Dyslipidemia Tutoring By Alaina Darby

KN, a 42 year-old male, has gained 40 pounds over the last 5 years since he injured his left knee and can no longer play basketball. He has a sedentary lifestyle including a job that requires him to be at a desk all day. He has tried the Atkins diet, South Beach diet, and many other popular diets but has gained the weight back. KN does not smoke and admits to having 1-3 alcoholic beverages per month. Lifestyle modifications have been inadequate in controlling his weight gain.      Allergies:  NKDA Vitals:  Height: 5'11"                   Weight: 225 lbs  BP: 140/80 mmHg           HR: 85 BPM             RR: 20 BPM  Temp: 98.6ºF                   Pain: 1/10        Current Medications:  Vasotec 10 mg daily  Norvasc 10 mg daily  Glucophage 850 mg BID  Claritin 10 mg daily  Tylenol 500 mg Q4-6H PRN  MVI daily      Past Medical History:  Allergic rhinitis  Dyslipidemia  Diabetes mellitus Hypertension      D

4/14 Labs: AST (units/L) = 37 (10 - 40) ALT (units/L) = 32 (10 - 40) CH, T (mg/dL) = 247 (125 - 200) TG (mg/dL) = 242 ( < 150) HDL (mg/dL) = 34 ( > 40) LDL (mg/dL) = 183 ( < 100) GLU (mg/dL) = 108 (65 - 99) Na (mEq/L) = 143 (135 - 145)                      K (mEq/L) = 4.1 (3.5 - 5)                             Cl (mEq/L) = 102 (95 - 103)                         HCO3 (mEq/L) = 26 (24 - 30)                       BUN (mg/dL) = 15 (7 - 20)                          SCr (mg/dL) = 0.8 (0.6 - 1.3)                 Mg (mEq/L) = 1.8 (1.3 - 2.1) PO4 (mg/dL) = 4.1 (2.3 - 4.7) Ca (mg/dL) = 9.7 (8.5 - 10.5) TSH (mIU/L) = 2.2 (0.3 - 3.0) Hgb A1C = 7.9% (4 - 6%)     10/9 Labs:  AST (units/L) = 168 (10 - 40) ALT (units/L) = 145 (10 - 40) CH, T (mg/dL) = 224 (125 - 200) TG (mg/dL) = 218 ( < 150) HDL (mg/dL) = 35 ( > 40) LDL (mg/dL) = 145 ( < 100) GLU (mg/dL) = 108 (65 - 99) Na (mEq/L) = 142 (135 - 145)                       K (mEq/L) = 4.2 (3.5 - 5)                            Cl (mEq/L) = 97 (95 - 103)                        HCO3 (mEq/L) = 29 (24 - 30)                       BUN (mg/dL) = 18 (7 - 20)                          SCr (mg/dL) = 0.9 (0.6 - 1.3)                Mg (mEq/L) = 1.9 (1.3 - 2.1) PO4 (mg/dL) = 4.3 (2.3 - 4.7) Ca (mg/dL) = 9.5 (8.5 - 10.5) TSH (mIU/L) = 1.8 (0.3 - 3.0) Hgb A1C = 7.7% (4 - 6%)    

C. Atorvastatin 40 mg daily D. Pravastatin 20 mg daily KN's estimated 10-year ASCVD risk is calculated at 6.9%. According to the ACC/AHA Treatment of Blood Cholesterol Guideline, what would be the most appropriate statin regimen to initiate on the 4/14 visit? A. Simvastatin 10 mg daily B. Simvastatin 40 mg daily C. Atorvastatin 40 mg daily D. Pravastatin 20 mg daily E. Pravastatin 40 mg daily E KN has diabetes, is between 40-75 years, has an LDL between 70-189 mg/dL, and an estimated 10-year ASCVD risk < 7.5%. Therefore he will require a moderate intensity statin. Although simvastatin 40 mg is considered moderate intensity, KN is also on amlodipine and should not exceed simvastatin 20 mg due to CYP3A4 interaction. Therefore, pravastatin 40 mg is the most appropriate statin. All other choices are not moderate intensity.

