Term
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Definition
HMG-CoA reductase inhibitor;
Decreases LDLs the most (20-60%)
Starting dose:
10 mg PO qd or qHS
Range: 10-80 mg;
Major P450: 3A4;
Preg. Cat. X;
Has much longer T1/2 than other statins (reason for dosing at any time during day) |
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Term
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Definition
HMG-CoA reductase inhibitor;
Decreases LDLs the most (20-60%);
Starting dose:
40 mg PO qHS
Range: 20-80 mg qHS;
Major P450: 3A4;
Preg. Cat. X;
Dose qHS |
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Term
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Definition
HMG-CoA reductase inhibitor;
Decreases LDLs the most (20-60%;
Starting Dose:
40 mg PO qHS
Range:
10-80 mg qHS;
Major P450: NONE!!!
Dose qHS |
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Term
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Definition
HMG-CoA reductase inhibitor;
Decreases LDLs the most (20-60%);
Starting Dose:
5 mg PO daily or qHS
Range:
5-40 mg PO qd or qHS;
Major P450: 2C9/2C19;
Preg. Cat. X;
Longer half-life: can dose anytime during day; |
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Term
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Definition
Decreases LDLs the most;
Starting Dose:
20 mg PO qHS
Range:
20-80 mg PO qHS;
Major P450: 3A4
Preg. Cat. X
Dose qHS |
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Term
| ezetimibe (Zetia, Vytorin [w/ simvastatin]) |
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Definition
cholesterol absorption inhibitor;
decreases LDL by 15-20% - use in combo with statins;
Starting & Maintenance dose:
10 mg PO daily;
ADRs:
back & joint pain, diarrhea, abdominal pain, increase in LFTs (hepatotoxicity), rhabdomyolysis, myalgias, pancreatitis;
Drug Interactions:
-bile acid sequestrants (separate doses), cyclosporine;
Monitoring: LFTs, CK, adverse effects;
Comes in combo w/ simvastatin as well; |
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Term
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Definition
Bile acid sequestrant;
Decreases LDLs by 15-30%, no effect or possible INCREASE in TGs (C/I in pts w/ TGs >400 mg/dL);
Starting Dose (625 mg tabs):
3 tablets PO BID or 6 tablets PO once daily;
DOES NOT interfere with fat-soluble vitamin absorption;
Take with meals;
May decrease absorption of other drugs (cations);
Give other drugs either 1 hr before or 4-6 hrs after this agent; |
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Term
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Definition
PPAR-alpha agonist, lipoprotein lipase agonist;
Decreases TGs (20-50%), INCREASES HDL 10-20%, decreases LDLs (15-30%);
Starting dose:
600 mg PO BID - take 30 min before meals;
ADRs: GALLSTONES, GI upset, constipation, myalgias, increased LFTS;
C/I: severe renal or hepatic impairment;
Drug Interactions: increased risk of rhabdomyolysis w/ Statins; Warfarin, sulfonlyureas, repaglinide & rosiglitazone, & interactions with 1A2, 2C8/9, 2C19;
Monitoring: LFTs - baseline, 3 months, then yearly;
Reduce dose in renal impairment (CrCl<50 ml/min) |
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Term
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Definition
PPAR-alpha agonist, lipoprotein lipase agonist;
Decreases TGs (20-50%), INCREASES HDL 10-20%, decreases LDLs (15-30%);
Starting dose:
48-150 mg daily;
ADRs: GALLSTONES, GI upset, constipation, myalgias, increased LFTS;
C/I: severe renal or hepatic impairment;
Drug Interactions: increased risk of rhabdomyolysis w/ Statins; Warfarin, sulfonlyureas, repaglinide & rosiglitazone, & interactions with 1A2, 2C8/9, 2C19;
Monitoring: LFTs - baseline, 3 months, then yearly;
Reduce dose in renal impairment (CrCl<50 ml/min) |
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Term
| nicotinic acid/niacin IR (Niacor), ER (Niaspan), CR (Slo-Niacin) |
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Definition
niacin/vitamin B3 IR, ER, CR;
Decreases LDL (5-25%), decreased TG (20-50%), INCREASES HDL (15-35%) - not as much decrease in LDL as other products;
IR Starting dose:
250 mg PO daily w/ evening meals, increase to 1,500 mg-3,000 mg/day (MAX: 4,500 mg/day) - give BID-TID;
ER Starting dose:
500 mg PO qHS - titrated slowly (monthly intervals) up to 2,000 mg PO qHS;
CR Starting Dose:
250-500 mg daily, increase slowly to max of 2,000 mg/day;
C/Is: active or chronic liver dx, severe gout, pts w/ DM & PUD;
Drug Interactions: combined w/ statins --> increased risk of rhabdomyolysis &/or myopathy;
Monitoring: LFTs - baseline, q2-3 months then periodically, Glucose & Uric Acid levels - baseline, after 6-8 wks, yearly;
Take w/ food to minimize flushing & upset stomach; |
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Term
| omega-3-acid ethylesters (Lovaza) |
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Definition
fish oils;
Decreases TGs (40-50%), may INCREASE LDLs (30-40%);
