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What is the step-wise process for treating hyperlipidemia?
- 1. determine lipoprotein levels
- 2. identify CHD or CHD risk equivalent
- 3. determine presence of major risk factors other than LDL
- 4. if 2+ risk factors w/out CHD or equivalent, assess 10-yr CHD risk
- 5. determine risk category: establish LDL goal, determine need for TLC or drug tx
- 6. initiate therapeutic lifestyle changes
- 7. consider adding drug tx
- 8. identify metabolic sndrome and treat, if present, after 3 mo TLC
- 9. treat elevated TG
- 9a. treat low HDL
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How do you calculate non-HDL level?
TC - HDL = non-HDL
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What is the non-HDL goal?
30 mg/dl above LDL goal
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When is non-HDL used?
when TG between 200 - 499 and LDL goal has been reached
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What do you do if TG > 500?
treat TG first to prevent pancreatitis, then treat LDL
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When should TG levels be checked?
on a 12h fast
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List the order of potency of statins from highest to lowest.
- Pitavastatin
- Rosuvastatin
- Atorvastatin
- Simvastatin
- Lovastatin
- Pravastatin
- Fluvastatin
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What is the goal for total cholesterol?
< 200
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What is the goal for LDL?
< 160
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What is the goal for HDL?
- > 40
- > 50 for diabetic females
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What is the goal for TG?
< 150
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What is considered clinical CHD?
- MI
- unstable angina
- chronic stable angina
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What are CHD equivalents?
- symptomatic carotid artery disease
- peripheral artery disease
- diabetes
- FR > 20%
- abdominal aortic aneurysm
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What are the major risk factors other than LDL for CAD?
- cigarette smoking in past month
- HTN (even if controlled by meds)
- low HDL
- 45 yo or more male
- 55 yo or more female
- premature menopause w/o HRT
- family hx of premature CAD (AMI or sudden death 55 or less in males, 65 or less in females)
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If pt has CAD or CAD risk equivalent, what is the goal LDL?
<100
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If pt has 2+ CAD risk factors, what is the LDL goal?
< 130
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If pt has 0-1 CAD risk factor, what is the LDL goal?
< 160
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What are the risk factors for metabolic syndrome?
- > 40 in waist in males
- > 35 in waist in females
- TG 150 or more
- HDL < 40
- BP 130/85 or higher
- fasting glucose 110 or higher
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What is first-line tx for high TC and LDL?
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What is first-line tx for high TC, LDL, and TG?
- Niacin if TG > 400
- Statin if TG < 400
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What is first-line tx for high TC, LDL, and TG with low HDL?
- niacin (nondiabetic)
- statin (diabetic)
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What is first-line tx for high TG?
- fibric acid (better tolerated than niacin)
- niacin
- lovaza
- statin (if < 400)
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What is first-line tx for high TG with low HDL?
- fibric acid (better tolerated than niacin)
- niacin
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What is first-line tx for low HDL?
- fibric acid (better tolerated than niacin)
- niacin
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What are the names of the bile acid resins (BAR)?
- cholestyramine 4g QD-BID
- colestipol 1-2g BID
- colesevelam 3 625mg tabs BID
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What are the effects of BAR on lipids?
- decrease LDL
- increase HDL
- increase TG
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What are the side effects of BAR?
- nausea
- constipation
- bloating
- flatulance
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What are the DI of BAR?
can form complexes with other drugs, decreasing their absorption
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What is the place in tx for BAR?
adjunct to statins when further LDL lowering is needed
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What are the names of niacin products?
- immediate release (niacor) 250mg BID
- intermediate release (niaspan) 500mg QHS
- sustained release (nicobid) 250mg BID
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At what point is there no added benefit by increasing niacin doses?
above 2g
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What are the effects on lipids of niacin?
- decrease LDL
- decrease TG
- increase HDL
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What are the SE of niacin?
- flushing
- NVD
- dyspepsia
- hyperuricemia
- hyperglycemia
- myopathy
- hepatotoxicity
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What should be monitored for niacin?
- AST/ALT baseline, 8-12 wks after dose changes, then q 6mo
- fasting plasma glucose baseline, then periodically (more if diabetic)
- uric acid (if gout present)
- CPK baseline, then if myopathy suspected
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What are the names of the fibric acids?
- fenofibrate 145mg QD
- micronized fenofibrate 200mg QD
- fenofibric acid 135mg QD
- gemfibrozil 600mg BID
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What are the effects of fibric acids on lipids?
- decrease TG
- increase HDL
- minimal effect on LDL
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What are the SE of fibric acids?
- N,D
- Myopathy (gemfibrozil worst)
- gall stones
- hepatotoxicity
- neutropenia
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What should be monitored for fibric acids?
- AST/ALT baseline, 8-12 wks, then q 6mo
- CPK baseline, then if suspect myopathy
- renal fx baseline and periodically
- CBC
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What is the place in tx for fibric acids?
first line for high TG and/or low HDL
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What are the names of the statins?
- pitavastatin 2mg
- rosuvastatin 5mg
- atorvastatin 10mg
- simvastatin 20mg
- lovastatin 40mg
- pravastatin 40mg
- fluvastatin 60mg
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What is the effect on lipids of statins?
- decrease LDL
- decrease TG (only rosuvastatin, atorvastatin, simvastatin)
- increase HDL
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What are the SE of statins?
- myopathy
- hepatitis
- insomnia
- vivid dreams
- difficulty concentrating
- proteinuria/hematuria
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What should be monitored for statins?
- AST/ALT baseline, 12 wks, then q 6mo
- CPK baseline then if suspect myopathy
- renal fx baseline
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What is the effect on lipids of ezetimibe?
- decrease LDL
- decrease TG (minimal)
- increase HDL (minimal)
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What are the SE of ezetimibe?
- Diarrhea
- abdominal pain
- increased transaminases (in combo with statins)
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What are the DI of ezetimibe?
fibric acids (increased risk of gall stones)
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What should be monitored for ezetimibe?
AST/ALT (if on a statin too)
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What is the place in tx for ezetimibe?
- adjunct to statins for decreasing LDL
- familial hypercholesterolemia
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What is the effect on lipids of Omega-3s?
decrease TG
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What are the SE of Omega-3s?
- fishy burp (take w/food to improve)
- dyspepsia
- taste perversion
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What is the place in tx for Omega-3s?
- tx of TG>500
- adjunct to statins to lower TG
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