C. Discontinue statin therapy D. Add a bile acid sequestrant Assuming the patient is now taking a statin, what intervention would be most appropriate on the 10/9 visit?   A. Increase statin dose B. Decrease statin dose C. Discontinue statin therapy D. Add a bile acid sequestrant E. Add niacin C AST or ALT levels are elevated and statin therapy should be discontinued when LFTs are greater than 3 times the upper limit of normal.

A patient is started on Lipitor 20 mg daily A patient is started on Lipitor 20 mg daily. According to the ACC/AHA Blood Cholesterol Guidelines, when should the lipid panel be checked? A. In 1-2 weeks B. In 3-4 weeks C. In 4-6 weeks D. In 4-12 weeks E. In 6-12 months D

A. Assess ASCVD risk by using the Global Risk Assessment tool. Tyrone Marshall, a 51 year-old male, is being seen for a routine physical exam. His past medical history is significant for hypertension and a previous ischemic stroke. Which of the following actions would be in accordance with the ACC/AHA Blood Cholesterol Guidelines?   A. Assess ASCVD risk by using the Global Risk Assessment tool. B. Check a lipid panel to decide if Mr. Marshall should be started on statin therapy. C. Initiate Crestor (rosuvastatin) 20 mg daily. D. Initiate Lipitor (atorvastatin) 20 mg daily. E. Mr. Marshall does not need to be started on statin therapy at this time. Reassess in 5 years. C

Allergies: penicillin Past Medical History: As per HPI Medications: SP is a 58 year old African-American female with hypertension, atrial fibrillation, NYHA Class II heart failure, history of ovarian cancer (treated with chemo 12 years ago), and dyslipidemia. She presents to a new PCP on 8/15 with complaints of pain in her left great toe, along with redness and warmth. Allergies: penicillin Past Medical History: As per HPI Medications: Toprol XL 50 mg PO daily, amiodarone 200 mg PO daily, Lasix 40 mg daily, Diovan 160 mg daily, Zocor 40 mg daily, and Caltrate 600+D 1 tablet BID and aspirin 81 mg PO daily  Physical Exam / Vitals:  Height: 5’5”  Weight: 179 pounds  BP: 150/95 mmHg  HR: 70 BPM   RR: 14 BPM  Temp: 97.8°F  Pain: 2/10 8/15 Labs: Na (mEq/L) = 137 (135 – 145)   A1C (%) = 5.8                          K (mEq/L) = 3.8 (3.5 – 5)     AST (IU/L) = 17 (10 – 40)  Cl (mEq/L) = 102 (95 – 103)       ALT (IU/L) = 13 (10 – 40)  HCO3 (mEq/L) = 27 (24 – 30)   LDL (mg/dL) = 132           BUN (mg/dL) = 15 (7 – 20)           HDL (mg/dL) = 22             SCr (mg/dL) = 0.9 (0.6 – 1.3)       TG (mg/dL) = 160                  Glucose (mg/dL) = 120 (100 – 125) Ca (mg/dL) = 9.1 (8.5 – 10.5) Mg (mEq/L) = 1.5 (1.3 – 2.1)             PO4 (mg/dL) = 3.9 (2.3 – 4.7) D

A. Rosuvastatin 20 mg daily B. Pravastatin 20 mg daily SP's 10-year ASCVD risk is found to be 17% and the ambulatory care pharmacist assesses her current statin therapy for appropriateness. Which of the following regimens would be appropriate for this patient? (Select ALL that apply).   A. Rosuvastatin 20 mg daily B. Pravastatin 20 mg daily C. Lovastatin 20 mg daily D. Atorvastatin 20 mg daily E. Continue simvastatin 40 mg daily AD SP is between the ages of 40 and 75 with an ASCVD risk > 7.5%, LDL is between 70 and 189; she is not diabetic. She should receive moderate to high intensity statin therapy; however, with amiodarone the maximum dose of simvastatin is 20 mg. Rosuvastatin or atorvastatin 20 mg would provide the appropriate intensity while avoiding the drug interaction.

