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CC Nov 2017 Non-statin therapy for hyperlipidemia

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echoecho's version from 2017-11-27 15:49

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Question Answer
*** In 2014, the American College of Cardiology and the American Heart Association released new guidelines for the treatment of elevated cholesterol?1) age 40-75 years old 2) presence of one or more risk factors (hyperlipidemia, DM, HTN, smoking) 3) calculated 10-year risk of CVD of > 10% 4) there is some benefit as well if the 10-year risk is between 7.5 - 10% 5) treatment is recommended if the LDL > 190 regardless of other risk factors 6) first-line treatment for all individuals is statin therapy with intensity of therapy delineated by the algorithm in the guideline
A significant proportion of patients are intolerant to statin therapy (due to myalgia). In 2016, the ACC released a guideline relateding the use of non-statin therapy in the management of ASCVD risk, true or false?true
*** List the lifestyle modifications that are recommended for all patients?1) exercise 2) smoking cessation 3) weight loss 4) dietary modification
*** List other interventions that can be helpful?1) plant sterols (mechanisms of action not fully known) 2) increased ingestion of soluble fiber that traps cholesterol and bile acids in the small intestine
Comment on the actual LDL reductions?are modest and studies are not available regarding long-term cardiovascular outcomes
*** If a patient has not reached > 50% reduction in LDL on maximally tolerated statin and is inherent to medications and lifestyle changes, a physician-patient discussion should occur regarding the possible use of non-statin agent. List what the discussion should include?1) potential for further reduction in ASCVD risk with the addition of another agents 2) the potential for adverse reactions or drug-to-drug interactions with the addition of another agent 3) patient preference 4) cost
List the the pharmaceutical interventions that are non-statins?1) ezetimibe (Zetia) 2) proprotein convertase subtilisin / Kevin type 9 (PCSK9) inhibitors and bile acid sequesters. PCSK9 inhibitors available in the US include alirocumab (Praluent) and evolocumab (Repatha)
List the mechanism, mean % LDL reduction, adverse events, cardiovascular outcomes and available agents regarding Ezetimibe?1) mechanism = reduces cholesterol absorption in small intestines 2) mean % LDL reduction = 18% as monotherapy and 25% with statin 3) adverse effects = upper respiratory infection, arthralgia, diarrhea 4) cardiovascular outcomes = with statin, lowered LDL and showed modest additional reduction in CV death, non-fatal MI, coronary revascularization, nonfatal stroke 5) available agents = Zetia
List the mechanism, mean % LDL reduction, adverse events, cardiovascular outcomes and available agents regarding PCSK9 inhibitors?1) mechanism = binds to PCSK9 and increases number of LDL receptors available to clear LDL 2) mean % LDL reduction = 45-64% reduction with statin depending on agent and dosing regimen 3) adverse effects = nasopharyngitis, injection site reactions 4) cardiovascular outcomes = studies currently in progress; current evidence shows little or no difference in mortality although studies were in high-risk patients 5) available agents = Alirocumab (Praluent), Evolocumab (Repatha)
List the mechanism, mean % LDL reduction, adverse events, cardiovascular outcomes and available agents regarding bile acid sequestrants ?1) mechanism = binds bile acids with multiple biochemical changes eventually resulting in increased LDL clearance 2) mean % LDL reduction = 10-15% reduction as monotherapy depending on agent; no studies with statins 3) adverse effects = constipation, dyspepsia, nausea 4) cardiovascular outcomes = risk reduction 19% for coronary heart disease and nonfatal myocardial infarction as monotherapy; effects on cardiovascular morbidity and mortality have not been determined 5) available agents = colesevelam (Welchol), cholestyramine (Questran)
Fibrates (Gemfibrozil (Lopid)) are not recommended for LDL reduction in the absence of hypertriglyceridemia, true or false?true
What is the increased risk when fibrates (Gemfibrozil) is added to statin therapy, comment on all cause or cardiovascular mortality?1) increased risk of rhabdomyolysis 2) has not been found to reduce all-cause or cardiovascular mortality
While niacin can lower LDL, comment on this?1) rarely used 2) poorly tolerated
As monotherapy, what is the niacin' effect on LDL cholesterol?modest
Is there any evidence of benefit, and possible increased risk with the addition of niacin to statin therapy?no
In 2016 guideline, what affects the decision about which non-statin therapy to offer?depends on patient's clinical status, LDL level and presence of absence of comorbidities
Non-statin therapy is a consideration after what criteria are met?1) the maximally tolerated statin does not achieve the goal of > 50% reduction in LDL 2) after discussion of potential benefits and risks with the patient
What is the first line choice and the second choice of a nonstatin therapy in a patient with stable ASCVD without comorbidites (secondary prevention)?1) first choice = Ezetimibe 2) second line choice = if goal LDL not met, consider adding or replacing with PCSK9 inhibitor
What is the first line choice and the second choice of a nonstatin therapy in a patient with clinical ASCVD with comorbidites (secondary prevention)?1) first choice = Ezetimibe 2) second line choice = if goal LDL not met, consider adding or replacing with PCSK9 inhibitor
What is the first line choice and the second choice of a nonstatin therapy in a patient with clinical ASCVD with baseline LDL > 190 mg/dL not due to secondary cause (secondary prevention)?1) first choice = Ezetimibe OR bile acid sequestrant if tgl are < 300 OR PSCK9 inhibitor 2) second line = if LDL goal not met with addition of one non-statin agent, a second non-statin agent can be considered
What is the first line choice and the second choice of a nonstatin therapy in a patient with NO ASCVD but LDL > 190 mg/dL with or without ASCVD risk factors (primary prevention)?1) first choice = Ezetimibe OR PSCK9 inhibitors 2) second choice = BAS can be considered as second line agent if tgl are < 300 mg/do. If ezetimibe is not tolerated, PSCK9 inhibitor is a better choice as alternative agents in view of efficacy
What is the first line choice and the second choice of a nonstatin therapy in a patient with NO ASCVD, aged 40-75 years, with diabetes and LDL 70-189 mg/dL (primary prevention)?1) first choice = Ezetimibe 2) BAS if tgl are < 300 mg/dL; PSCK9 inhibitors have NO role
What is the first line choice and the second choice of a nonstatin therapy in a patient with NO ASCVD or diabetes, aged 40-75 years and LDL 70-189 mg/dL but estimated 10-year ASCVD risk > 7.5% (primary prevention)?1) first choice = Ezetimibe 2) BAS are second-line agents if tgl are < 300 mg/dL; PSCK9 inhibitors NOT indicated due to lack of safety and efficacy data
*** SUMMARY = What 3 medications may be considered when LDL cholesterol reduction is not adequate?1) Ezetimibe (Zetia) 2) proprotein convertase subtilisin / Kevin type 9 (PSCK9) inhibitors 3) bile acid sequestrants
*** SUMMARY = Are fibrates and niacin recommended as add-on medications to statin therapy?no
*** SUMMARY = What 4 considerations should go into the decision to add a non-statin agent?1) consider the potential benefits of additional LDL lowering 2) potential for adverse drug reactions 3) drug-to-drug interactions 4) patient preference
*** SUMMARY = What is the only medication that currently has evidence demonstrating benefit when added to statin therapy?1) Ezetimibe (Zetia)
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