Starting Dose:
2 grams PO BID or 4 grams PO daily;
ADRs: belching, taste perversion;
C/Is: fish allergy, may prolong bleeding time;
Drug Interactions: anticoagulants;
Monitor: LFTs periodically;
Approved for tx of hypertriglyceridemia (TG >=500 mg/dL;
Administer w/ meals; |
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Term
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Definition
imbalance of O2 supply & O2 demand in heart that leads to ischemia;
Ex: MI, angina, CABG, PTCA |
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Term
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Definition
dx of arteries where fatty plaques develop in inner walls & may eventually lead to either decreased blood flow or an obstruction of blood flow;
build-up of cholesterol, Ca, other wastes form plaques; |
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Term
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Definition
| therapy aimed at preventing 1st event (MI, stroke); pts who are considered high risk due to other risk factors but who do not have documented CHD |
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Term
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Definition
therapy that is aimed at preventing a 2nd event or subsequent event;
pts who already had an event (documented CHD or stroke) |
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Term
| Major Risk Factor for CHD |
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Definition
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Term
| Very Low Density Lipoprotein (VLDL) |
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Definition
precursor to LDL;
limited effect on atherosclerosis |
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Term
| Low Density Lipoprotein (LDL) |
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Definition
major source of atherosclerosis;
very rich in cholesterol |
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Term
| High Density Lipoprotein (HDL) |
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Definition
high levels of HDL may actually REDUCE athersclerosis;
it removes cholesterol from periphery and brings it to liver for breakdown |
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Term
| Familial Hypercholesterolemia (FH) |
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Definition
severely eleveated LDLs;
Homozygotes - CHD events by age 20;
- few or NO LDL receptors
- very elevated LDLs & TC = 650-1000 mg/dL
Heterozygotes - CHD events b/w age 30-50;
have 50% of normal qty of LDL receptors
elevated LDL levels & TC = 350-550 mg/dL |
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Term
| Familial Hypertriglyceridemia |
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Definition
| severely elevated TG levels |
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Term
| Familial Combined Hyperlipidemia (FCHL) |
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Definition
linked w/ increased risk of vascular dx;
may have elevated cholesterol, TGs, or both |
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Term
| 2nday causes of Hypercholesterolemia (elevated LDL levels) |
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Definition
| hypothyroidism, obstructive liver dx, nephrotic syndrome, anorexia nervosa, drugs - progestins, thiazide diuretics, glucocorticoids, Beta-blockers, isotretinoin, protease inhibitors, cyclosporine, sirolimus, mirtazapine |
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Term
| Step 1 - Detection & Evaluation |
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Definition
Starting at 20 yrs old:
- all pts should get fasting lipid panel every 5 years;
FLP:
- done after 12 hr fast, results include: total cholesterol (TC), LDL, HDL, triglycerides (TG);
Primary Target of Therapy: LDL cholesterol;
- elevated LDL are major cause of CHD
- lowering LDL reduces risk of CHD
- if TG >500 mg/dL --> more at risk for pancreatitis |
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Term
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Definition
= TC - HDL - (TG/5)
TG/5 = VLDL
CAN NOT use this formula if TG >400 mg/dL |
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Term
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Definition
<200 = desirable;
>= 240 = HIGH |
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Term
| LDL Cholesterol - Primary Target of Therapy |
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Definition
<100 = OPTIMAL
>= 190 = VERY HIGH |
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Term
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Definition
<40 = LOW (bad)
>= 60 = HIGH (good) |
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Term
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Definition
<150 = normal;
>= 500 = VERY HIGH |
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Term
| Step 2- Identify Presence of CHD or CHD Risk Equivalents |