SP's 10-year ASCVD risk is found to be 17% and the ambulatory care pharmacist assesses her current statin therapy for appropriateness. Which of the following statements is accurate? A. The patient does not require statin therapy at this time, but is taking a moderate-intensity statin regimen. B. The patient requires moderate-to-high intensity statin therapy and is taking a low- intensity statin regimen. C. The patient requires moderate-to-high intensity statin therapy and is taking a moderate- intensity statin regimen. D. The patient requires moderate-to-high intensity statin therapy and is taking a high- intensity statin regimen. E. The patient requires high intensity statin therapy, but is taking a moderate-intensity statin regimen. C SP is between the ages of 40 and 75 with an ASCVD risk > 7.5%, LDL is between 70 and 189; she is not diabetic. She should receive moderate-high intensity statin therapy such as simvastatin 40 mg daily.

Which of the following statements concerning simvastatin is correct?   A. Simvastatin should be taken with food. B. Liver enzymes should be checked at baseline. C. Simvastatin should be taken with breakfast. D. The brand name of simvastatin is Crestor. E. Simvastatin can cause an increase in fractures in the elderly. B

LD is a 61 year-old male being seen for routine follow up including his risk for ASCVD.   Current Medications:  Inderal LA 80 mg daily  Hydrochlorothiazide 25 mg daily  Prinivil 10 mg daily Mylanta 20 mL Q6H Plavix 75 mg daily Aspirin 81 mg Nitroglycerin 0.3 mg PRN MVI daily     Past Medical History:  Hypertension Dyslipidemia GERD s/p MI   Vitals: Height: 5'11"                   Weight: 202 lbs BP: 140/80 mmHg   HR: 85 BPM         RR: 20 BPM Temp: 98.6ºF               Pain: 1/10    Labs:  AST (units/L) =  32 (10 - 40) ALT (units/L) = 20 (10 - 40) CH, T (mg/dL) = 221 (125 - 200) TG (mg/dL) = 238 ( < 150) HDL (mg/dL) = 32 ( > 40) LDL (mg/dL) =  GLU (mg/dL) = 108 (65 - 99) Na (mEq/L) = 143 (135 - 145)                      K (mEq/L) = 4.1 (3.5 - 5)                            Cl (mEq/L) = 102 (95 - 103)                         HCO3 (mEq/L) = 26 (24 - 30)                       BUN (mg/dL) = 15 (7 - 20)                           SCr (mg/dL) = 0.8 (0.6 - 1.3)                 Mg (mEq/L) = 1.8 (1.3 - 2.1) PO4 (mg/dL) = 4.1 (2.3 - 4.7) Ca (mg/dL) = 9.7 (8.5 - 10.5) TSH (mIU/L) = 1.8 (0.3 - 3.0) Free T4 (mg/dL) = 0.7 (0.9 - 2.3)  

What is LD's calculated LDL? A. 129 mg/dL B. 141 mg/dL C. 149 mg/dL   A. 129 mg/dL B. 141 mg/dL C. 149 mg/dL D. 161 mg/dL E. 173 mg/dL B

B. Rosuvastatin 20 mg daily C. Lovastatin 40 mg daily According to the ACC/AHA Treatment of Blood Cholesterol Guideline, what would be the most appropriate statin regimen for LD?   A. Pravastatin 40 mg daily B. Rosuvastatin 20 mg daily C. Lovastatin 40 mg daily D. Atorvastatin 20 mg daily E. Pitavastatin 4 mg daily B

LD was prescribed Crestor (rosuvastatin) 40 mg, but it is not the preferred statin on his insurance plan. Which statin would be an appropriate alternative?   A. Atorvastatin 20 mg B. Pravastatin 40 mg C. Atorvastatin 40 mg D. Atorvastatin 80 mg E. Pravastatin 80 mg D Rosuvastatin 5 mg is equivalent to atorvastatin 10 mg. Therefore, an appropriate equivalent dose would be atorvastatin 80 mg. The other statins are not equivalent to rosuvastatin 40 mg.

