Hyperlipidemia Drugs

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Questions and Answers

A 62-year-old male with a history of hypertension and type 2 diabetes mellitus has an LDL-C level of 170 mg/dL despite lifestyle modifications. His 10-year ASCVD risk score is calculated to be 12%. According to the guidelines, what is the most appropriate initial treatment?

  • Ezetimibe monotherapy
  • Moderate-intensity statin therapy
  • Bile acid sequestrant
  • High-intensity statin therapy (correct)

Which of the following is the primary mechanism of action of HMG-CoA reductase inhibitors (statins)?

  • Increasing the excretion of bile acids
  • Inhibiting the synthesis of cholesterol in the liver (correct)
  • Increasing the expression of LDL receptors
  • Inhibiting the absorption of cholesterol in the small intestine

A 58-year-old female is started on atorvastatin for hyperlipidemia. Which laboratory value is most important to check before initiating statin therapy?

  • Thyroid-stimulating hormone (TSH)
  • Vitamin D level
  • Creatine kinase (CK)
  • Liver function tests (LFTs) (correct)

Which of the following statins is considered a high-intensity statin at commonly prescribed doses?

<p>Atorvastatin (B)</p> Signup and view all the answers

A patient on warfarin is prescribed gemfibrozil for hypertriglyceridemia. What potential interaction should the healthcare provider monitor for?

<p>Increased risk of bleeding (D)</p> Signup and view all the answers

Which of the following is a common side effect of niacin, and what strategy can be used to mitigate it?

<p>Flushing, reduced by taking aspirin prior to niacin (D)</p> Signup and view all the answers

A 45-year-old patient with a history of premature coronary artery disease (CAD) presents with an LDL-C level of 180 mg/dL despite being on a moderate-intensity statin. What is the next best step in management?

<p>Switch to a high-intensity statin. (B)</p> Signup and view all the answers

Which lipid-lowering agent is most effective at lowering triglyceride levels?

<p>Fibrates (A)</p> Signup and view all the answers

Which of the following is a contraindication to the use of HMG-CoA reductase inhibitors (statins)?

<p>Pregnancy (C)</p> Signup and view all the answers

A patient taking simvastatin reports muscle pain and weakness. What is the most appropriate initial action?

<p>Immediately discontinue the statin and check creatine kinase (CK) levels (C)</p> Signup and view all the answers

Which of the following best describes the action of omega-3 fatty acids in managing hypertriglyceridemia?

<p>Inhibiting VLDL and triglyceride synthesis in the liver (B)</p> Signup and view all the answers

A patient with severe hypertriglyceridemia (TG > 500 mg/dL) is started on fenofibrate. What potential adverse effect should the patient be educated about?

<p>Muscle weakness or tenderness (C)</p> Signup and view all the answers

Which of the following lipid-lowering medications is a prodrug?

<p>Lovastatin (C)</p> Signup and view all the answers

A 68-year-old patient with known coronary artery disease (CAD) has an LDL-C level of 85 mg/dL despite being on a high-intensity statin. According to current guidelines, what should be considered?

<p>Add ezetimibe to the current statin therapy. (B)</p> Signup and view all the answers

Which of the following laboratory values should be monitored in patients taking niacin?

<p>Liver function tests and uric acid (C)</p> Signup and view all the answers

Which of the following patients would be the best candidate for bile acid sequestrants?

<p>A patient with type IIA or IIB hypercholesterolemia (A)</p> Signup and view all the answers

A patient with a history of ASCVD has been on maximally tolerated statin therapy for several years, achieving a 40% reduction in LDL-C. His LDL-C remains above target. Which of the following would be the most appropriate next step?

<p>Add a PCSK9 inhibitor (B)</p> Signup and view all the answers

A patient is started on cholestyramine. To avoid drug interactions, when should other medications be administered?

<p>4-6 hours after cholestyramine (A)</p> Signup and view all the answers

Which of the following patients with hyperlipidemia would be LEAST likely to benefit from statin therapy?