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Definition
Need to determine if pt already HAS CHD or other dx states which confer HIGH RISK for CHD;
CHD: history of MI, angina, CABG, angioplasty, etc.;
CHD Risk Equivalents:
-peripheral arterial dx (PAD)
-abdominal aortic aneurysm
-carotid artery dx (TIA, stroke)
-diabetes
-multiple risk factors + 10 yr risk of >20% based on Framingham |
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Term
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Definition
PAD;
abdominal aortic aneurysm;
carotid artery dx;
diabetes;
multiple risk factors + 10 yr risk of >20% based on Framingham |
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Term
| Step 3 - Determine Presence of Major Risk Factors (other than LDL) |
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Definition
Major Risk Factors:
-current cigarette smoking
-HTN (BP>140/90) or taking BP-lowering meds;
-low HDL level (<40)
-family hx of premature CHD;
-age: men>45 yrs, women>55 yrs |
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Term
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Definition
| considered a negative risk factor for for CHD --> can "take away" one of the other risk factors from total count |
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Term
| Positive Family History of Premature CHD |
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Definition
1st degree relative that HAS HAD an actual CHD event that has occurred before the age of:
males: <55 yrs old;
females: <65 yrs old; |
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Term
| Step 4 - Assessing 10 yr CHD risk (Framingham scores) |
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Definition
If pt has >= 2 risk factors, you need to calculate this;
If pt already HAS CHD or a CHD risk equivalent, this can be SKIPPED;
If pt has <= 1 risk factor, SKIP this step |
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Term
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Definition
a calculated risk for a specific pt;
Identifies what pt's risk is for developing a cardiac event in the next 10 yrs |
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Term
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Definition
>20% = CHD risk equivalent;
10-20% = moderate to high risk for CHD event;
<10% = lower risk for CHD event |
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Term
| Step 5 - Determining Goals of Therapy and Need for Treatment |
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Definition
Determine pt's goal LDL;
Determine whether pt needs therapeutic lifestyle changes;
Determine whether pt needs drug therapy;
Optional goals:
- more aggressive LDL lowering may be beneficial;
- especially true in very high risk individuals;
- based on clinical judgment & specific pt scenarios |
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Term
| LDL Goal for pts w/ CHD or CHD risk equivalent (Framingham >20% 10-yr risk) |
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Definition
<100 mg/dL;
Optional: <70 mg/dL;
When to start TLC: >=100 mg/dL
When to start drugs: >=100 mg/dL |
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Term
| LDL goal for Pts w/ >=2 risk factors (Framingham: <=20% 10-yr risk) |
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Definition
<130 mg/dL;
Optional (10-20%): <100 mg/dL;
When to start TLC: >=130 mg/dL;
When to start drugs:
-10 yr risk 10-20% = >=130 mg/dL;
-10 yr risk <10% = >=160 mg/dL; |
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Term
| LDL goal for pts w/ 0-1 risk factors |
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Definition
<160 mg/dL;
When to start TLC: >= 160 mg/dL
When to start drugs: >=190 mg/dL |
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Term
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Definition
Initiated based on pt's risk category, goal LDL, & current lipid parameters;
Initiate when:
- CHD or CHD risk equivalents & LDL >=100 mg/dL;
- 2+ risk factors & 10-yr risk of 10-20% and LDL >=130 mg/dL;
- LDL levels are >30 mg/dL ABOVE goal LDL;
- pts STILL ABOVE LDL goal after 3 months of TLC |
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Term
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Definition
| decrease LDL (Best at it - 50-60% reduction) |
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Term
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Definition
| decrease LDLs by 25-30% (but big "horse" pills) |
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Term
|
Definition
|
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Term
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Definition
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Term
| Calculating Pt's LDL reduction to determine Goal LDL for therapy |
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Definition
| % reduction = (current LDL - goal LDL)/current LDL x 100 |