What other names is niacin known by? (Select ALL that apply.) A. B1   A. B1 B. B2 C. B3 D. Biotin E. Nicotinic Acid CE

A. Initiate simvastatin 20 mg daily B. Initiate ezetimibe 10 mg daily A 47 year-old patient comes to the clinic for routine follow up. The patient has hypertension and is a smoker. The Global Risk Assessment score for this patient is 8.5%. Laboratory assessment reveals the following:   Which of the following would be the best recommendation to treat according to the ACC/AHA Blood Cholesterol Guidelines? A. Initiate simvastatin 20 mg daily B. Initiate ezetimibe 10 mg daily C. Initiate gemfibrozil 600 mg BID D. Initiate atorvastatin 40 mg daily E. None of the above options are appropriate. Na+ 135 mEq/L K+ 4.5 mEq/L SCr 2.1 mg/dL AST 187 units/L ALT 217 units/L A1C 6.2% LDL 140 mg/dL E This patient should not be started on a statin, ezetimibe, or a fibrate due to liver impairment.

E. Simvastatin is contraindicated in patients with heart failure. A patient with heart failure is currently taking amiodarone, digoxin and furosemide. The physician wants to start the patient on simvastatin. Which of the following statements is correct?   A. The maximum dose of simvastatin is 10 mg daily due to the drug interaction with amiodarone. B. The maximum dose of simvastatin is 20 mg daily due to the drug interaction with amiodarone. C. The maximum dose of simvastatin is 10 mg daily due to the drug interaction with digoxin. D. The maximum dose of simvastatin is 20 mg daily due to the drug interaction with digoxin. E. Simvastatin is contraindicated in patients with heart failure. B

Which three statins undergo first pass metabolism by which CYP enzyme?   A. Simvastatin, lovastatin, rosuvastatin; CYP3A4 B. Simvastatin, fluvastatin, atorvastatin; CYP2D6 C. Simvastatin, lovastatin, pravastatin; CYP2C19 D. Simvastatin, lovastatin, atorvastatin; CYP3A4 E. Simvastatin, lovastatin, atorvastatin; CYP2D6 D

What is the mechanism of action of alirocumab?   A. Blocks the receptor on hepatocytes that is responsible for removing LDL cholesterol B. Blocks the binding of LDL to the LDL receptor on hepatocytes C. Inhibits LDL receptor degradation allowing LDL to bind to the receptor on hepatocytes D. Stimulates the LDL receptor on hepatocytes to bind to LDL E. Antagonizes the LDL receptor on hepatocytes from binding to LDL C

What is the correct mechanism of action of fenofibrates?   A. Fenofibrates inhibit the enzyme HMG-CoA reductase. B. Fenofibrates bind to bile acids in the gut. C. Fenofibrates reduce cholesterol absorption at the brush-border. D. Fenofibrates are peroxisome proliferator alpha activators. E. Fenofibrates bind to and inhibit microsomal triglyceride transfer protein (MTP) in the endoplasmic reticulum. D

A. A weekly dose that decreases TGs by ≥ 50% Which of the following represent the correct definition of high-intensity statin therapy?   A. A weekly dose that decreases TGs by ≥ 50% B. A daily dose that decreases TGs by ≥ 50% C. A weekly dose that decreases LDL by ≥ 50% D. A daily dose that decreases LDL by ≥ 50% E. A daily dose that decreases LDL by 30-50% D

What effects can gemfibrozil have on lipids? (Select ALL that apply.)   A. Decreases TG B. Increases HDL C. Decreases LDL D. Increases LDL E. Decreases HDL ABCD Fibrates, such as gemfibrozil, generally decrease TG by 20-50%, increase HDL by 15%, and decrease LDL by 5-20%. However, if TG levels are high, LDL can actually be increased.

Which lipid lowering therapy is contraindicated in patients with a history of gallstones?   A. Fibrates B. Statins C. Ezetimibe D. Bile acid resins E. Fish oils A

C. Rosuvastatin 10 mg daily D. Atorvastatin 80 mg daily A patient is admitted to the hospital with an acute myocardial infarction. Which statin regimen, when initiated immediately, has been shown to improve short term outcomes by reducing the risk of recurrent ischemia?   A. Simvastatin 40 mg daily B. Lovastatin 80 mg daily C. Rosuvastatin 10 mg daily D. Atorvastatin 80 mg daily E. Pravastatin 40 mg daily D High-intensity statin therapy initiated within 96 hours of hospitalization for an acute coronary syndrome has been shown to reduce the incidence of recurrent ischemia. The statin and regimen used in these studies (MIRACL and PROVE-IT TIMI 22) was atorvastatin 80 mg daily and this is the only high-intensity regimen listed.

