC= (TG/5) + HDL +LDL

*When TG is over 500 we dont look at LDL

Non-HDL-C=

Non-HDL-C= total cholesterol- HDL-C

Primary Lipid Disorder

Genetic diseases should be strongly suspected in a patient with elevated total serum cholesterol greater than 300 mg/dL or in a patient with LDL cholesterol greater than or equal to 190 mg/dL

What are the best lipid-lowering therapy drugs 

Statins

Statins Absolute contraindications

Liver disease, preg/lac

High-intensity statins

Atorvastatin 40 or 80

Rosuvastatin 20 or 40

Moderate Intensity Statins

Atorvastatin 10 or 20

Rosuvastatin 5 or 10

Simvastatin 20-40

Pravastatin 40 or 80

Lovastatin 40 or 80

Fluvastatin 40 BID 

Low Intensity Statins

Pravastatin 10-20

Lovastatin 20

Statin side effects (CNS, GI, Serious)

CNS: headache, insomnia

GI: epigastric discomfort, flatulence, diarrhea, constipation

Serious: hepatitis, rhabdomyolysis 

CYP3A4 inhibtors - Statin interaction

Itraconazole

Ketoconazole 

Erythromycin

Clarithromycin

Protease inhibitors (ritonavir)

Amiodarone

Verapamil, diltiazem

Statins ____ the INR when patients are also on____

INR, Warfarin

Bild acid resins and statins interactions

Adsorption

What medcications cause Rhabdomyolysis with statins

Cyclosporine, erythromycin, gemfibrozil, niacin

Statin lab monitoring

 FLP baseline and 6-12 weeks after dose adjustments then every 6-12 months after the goal is reached 

Which statins are the most potent?

Pitavastatin>Rosuvastatin>Atorvastatin 

What indicates rhabdomyolysis?

CL levels→ Normal levels are 45-260 U/L

Which statins decrease TG the most? (Max, Good, Fair)

Max: Rosuvastatin

Good: Atorvastatin

Fair: Simvastatin, pravastatin

Can statins cause diabetes?

The risk of CV events from no treatment is higher than diabetes risk

Ezetimibe (Zetia)

Add on therapy only!!

Well tolerated

No need to adjust for hepatic/renal/gastric

Same lab monitoring as statins

What medications interact with ezetimibe

Cholestyramine reduces ezetimibe AUC

Fibrates can cause cholelithiasis

Cyclosporine can increase serum concn of ezetimibe

Evolocumab(Repatha)

Alirocumab (Praluent)

Used with max statin therapy in adults with heterozygous familial hypercholesteremia and homozygous familial hypercholesterolemia

SEs: itching, flu, nasopharyngitis,

Bempedoic (Nexletol)

Adjunct to diet and max tolerates statin therapy for adults with heterozygous familial hypercholesteremia or CVD who need additional lowering

Inclisiran (Leqvio)

Given in office, rarely used

Fish oil

Used to decrease TG

1)No shark, swordfish or king mackerel

2)Up to 2 meals of shrimp, canned tuna, salmon, pollock, catfish

Mercury poisoning

Lovaza & Vascepa

Lovaza indicated for pts with TG levels over 500

Vascepa lowers TG about 27%

Fibrates

Gemfibrozil (Lopid)- AVOID!

Fenofibrate  (Antara, Lofibra, tricor, Triglide, Triglide. Trilipix)

Clofibrate 

Drug interaction between statin +fibrates

increased rhabdomyolysis risk 

Bile acid resins contraindications

TG>500

Preg

Soluble fiber

oranges, pinto beans, brown rice, apples can lower TChol and LDL

Cholestin

Red yeast from fermented rice or extracted from honeybee wax

Same MOA as statins

Lowers cholest 25-40

Familial hypercholesteremia

Genetic disorder, untreated LDL-C of 200-400 mg/dL

High CV risk Population

Previous MI/stroke/CVD or multiple CV risk factors

→Difficult to achieve LDL goals despite therapy

Statin-intolerant population

Many discontinue do to muscle pain and/or weakness

What drugs lower LDL the most

PCSK9: 35-65%

Statins: 15-60%

Bile acid sequestrants: 5-35%

Ezetimibe: 15-20%

Fibrates: 10-20%