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Term
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Definition
HMG-CoA reductase inhibitor;
Decreases LDLs the most (20-60%);
Starting Dose:
20 mg PO qHS
Range:
20-80 mg PO qHS;
Major P450: 2C9;
Preg. Cat. X;
Dose qHS |
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Term
| Adverse Effects of Statins |
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Definition
myalgias;
GI upset (very minor);
HA;
Rhabdomyolysis (VERY RARE);
LFT elevations (hepatotoxicity) |
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Term
| Drugs that Inhibit P450 CYP3A4 - Drug interactions with atorvastatin (Lipitor), lovastatin (Mevacor), and simvastatin (Zocor) |
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Definition
erithromycin, clarithromycin - switch to azithromycin or hold while on antibiotic;
grapefruit juice, azole antifungals, amiodarone, diltiazem, verapamil, protease inhibitors (ritonavir) --> increased risk of rhabdomyolysis;
Inducers: rifampin, St. John's wort |
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Term
| Monitoring Parameters for Statins |
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Definition
LFTs - baseline, after 12 wks, and annually; D/C drug if LFTs >3x UNL;
CK - baseline & when pt experiences muscle pain, tenderness, weakness; D/C drug if CK >10x UNL;
Adverse Effects |
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Term
| Step 6 - Therapeutic Lifestyle Changes |
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Definition
Diet: reduce saturated fat intake (<7% of total cals/day), cholesterol <200 mg/day, increases soluble fiber intake, increase plant stanols/sterols;
Weight Management - healthy lifestyle, gradual weight loss;
Increase physical activity - start slow, increase gradually; aerobic in nature x30 min - most days of wk; increase activity of normal daily tasks;
Smoking Cessation - major independent risk factor for CHD, quitting reduces CHD risk within months, Smoking is source of lipid abnormalities (low HDL) |
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Term
| Practical Tips to tell Pts about TLCs |
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Definition
Teach how to read nutrition labels;
Avoid fast food;
Decrease or eliminate red meat;
No fried foods;
Remove skin from poultry;
Whole wheat or increase veggie intake;
Skim or low-fat dairy products; |
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Term
| cholestyramine (Questran, Questran Light, Prevalite) |
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Definition
bile acid sequestrant;
Decreases LDL 15-30%, no effect/possible INCREASE in TGs (C/I in pts w/ TGs >400 mg/dL;)
Starting dose:
4-24 g/day in multiple doses (BID to 6x/day);
May decrease absorption of other drug: give other drugs either 1 hr before or 4-6 hrs after this agent;
Mix correct dose w/ 4-6 oz of fluids until uniform suspension & drink. Rinse glass with more fluids & drink again;
Fat soluble vitamines, folic acid iron, & Ca may need to be supplemented;
May contain aspartame; |
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Term
| colestipol (Colestid - powder packets & tabs) |
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Definition
bile acid sequestrant;
Decreases LDL 15-30%, no effect/possible INCREASE in TGs (C/I in pts w/ TGs >400 mg/dL);
Starting Doses:
5-30 g/day (BID to QID);
May decrease absorption of other drugs: give other drugs either 1 hr before or 4-6 hrs after this agent;
Mix correct dose w/ 4-6 oz of fluids until uniform suspension & drink. Rinse glass w/ more fluids & drink again;
Fat soluble vitamins, folic acid, iron, & Ca may need to be supplemented;
May contain aspartame; |
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Term
| Adverse Effects of Bile Acid Sequestrants |
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Definition
| GI upset; N/V; bloating; constipation; abdominal pain |
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Term
| Adverse Effects of Nicotinic Acid |
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Definition
| flushing; hyperglycemia; hyperuricemia; GI upset; hepatotoxicity; |
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Term
| Progression of Drug Therapy |
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Definition
Initiate LDL-lowering drug therapy: statins are preferred but bile-acid sequestrants, ezetimibe, & nicotinic acid are options;
After 6-12 wks, check a lipid panel: if LDL is not at goal, intensify drug therapy by increasing dose of statin or adding other agents;
After another 6-12 wks, check a lipid panel: if LDL is NOT at goal - intensify drug therapy, if LDL is AT GOAL - treat other lipid risk factors;
Every 4-6 months, monitor response & adherence |
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Term
| Step 8 - Identifying Metabolic Syndrome |
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Definition