<p>A 25-year-old female with homozygous familial hypercholesterolemia (B)</p> Signup and view all the answers

Which of the following is a risk factor for myopathy and rhabdomyolysis in patients taking statins?

<p>Hypothyroidism (C)</p> Signup and view all the answers

A 70-year-old patient has an LDL-C level of 150 mg/dL and is started on simvastatin 20 mg daily. After 6 weeks, LDL-C is 120 mg/dL. What is the next appropriate step?

<p>Increase simvastatin to 40 mg daily (D)</p> Signup and view all the answers

A 55-year-old male with a history of hypertension and a 10-year ASCVD risk of 8% has an LDL-C of 140 mg/dL. Which of the following is the MOST appropriate recommendation, according to current guidelines?

<p>Initiate moderate-intensity statin therapy (C)</p> Signup and view all the answers

Which of the following is a potential benefit of using a cholesterol absorption inhibitor like ezetimibe in addition to a statin?

<p>Increased LDL cholesterol reduction (D)</p> Signup and view all the answers

Which of the following is considered a risk-enhancing factor that may favor the initiation of statin therapy in individuals with borderline to intermediate ASCVD risk?

<p>Family history of premature ASCVD (A)</p> Signup and view all the answers

Which of the following statins is a prodrug that requires hydrolysis to its active form?

<p>Simvastatin (A)</p> Signup and view all the answers

Which of the following medications is most effective for lowering LDL cholesterol?

<p>Rosuvastatin (B)</p> Signup and view all the answers

A patient with severe hypertriglyceridemia (TG > 500 mg/dL) should be started on which therapy?

<p>Omega-3 fatty acids (B)</p> Signup and view all the answers

Which of the following statin doses is considered high-intensity?

<p>Rosuvastatin 40 mg (B)</p> Signup and view all the answers

A 55-year-old patient with an ASCVD score of 10% and no history of cardiovascular disease should be started on which therapy?

<p>Moderate-intensity statin (C)</p> Signup and view all the answers

A patient taking niacin reports significant flushing. What can help reduce this side effect?

<p>Administering it with aspirin 30 minutes prior (B)</p> Signup and view all the answers

Which drug class is the most effective at increasing HDL levels?

<p>Niacin (A)</p> Signup and view all the answers

A 45-year-old with diabetes and an ASCVD score of 6% should be started on which therapy?

<p>Moderate-intensity statin (B)</p> Signup and view all the answers

Which of the following side effects is most concerning in a patient taking a statin?

<p>Muscle pain with elevated creatine kinase (B)</p> Signup and view all the answers

Which lab should be checked prior to initiating statin therapy?

<p>Liver function tests (LFTs) (A)</p> Signup and view all the answers

A patient on maximally tolerated statin therapy still has high LDL. What is the next step?

<p>Add ezetimibe (C)</p> Signup and view all the answers

Which lab test is the most important to monitor for statin-induced myopathy?

<p>Creatine kinase (C)</p> Signup and view all the answers

Which of the following lipid-lowering drugs increases the anticoagulant effect of warfarin?

<p>Gemfibrozil (A)</p> Signup and view all the answers

Which lipid-lowering medication is contraindicated in pregnancy?

<p>Atorvastatin (C)</p> Signup and view all the answers

Which of the following patients should be started on high-intensity statin therapy?

<p>66-year-old male with an ASCVD score of 22% (C)</p> Signup and view all the answers

Which medication is most effective at lowering LDL cholesterol?

<p>Rosuvastatin (C)</p> Signup and view all the answers

Which statement about omega-3 fatty acids is correct?

<p>They primarily lower triglycerides (D)</p> Signup and view all the answers

Which of the following is a known adverse effect of statins?

<p>Liver enzyme elevation (A)</p> Signup and view all the answers

Which of the following is NOT a major risk factor for hyperlipidemia?

<p>Hypothyroidism (B)</p> Signup and view all the answers

Which lipid-lowering agent can increase the effect of warfarin, increasing the risk of bleeding?

