Term
| What are the goals of therapy for management of VERY HIGH TG > 500? |
|
Definition
| Prevent acute pancreatitis |
|
|
Term
| For management of very high TG > 500, what is the recommended diet? |
|
Definition
| Very low fat diets: <15% of caloric intake |
|
|
Term
| For management of very high TG > 500, what medications are required? |
|
Definition
TG-lowering is usually required:
- Fibrates
- Nicotinic acid (onset of efficacy is limited by titration issues)
- Omega 3 is an alternative (limited use bc lack of M/M data) |
|
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Term
| What are the causes of elevated TG? |
|
Definition
1. High carbohydrate diets (>60% of energy intake)
2. Several diseases (Type II DM, Chronic renal failure, nephrotic syndrome)
3. Drugs (corticosteroids, estrogens, retinoids (Vit A), high doses of BB)
4. Various genetic dyslipidemias |
|
|
Term
| What is the primary target of therapy for management of low HDL? |
|
Definition
1. Lowering LDL cholesterol
2. Weight reduction and increased physical activity (if the metabolic syndrome is present) |
|
|
Term
| What medications would you recommend for management of low HDL? |
|
Definition
| Nicotinic acid or fibrates |
|
|
Term
| What are 2 new drugs that can be used in the management of low HDL? |
|
Definition
1. Torcetrapib = CETP inhibitor (cholesteryl ester transfer protein)
- increases CV death by incr. Aldosterone/BP
2. Anacetrapid = CETP inhibitor |
|
|
Term
| What are causes of low HDL (<40 mg/dL) |
|
Definition
1. Elevated TG
2. Overweight and obesity
3. Physical inactivity
4. Type II DM
5. Cigarette smoking
6. Very high carb intakes (>60% energy)
7. Certain drugs (BB, anabolic steroids, progestational agents) |
|
|
Term
| How do we get patients to goal? |
|
Definition
2 options, usually used in combo:
1. Therapeutic Lifestyle changes (TLC)
2. Drug therapy |
|
|
Term
| If patients are close to goal, would we just TLC only? |
|
Definition
Yes, if patients are close to their goal, TLC only (EXCEPT in high risk patients with 30-40% reduction!) Then reevaluate in 3 months, if not at goal, then add drug
TLC is ALWAYS added if patient is on drug therapy |
|
|
Term
| What TLC would you recommend to patient? |
|
Definition
1. Reduced intake of saturated fats < 7% of total calories, Trans-FA, and dietary cholesterol < 200 mg per day
2. LDL-lowering therapeutic options:
- Plant stanols/sterols (2 g/day)
- Viscous (soluble) fiber (10-25 g/day)
3. Weight reduction
4. Increased physical activity, minimum 3x/week for 30 minutes |
|
|
Term
| What statins are given daily? |
|
Definition
These statins are very potent so given once daily:
1. Rosuvastatin
2. Atorvastatin
3. Pravastatin |
|
|
Term
| Which statin must be taken with food? |
|
Definition
| Lovastatin (take with evening meal to enhance absorption) |
|
|
Term
| When should statins be taken? |
|
Definition
| Taken at night bc cholesterol is made at night, but if someone is doing a night shift, then take before sleeping |
|
|
Term
| In general, what does doubling the dose of any statin do? |
|
Definition
|
|
Term
| What are the 2 classes of HLD drugs that don't have M/M benefits? |
|
Definition
|
|
Term
| What is 1st line for management of high LDL? |
|
Definition
| Statins! HMG CoA Reductase Inhibitor |
|
|
Term
| Which statin has the lowest potential for DDIs? |
|
Definition
| Pravastatin is the only non-CYP450 S and has the least drug interactions. Use for patients who are on alot of drugs. |
|
|
Term
| When statins are used with fibrates, what risk is increased? |
|
Definition
| Myopathy! Highest rate with gemfibrozil. |
|
|
Term
|
Definition
| Contradicted in: - CYP3A4 inhibitors (incr. risk of rhabdo/hepatotoxicity) - Azole antifungals (itraconazole, ketoconazole) - Macrolide Abx (erythromycin, clarithromycin) - Grapefruite juice if > 1 quart/day - Nefazodone - HIV drugs (protease inhbitors) |
|
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Term
| Which drug when combined with simva/lova do you have to use with caution? |
|
Definition
Must decrease doses:
1. Verapamil
2. Gemfibrozil
3. Niacin
4. Danazol
5. Cyclosporin
6. Amiodarone |
|
|
Term
|
Definition
| Absolute CI: liver disease & pregnancy category X Relative CI: use w/ certain drugs |
|
|
Term
What are SE of Statins?
