MOA
Decreases the production of cholesterol by binding to HMG-COA reductase
Statins
Name 2 high-intensity statins/doses and what percentage do they lower LDL?
Atorvastatin 40-80mg
Rosuvastatin 20-40mg
50% or greater reduction
Name 3 examples of ASCVD.
Acute coronary syndrome (ACS)
MI
stable or unstable angina
coronary artery revascularization
stroke/TIA
Peripheral artery disease (PAD)
Name 2 counseling points for patients starting a statin?
Contact your MD if you have any muscle weakness, tenderness, aching or pain that happens without good reason.
Grapefruit and grapefruit juice can interact with this medication which can lead to higher statin concentrations.
This lipid lowering drug may increase blood glucose
Niacin
Statins
Inhibits absorption of cholesterol at the brush border in the small intestine
Ezetimibe
Which high intensity statin is preferred in renal dysfunction?
Atorvastatin (rosuvastatin dose is limited to 5mg daily when CrCl is less than 30)
What is the difference between primary and secondary prevention?
primary - effort to prevent/delay ASCVD in patients without a history
secondary - efforts to treat known ASCVD
Name a statin that should be taken with meals
lovastatin
This lipid lowering agent should NOT be used in patients with trigs >400.
Bile Acid Sequestrants
Decreases cholesterol by binding to bile acids in the GI preventing their reabsorption
Bile acid sequestrants
Name 2 moderate-intensity statin/doses and what percentage do they lower LDL?
Rosuvastatin 5-10mg
Simvastatin 20-40mg
Pravastatin 40-80mg
Lovastatin 40mg
Fluvastatin 40mg BID or XL 80mg
Pitavastatin 2-4mg
30-49% reduction
Omega 3 FA or fenofibrate (35-53% trig lowering)
Name 2 side effects to counsel a patient who is starting fish oil?
nausea/diarrhea/indigestion - take with food
Fishy taste/burp - try freezing capsules
This lipid lowering therapy should NOT be used in patients with active peptic ulcer disease.
Niacin
Binds to a protease and inhibits its function, resulting in higher levels of cholesterol receptor
PCSK9 inhibitor
Which two statins have the least amount of drug-drug interactions?
Rosuvastatin
Pravastatin
A 77 yr old Veteran has a PMH significant for DM, HTN, HLD, MI, and atrial fibrillation. His meds are the following - metformin 1000mg BID, apixaban 5mg BID, lisinopril 20mg daily, metoprolol succ 25mg daily, and rosuvastatin 5mg daily. His current labs are: LDL 83 (baseline 110), HDL 56, Trig 145, SrCr 1.1, eGFR 63. Is Veteran's current lipid therapy appropriate?
No - currently on moderate intensity statin, recommend increasing to high intensity statin dose 20mg/day
Which statins have to be taken at night?
Simvastatin, lovastatin (think SLeep)
How would you define the following:
- Myalgias
- Myopathy
Myalgias: muscle soreness and tenderness
Myopathy: muscle weakness +/- CPK elevations
Increases lipolysis through activation of the PPAR-alpha receptor
Fibrates
Name 2 low-intensity statins/doses and what percentage do they lower LDL?
Simvastatin 10mg
Pravastatin 10-20mg
Lovastatin 20mg
Fluvastatin 20-40mg daily
Pitavastatin 1mg
< 30% reduction
KX is a 72 yr old Veteran with a PMH of HTN, HLD, GERD. He currently smokes 0.25 ppd and denies alcohol use. He is on lisinopril 40mg daily, famotidine 40mg daily, pravastatin 10mg daily. His labs are: LDL 142, HDL 35, Trig 125, SrCr 1.2, eGFR 76. His ASCVD risk score is 32.8%. Would this patient be treated as primary or secondary prevention and given his ASCVD risk is his statin dose appropriate?
Primary prevention
ASCVD risk >20%, recommend consider high-intensity statin for >50% LDL reduction
Name 2 counseling points for patients taking a bile acid sequestrant?
Drink plenty of water and eat food with fiber as this medication can cause constipation.
Separate this medication from multivitamins since it can decrease the absorption of vitamin A, D, E, and K (providers may also recommend taking a multivitamin with this medication).
How would you define the following:
- Myositis
-Rhabdomyolysis
Myositis: muscle inflammation
Rhabdomyolysis: muscle symptoms with very high CPK (>10,000) and muscle protein in urine (myoglobinuria) which leads to renal failure