Ch 20 Hyperlipidemia

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1. 1. Clinical ASCVD ≤ 75 YO → High intensity 15. Clinical ASCVD 1. Acute Coronary Syndrome (angina,
Intensity > 75 YO → Moderate intensity Types (3) MI, revascularization)
• Angina
2. 2. LDL ≥ 190 Intensity High intensity
• Myocardia infarction
3. 3. DM + 40-75 YO + LDL Moderate intensity • Revascularization
70-189 Intensity Risk assessment - high intensity 2. Peripheral Artery disease
4. 4. 40-75 YO + LDL 70- 5-7.5% → risk assess - moderate • Aortic aneurysm
189 Intensity 7.5-20% → moderate 3. Stroke/TIA
≥20% → high 16. Fibric Acid - GI related
5. Bile Acid - ↑ Triglycerides (TG) Derivatives adverse - hepatotoxicity (monitor LFTs)
Resin/Sequestrant - flatulence effects - increase effects of anticoagulants
adverse effects - bloating 17. Fibric Acid - History of gallstones
- abdominal pain Derivatives - severe hepatic or renal dysfunction
- heartburn contraindications - use with simvastatin
- constipation
18. Fibric Acid Gemfibrozil should not be initiated
6. Bile Acid - Biliary obstruction Derivatives drug with a statin therapy due to
Resin/Sequestrant - chronic constipation interactions increased risk of myopathy
contraindications - TG > 500 mg/dL (Gemfibrozil)
7. Bile Acid - Cholestyramine 19. Fibric Acid - Gemfibrozil
Resin/Sequestrant drug - Cholesevelam Derivatives drugs - Fenofibrate
8. Bile Acid Taken 1 hour before or 4 hours 20. Fibric Acid - 1st line for hypertriglyceridemia
Resin/Sequestrant drug after any other drugs Derivatives MOA Stimulates lipoprotein lipase and
interactions inhibits VLDL production, primarily
9. Bile Acid Bind to bile acids in the intestines decreases triglycerides
Resin/Sequestrant to prevent absorption 21. Myopathy symptoms - pain
MOA *take with food - tenderness
10. Cholesterol Absorption - Headache - stiffness
Inhibitor adverse - diarrhea - cramping
effects - abdominal pain - weakness
- generalized fatigue
11. Cholesterol Absorption CV death, nonfatal MI, unstable
- muscle symptoms + CPK > 10 x
Inhibitor *Composite angina requiring hospitalization,
ULN
outcome coronary revascularization, or
nonfatal stroke 22. Niacin adverse - Flushing*
effects - Pruritus*
12. Cholesterol Absorption Ezetimibe
- rash
Inhibitor drug
- hepatotoxicity
13. Cholesterol Absorption - Ezetimibe 10 mg daily +
23. Niacin Baseline Labs Glucose/A1C, LFTs, uric acid
Inhibitor IMPROVE-IT simvastatin 40 mg daily
Trial - secondary - 2% absolute risk reduction of 24. Niacin - Hepatic dysfunction
prevention composite outcome* compared to contraindications - severe hypotension
simvastatin 40 mg alone - hyperglycemia
- gout
14. Cholesterol Absorption Inhibits absorption of cholesterol
- new onset atrial fibrillation
Inhibitor MOA at small intestine
- active peptic ulcer
25. Niacin MOA Decreases VLDL synthesis, inhibit
lipolysis, increases lipoprotein lipase
activity
26. Omega-3 Fatty Acids adverse - Belching 38. Statin Intolerance -Give original or lower dose to
effects - fishy taste mild-moderate establish causal relationship
- upset stomach symptoms if -If causal, give low dose of different
- back pain symptoms resolve statin
- diarrhea and increase dose as tolerated
*Do NOT recommend D/C statin in pt
27. Omega-3 Fatty Acids Known hypersensitivity to
who has mild to moderate symptoms
contraindications this drug
that resolve, after they resolve statin
28. Omega-3 Fatty Acids MOA Unknown mechanism, should be reinitiated
decrease triglycerides
39. Statin Intolerance discontinue and evaluate for
29. Other Lipid Lowering - Cholesterol absorption severe symptoms rhabdomyolysis
Therapies (6) inhibitor
40. Statin Intolerance - CPK
- Bile acid resin/sequestrant
severe symptoms - creatinine
- Niacin
Assess - urine analysis for myoglobinuria
- Fibric acid derivatives
- Omega-3 fatty acids 41. Statin Monitoring adherence
- Proprotein convertase Fasting lipid panel
subtilisin/kexin type 9 for
(PCSK9) inhibitors
42. Statins are pregnancy
30. Proprotein convertase - Evolocumab (Repatha) contraindicated in
subtilisin/kexin type 9 (PCSK9) - Alirocumab (Praluent)
inhibitors drugs
31. Statin Adverse effects - Muscle pain, tenderness,
weakness, fatigue
- Gastrointestinal
complaints
- Headache
32. Statin benefit groups 1. Clinical ASCVD
2. LDL ≥ 190
3. DM + 40-75 YO + LDL
70-189
4. 40-75 YO + LDL 70-189
33. Statin Contraindications - Pregnancy/Breastfeeding
- Liver disease
- Excessive alcohol
consumption
34. Statin Drug Interactions - Azole antifungals
- Erythromycin
- Cyclosporine
- Grapefruit juice
35. Statin Intolerance defined as Myopathy
36. Statin Intolerance mild- discontinue until able to
moderate symptoms evaluate
37. Statin Intolerance mild- Assess other causes that
moderate symptoms Assess might increase the risk
for muscle symptoms
(exercise)