<p>Gemfibrozil (C)</p> Signup and view all the answers

Which lipid-lowering medication is absolutely contraindicated in pregnancy?

<p>Atorvastatin (A)</p> Signup and view all the answers

A patient on a high-intensity statin still has an elevated LDL. What is the preferred add-on therapy?

<p>Ezetimibe (D)</p> Signup and view all the answers

Which of the following medications is most effective for lowering triglycerides?

<p>Fenofibrate (C)</p> Signup and view all the answers

Which statement about PCSK9 inhibitors is correct?

<p>They lower LDL by 50-70% (D)</p> Signup and view all the answers

What is the mechanism of action of ezetimibe?

<p>Inhibits cholesterol absorption in the small intestine (C)</p> Signup and view all the answers

Flashcards

What lipid levels indicate hyperlipidemia?

High LDL, total cholesterol, and low HDL.

Name the risk factors for hyperlipidemia

Smoking, HTN, obesity, DM, CKD, and advanced age.

What are the two main hyperlipidemia treatments?

Lifestyle modifications and pharmacotherapy.

ASCVD patients treatment

Reduce LDL-C with high-intensity statins or maximally tolerated statins.

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Treatment for very high-risk ASCVD

Consider adding nonstatins if LDL-C remains ≥70 mg/dL.

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Treatment for LDL-C ≥190 mg/dL

Begin high-intensity statin therapy.

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Treatment for diabetics with LDL-C ≥70 mg/dL?

Moderate-intensity statin therapy.

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What are the two high-intensity statins?

Atorvastatin and Rosuvastatin.

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How do statins work?

Inhibits HMG-CoA reductase, reducing cholesterol synthesis.

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In very high-risk ASCVD when should nonstatins be added

LDL-C < 70mg/dL

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What the the dose of atorvastatin to be high intensity?

40-80mg

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What the the dose of rosuvastatin to be high intensity?

20-40mg

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What are major statin side effects to monitor?

Elevated liver enzymes and myopathy/rhabdomyolysis.

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Which lab value needs to be checked when starting statins?

LFTs before treatment and if liver dysfunction is suspected.

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What to check with statin-associated muscle symptoms?

Check plasma creatine kinase levels.

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Which statins are prodrugs?

Lovastatin and Simvastatin.

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Which statin lowers LDL the most?

Rosuvastatin (60%)

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How does niacin work?

Inhibits lipolysis in adipose tissue, reduces TG, increases HDL.

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What are common side effects of Niacin?

Flushing, nausea, hyperuricemia, glucose intolerance, hepatotoxicity.

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How do you reduce niacin-induced flushing?

Administer aspirin and titrate dose slowly.

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What lipid does fibrates affect the most?

Decreases TG the most.

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What are drug interactions with fibrates?

Gemfibrozil with statins due to myopathy risk; warfarin due to increased INR.

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Omega-3 fatty acids action to treat?

Lower TG 25-30% by inhibiting VLDL and TG synthesis.

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How do bile acid sequestrants like cholestyramine work?

Form complex with bile acids, excreted in feces.

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Bile acid sequestrants side effects

GI disturbances, impaired absorption of fat-soluble vitamins (KADE).

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What is a prodrug?

Activated by hydrolysis in the body.

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How to reduce niacin flushing?

Using aspirin

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What baseline labs are needed when starting statins?

Liver function tests (LFTs).

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How does ezetimibe work?

Inhibits cholesterol absorption in the small intestine

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Cholestyramine counseling important to remember?

Take other medications 1 hour before or 4-6 hours after cholestyramine

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PCSK9 inhibitor effect on LDL

Lowers LDL by 50-70%

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What statin use is contraindicated in pregnancy?

Atorvastatin

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Which lipid lowering drug interacts with warfarin?

Gemfibrozil

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Study Notes

Prodrugs

  • Simvastatin and lovastatin are statin prodrugs needing activation through hydrolysis.