- Common SE
- Less common SE
- RARE SE |
|
Definition
Common side effects:
- Abdominal pain, flatulence, constipation, HA, muscle ache/weakness
Less common:
- abnormal LFT (chk baseline, 12 weeks, after dose increase, and then 2x/year) > 3xULN on 2 occasions, then d/c the statin
Rare - rhabdomyolysis (muscle toxicity - urine is dark and frothy - renal failure may occur) Check CK (if >10xULN, d/c statin) |
|
|
Term
| What is rhabdomyolysis? And what may it cause? |
|
Definition
| It is the breakdown of striated muscle which may result in electrolyte abnormalities, clotting disorders, acidosis, hypovolemia, and acute renal failure |
|
|
Term
| What are symptoms of rhabdomyolysis? |
|
Definition
- muscle pain, stiffness and/or weakness
- Dark frothy urine, red or cola color |
|
|
Term
| What is treatment of rhabdomyolysis? |
|
Definition
Goal: prevent shock and preserve kidney function
- use normal saline or sodium bicarb |
|
|
Term
| If patient has DM, should statins not be given? |
|
Definition
| No, clinical practice in patients with moderate or high CV risk or existing CV disease should not change (risk of developing DM is low even though the risk exists) |
|
|
Term
| In what drugs should you not exceed 10 mg Simvastatin daily? |
|
Definition
- Amiodarone
- Verapamil
- Diltiazem |
|
|
Term
| In which drugs should you not exceed 20 mg simvastatin daily? |
|
Definition
- Amlodipine
- Ranolazine
- > 1 g/day of niacin |
|
|
Term
What are the max Lovastatin doses when taken with:
- cyclosporine
- >1g/d niacin
- Gemfibrozil
- Danazol
- Amiodarone
- Verapamil |
|
Definition
- Cyclosporine: NTE 20mg/d
- >1g/day niacin: NTE 20mg/d
- Gemfibrozil: NTE 20mg/d
- Danazol: NTE 20mg/d
- Amiodarone: NTE 40mg/d
- Verapamil: NTE 40mg/d |
|
|
Term
What is the max dose of Rosuvastatin when taking it along with:
- Cyclosporine
- Gemfibrozil |
|
Definition
- Cyclosporine: NTE 5mg/d
- Gemfibrozil: NTE 10mg/d |
|
|
Term
| What was the result of the SATURN trial? |
|
Definition
| Maximal doses of Rosuvastatin and Atorvastatin resulted in sig. regression of coronary atherosclerosis. |
|
|
Term
| When do we use Fibric Acid Derivatives? |
|
Definition
1. Use first line in patients with very high TG levels > 500
2. In combo with statins when they have reached LDL goal and are now trying to reach non-HDL goal |
|
|
Term
| What are common and rare side effects of Fibric Acid Derivatives? |
|
Definition
Common side effects:
1. Rash
2. Dyspepsia
3. Abdominal pain
4. N/V
5. Diarrhea
6. Fatigue
Rare side effects:
1. Gallstones
2. Hepatitis
3. Cholelithiasis
4. Myopathy
- increased rate when combined with statins (esp simvastatin with gemfibrozil) |
|
|
Term
| What are CI of Fibric Acid Derivatives? |
|
Definition
| Severe renal or hepatic disease |
|
|
Term
| DDIs with Fibric Acid Derivatives? |
|
Definition
- Statins (esp Gemfibrozil)
- Displaces protein bound drugs (warfarin, phenytoin, etc) |
|
|
Term
| When should you avoid using Gemfibrozil? |
|
Definition
|
|
Term
| Rhabdo is more likely to occur when taking statins (lova/simva) with which fibric acid derivative? |
|
Definition
|
|
Term
| If CrCl < 50mL/min, which dose Fenofibrate should be used? |
|
Definition
|
|
Term
| If CrCl = 30-80 mL/min, which dose Fenofibric acid should be used? |
|
Definition
|
|
Term
| What are the SE of Niacin? |
|
Definition
1. Flushing/itching (take ASA 30 min prior to dose, usually subsides after a couple of weeks)
2. GI distress (take with dinner)
3. Hepatitis (monitor LFTs q 6-12 weeks for a year, then every 6 months, d/c id 3xULN)
4. Hyperglycemia - monitor BG in DM pts
5. Hyperuricemia (gout)
6. myopathy
7. rash and HA |
|
|
Term
|
Definition
1. Severe gout
2. Active PUD
3. Active liver disease |
|
|
Term
| What are the advantages of Colesevelam? |
|
Definition
Advantages: fewer DDI and GI side effects
Used in type II DM to help control blood sugar |
|
|
Term
| What are the SE of Bile Acid Sequestrants? |
|
Definition
1. GI (bloating, abdominal pain, constipation, flatulence, and nausea)
2. Decreased absorption of other drugs |
|
|
Term
| What are the CIs of Bile Acid Sequestrants? |
|
Definition
1. Dysbetalipoproteinemia
2. Raised TG (esp > 400 mg/dL) |
|
|
Term
| Cholestyramine and Colestipol decreases the absorption of what drugs? What should be done? |
|
Definition
Decrease absorption of:
1. Gemfibrozil
2. Fenofibrate
3. HMG CoA reductase inhibitors
4. Digoxin
5. Warfarin
6. thyroid hormones
7. thiazide diuretics
8. propranolol
9. fat soluble vitamins
Take these drugs 1 hr before or 4-6 hrs after resin |
|
|
Term
| What are side effects of Omega 3 FA? |
|
Definition
GI: fishy after taste, dyspepsia, belching
- possibly flu like symptoms
- slight hepatitis (monitor LFTs) |
|
|
Term
| What drug can interact with omega 3 FA? |
|
Definition
|
|
Term
| What are the SE of Ezetimibe? |
|
Definition
1. GI: diarrhea
2. Muscle pain
3. upper respiratory tract infections
4. Hepatitis - monitor LFTs |
|
|
Term
| Does Ezetimibe decrease M/M? |
|
Definition
|
|
Term
|
Definition
|
|
Term
|
Definition
|
|
Term
|
Definition
|
|
Term
|
Definition
| Amlodipine + atorvastatin |
|
|
Term
|
Definition
|
|
Term
| What is the best drug at increasing HDL? |
|
Definition
| Niacin - must be titrated! |
|
|
Term
| Which drug is most effective at decreasing TG? |
|
Definition
|
|
Term
| What risk is increased when taking statins + niacin? |
|
Definition
|
|
Term
| What risk is increased when taking statins + fibric acid derivatives? |
|
Definition
| Rhabdomyolysis + hepatotoxicity |
|
|
Term
| What risk is increased when taking statins + ezetimibe/resin? |
|
Definition
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