AKA - Syndrome X, Insulin Resistance Syndrome;
Causes: obesity, physical inactivity, high carb diet, family history;
Diagnosed after 3 months of TLC;
Treat as 2ndary target of therapy;
To Identify:
- abdominal obesity
- TGs >=150 mg/dL OR taking med for high TG;
- Low HDLs OR taking meds for low HDL;
- higher blood pressure (systolic BP >130 OR diastolic >85) OR taking HTN med
- fasting glucose >=100 mg/dL OR taking DM meds; |
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Term
| Treatment Options for Metabolic Syndrome |
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Definition
Treat underlying causes:
- weight reduction plans
- exercise regimens
Treat lipid & non-lipid risk factors:
- tx HTN if present
- use aspirin in CHD pts to minimize thrombotic events
- treat elevated TGs and/or low HDL |
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Term
| Step 9: Treat Elevated TGs |
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Definition
If levels are:
150-199 mg/dL --> primary target is LDL goal;
200-499 mg/dL --> Intensify lipid therapy, weight management, & physical activity; IF >200 mg/dL after LDL goal reached, set 2ndary target of non-HDL;
>=500 mg/dL --> very high - HIGH RISK OF PANCREATITIS --> Use a fibrate, nicotinic acid, or omega-3-acid; VERY low-fat diet; Intensify weight reduction & exercise; Avoid alcohol |
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Term
| Possible Causes of Hypertriglyceridemia |
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Definition
| TYPE 2 DIABETES MELLITUS; obesity; physical inactivity; pregnancy; acute hepatitis; lupus; nephrotic syndrome; genetic disorders; |
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Term
| Drugs that Cause Hypertriglyceridemia |
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Definition
| ALCOHOL CONSUMPTION; bile acid sequestrants; estrogens; isotretinoin; beta-blockers; thiazide diuretics; glucocorticoids; interferons |
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Term
| Non-HDL cholesterol as a 2ndary goal of therapy |
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Definition
if TG >=200 AFTER LDL goal is reached, set a 2ndary goal of non-HDL cholesterol & target therapy to reach that goal;
Non-HDL cholesterol = VLDL + LDL cholesterol = (Total cholesterol - HDL) |
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Term
| Heart Protection Study (HPS) |
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Definition
Study that lookes at pts w/ high risk for CV event (pts w/ hx of CHD, arterial dx, or DM);
Therapy: simvastatin 40 mg qHS vs. placebo;
Results:
- decrease in all-cause mortality;
- decrease in coronary death, MI, stroke, revascularization;
Found:
- pts w/ DM & CHD at very high risk
- most pts benefited from statin therapy
Discussion:
- support to consider using AGGRESSIVE therapy in pts w/ DM & CHD (very high risk): optional goal LDL <70 mg/dL |
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Term
| ASCOT-LLA (Anglo-Scandinavian Cardiac Outcomes Trial-Lipid Lowering Arm) |
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Definition
Study that looked at pts at moderately high risk: multiple CV risk factors but NO history of CHD or DM;
Therapy: atorvastatin 10 mg daily vs. placebo;
Results:
- significant decreases in MI, CHD death, & stroke;
Benefits in pts even if baseline LDL <130 mg/dL;
Conclusions:
Pts at moderately high risk could benefit from an optional LDL goal of <100 mg/dL |
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Term
| PROVE-IT (Pravastatin or Atorvastatin Evaluation & Infection Therapy) |
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Definition
Study that looked at pts hospitalized w/ acute coronary syndrome;
Therapy: atorvastatin 80 mg vs. pravastatin 40 mg;
Looked at difference b/w intensive therapy & standard therapy;
Results:
- atorvastatin: mean LDL = 62 mg/dL;
- pravastatin: mean LDL = 95 mg/dL;
- composite endpoint of mortality, MI, unstable angina, or revascularization was DECREASED by 16% in atorvastatin vs. pravastatin;
Conclusions:
- aggressive therapy w/ high dose statins provides additional benefits, option for pts with RECENT MI or unstable angina |
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Term
| TNT (Intensive Lipid Lowering w/ Atorvastatin in Pts w/ Stable Coronary Dx) |
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Definition
Study that looked at pts w/ established CHD (previous MI, previous/current angina or past revascularization);
Therapy: 10 mg atorvastatin vs. 80 mg atorvastatin;
Looked at differences b/w intensive therapy & standard therapy;
Results:
- 80 mg mean LDL = 77 mg/dL;
- 10 mg mean LDL = 101 mg/dL;
- composite endpt of death from CHD, nonfatal MI, cardiac resuscitation, or stroke was DECREASED by 22%;
Conclusions:
- aggressive therapy w/ high dose statins may benefit pts w/ hx of CHD |
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