Best Drug for Hyperlipidemia & Hypertriglyceridemia

  • High-intensity statins like rosuvastatin and atorvastatin are most effective for lowering LDL.

Hypertriglyceridemia Treatment

  • Omega-3 fatty acids significantly lower triglycerides (25-30%) and serve as an adjunct for severe hypertriglyceridemia (TG > 500 mg/dL).

Statin Intensity Levels

  • High-intensity statin doses include atorvastatin 40-80 mg and rosuvastatin 20-40 mg.

Algorithm Based on Age/Risk

  • Initiate moderate-intensity statin therapy for a 55-year-old patient with a 10% ASCVD score and no history of cardiovascular disease.
  • ASCVD risk ≥ 7.5% but < 20% warrants a moderate-intensity statin.

Flushing and How to Reduce It

  • Aspirin 30 minutes before niacin helps reduce prostaglandin-mediated flushing.

Benefits of Each Drug Class

  • Niacin is the most effective drug class at increasing HDL levels (15-35%).

ASCVD Score & Best Drug Choice

  • Diabetic patients aged 40-75 years should be started on at least moderate-intensity statins regardless of ASCVD score.

Side Effects of Statins

  • Muscle pain with elevated creatine kinase is a concerning symptom with statin use due to myopathy and rhabdomyolysis risk, which should be monitored.

Monitoring When Starting Statins

  • Check liver function tests (LFTs) before starting statin therapy to assess for underlying liver disease.

Add-On Therapy for Patients Already on Statins

  • Add ezetimibe for patients on maximally tolerated statin therapy with persistently high LDL.
  • Ezetimibe is the preferred add-on when LDL remains elevated.

Most Important Lab Monitoring

  • Monitor creatine kinase (CK) levels in patients with muscle complaints while on statins because it can indicate Statin-induced myopathy.

Warfarin Interactions

  • Gemfibrozil increases INR when used with warfarin, increasing bleeding risk.

Drugs Contraindicated in Pregnancy

  • Statins (like atorvastatin) are teratogenic and contraindicated in pregnancy.

Statin Benefit Groups

  • Patients with ASCVD risk ≥ 20% warrant high-intensity statin therapy.

Which Drug Lowers LDL the Most?

  • High-intensity statins, like rosuvastatin and atorvastatin, lower LDL the most.

High-Intensity Statin Doses

  • High-intensity statins include atorvastatin 40 mg.

Omega-3 Fatty Acids

  • Omega-3 fatty acids primarily lower triglycerides and are used as an adjunct in severe hypertriglyceridemia.

Side Effects of Statins

  • Statins can cause elevated liver enzymes, requiring LFT monitoring before initiation.

What to Check If a Certain Side Effect Occurs

  • Check creatine kinase levels in patients on atorvastatin presenting with muscle pain and weakness to assess for myopathy or rhabdomyolysis.

What to Do When Starting an Agent

  • Baseline LFTs are required before starting statins to assess liver function.

Risk Factors for Hyperlipidemia

  • Hypothyroidism can contribute to lipid abnormalities but is not a primary risk factor for hyperlipidemia.

Warfarin Interactions

  • Gemfibrozil increases INR when used with warfarin, leading to a higher bleeding risk.

Contraindicated in Pregnancy

  • Statins are contraindicated in pregnancy due to teratogenic effects.

What to Add When LDL Remains High on Statins

  • Ezetimibe is commonly added to statins when additional LDL lowering is needed.

Fibrates and Triglycerides

  • Fibrates such as fenofibrate are the most effective at lowering triglycerides.

Bile Acid Sequestrants

  • Bile acid sequestrants impair drug absorption and should be taken separately from other medications.

PCSK9 Inhibitors

  • PCSK9 inhibitors significantly lower LDL and are used in statin-intolerant patients or those needing additional LDL lowering.
  • PCSK9 inhibitors lower LDL by 50-70%.

Cholesterol Absorption Inhibitors

  • Ezetimibe blocks cholesterol absorption, reducing LDL.

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