1
Non pharm
Dash diet, exercise
For adults 40-75 without diabetes...
Calculate 10 yr ASCVD
low risk (<5%), borderline (5-7.5%), intermediate (7.5-20%), high risk (>20%)
Statins MOA and AE
HMG-CoA reductase inhibitor, cholesterol synthesis inhibitor
Myalgia, myopathy, rhabdomyolysis, hepatotoxicity
PCSK9 Inhibitors indication, MOA, and AE
Primary hyperlipidemia, secondary prevention of CV disease, HoFH
increases LDL recptors
Nasopharyngitis, injection site rxns, influenza
Lomitapide indication, MOA, AE
HoFH
MTP inhibitor, prevents assembly of apo-B
Hepatotoxicity, GI
Do we want to target a certain TG and HDL level?
No, does not demonstrate benefit
For diabetes, age 40-75...
Calculate 10 year ASCVD risk
if score is <20%, moderate intensity statin
if score is greater, high intensity
Statin monitoring
Fasting lipid panel 4-12 weeks after initiating, every 3-12 months maintenance
Liver function tests, repeat only if symptoms suggesting hepatotoxicity arise
creatine kinase, should not be routinely measured
Bempedoic acid indication, MOA, AE
Decrease LDL, artherosclerotic CV disease, HFH
ACL inhibitor, inhibits cholesterol synthesis
Hyperuricemia, gout, thrombocytopenia, tendon rupture
Mipomersen indication, MOA, AE
HoFH
Inhibitor of apo-B 100 synthesis, decreases LDL
Hepatotoxicity, injection site, flu-like
Goals of therapy (2 steps for medications)
Optimize statin therapy
consider non-statin lipid lowering agent if LDL goal is not achieved, TG>500 still, statin intolerance
How much does each statin intensity lower the LDL?
High: decrease at least 50%
Moderate: lowers 30-50%
Low: lowers by less than 30%
Ezetimibe indication, MOA, and AE
Primary hyperlipidemia, HoFH
Block cholesterol absorption via NPC1L1
myalgias, diarrhea, increased LFT
Fibrates indication, MOA, AE
Hypertriglyceridemia, mixed hyperlipidemia
Activation of PPAR alpha, increase of lipoprotein lipase
Nausea, diarrhea, gallstones, myalgia, myopathy, hepatotoxicity, renal impairment
Low intensity Statins
Pravastatin 10-20
Lovastatin 20
What is the indicator for primary hypercholesterolemia and what statin intensity should be started?
LDL>190
Start high intensity
What should we add if TG remains >500 while on optimal statin therapy?
fenofibrate, omega-3, niacin
D/C statin, evaluate possibility of rhabdomyolysis and other conditions that may cause muscle symptoms
Omega-3 FA MOA, AE
Inhibit the release of TG, reducing VLDL
Dyspepsia, belching, bleeding
Moderate intensity statin
Atorvastatin 10-20
Rosuvastatin 5-10
Simvastatin 20-40
Pravastatin 40-80
Lovastatin 40
Fluvastatin 40 BID
What is clinical ASCVD?
ACS, MI, angina, stroke, TIA, PAD, revascularization
What meds increase risk of myopathy when combined with statins?
fibrates, niacin, CYP3A4 inhibitors, red yeast rice
Bile acid sequestrants indication, MOA, AE, CI
Primary hyperlipidemia
Binds to bile acids, excreted through feces
Not well tolerated, GI, increased TG, take 1 hour before or 4 hours after other drugs
Avoid if TG>300
Niacin MOA, AE, Monitoring
Vitamin, inhibits FA release from adipose tissue
Dyspepsia, flushing (IR is worse), hepatotoxicity (OTC has decreased flushing but increased hepatotoxicity), increase uric acid, increase glucose, myalgia, myopathy
Baseline and every 6 months, LFTs, blood glucose, uric acid
High intensity statins
Atorvastatin 40-80
Rosuvastatin 20-40