A. Trilipix (fenofibrate) B. Welchol (cholesevelam) Which of the following cholesterol medications should not be taken with grapefruit or grapefruit juice?   A. Trilipix (fenofibrate) B. Welchol (cholesevelam) C. Zocor (simvastatin) D. Vascepa (icosapent) E. Pravachol (pravastatin) C Zocor cannot be taken with grapefruit. Counsel patients to avoid grapefruit (the juice and the fruit), or try an alternative drug that does not interact. Separating the time a person drinks or eats grapefruit from the drug will not work, unless it is separated by at least several days. Grapefruit inhibits the drug-metabolizing enzyme; it is not a gut-binding interaction that could be helped by separation.

B. Lofibra (fenofibrate) C. Zetia (ezetimibe) D. Lescol (fluvastatin) A patient with hypertriglyceridemia develops acute pancreatitis after a lipid lowering therapy is initiated. Which dyslipidemia therapy is associated with an increase in triglycerides? A. Lopid (gemfibrozil) B. Lofibra (fenofibrate) C. Zetia (ezetimibe) D. Lescol (fluvastatin) E. Questran (cholestyramine) E

Which statin can be taken in the morning without significantly affecting the LDL-lowering effectiveness?   A. Fluvastatin B. Simvastatin C. Atorvastatin D. Lovastatin E. Myostatin C Atorvastatin (and others) has a long half-life and does not need to be given in the evening to maximize inhibition of cholesterol synthesis which peaks in the early morning hours.

Hydrochlorothiazide 25 mg daily Ambien 5 mg QHS PRN FS is a 40 year-old female being for evaluated for her dyslipidemia. She has an estimated ASCVD risk of 6.4%. Current Medications:  Hydrochlorothiazide 25 mg daily Ambien 5 mg QHS PRN Levothyroxine 112 mcg daily Prenatal MVI daily    Past Medical History: Dyslipidemia Hypertension Insomnia Hypothyroidism Vitals: Height: 5'6"                 Weight: 160 lbs BP: 140/80 mmHg   HR: 85 BPM           RR: 20 BPM Temp: 98.6ºF               Pain: 1/10  Labs: AST (units/L) =  24 (10 - 40) ALT (units/L) = 21 (10 - 40) CH, T (mg/dL) = 242 (125-200) TG (mg/dL) = 189 ( < 150) HDL (mg/dL) = 38 ( > 40) LDL (mg/dL) = 166 ( < 100) GLU (mg/dL) = 108 (65 - 99) Na (mEq/L) = 141 (135 - 145)                     K (mEq/L) = 4.2 (3.5 - 5)                          Cl (mEq/L) = 100 (95 - 103)                       HCO3 (mEq/L) = 28 (24 - 30)                      BUN (mg/dL) = 18 (7 - 20)                         SCr (mg/dL) = 0.9 (0.6 - 1.3)                Mg (mEq/L) = 1.9 (1.3 - 2.1) PO4 (mg/dL) = 4.4 (2.3 - 4.7) Ca (mg/dL) = 9.5 (8.5 - 10.5) TSH (mIU/L) = 2.2 (0.3 - 3.0) Urine hCG = positive    

B. Hydrochlorothiazide C. Levothyroxine D. Prenatal vitamin Which of her medications could contribute to her lipid panel abnormalities?   A. Ambien B. Hydrochlorothiazide C. Levothyroxine D. Prenatal vitamin E. None of her medications are associated with lipid abnormalities. B Thiazides are associated with increases in LDL and triglycerides. Loop diuretics can cause increases in triglycerides and total cholesterol.

What statin therapy is most appropriate for her?   A. Simvastatin 10 mg daily B. Lovastatin 20 mg daily C. Atorvastatin 20 mg daily D. Rosuvastatin 20 mg daily E. Statin therapy is not appropriate C Patient is hCG+, statins are contraindicated in pregnancy due to embryofetal toxicity and should not be given to pregnant patients.

A. BMI should be between 18.5-24.9 kg/m2. Lifestyle recommendations should be made to patients with hyperlipidemia. These recommendations include: (Select ALL that apply.)   A. BMI should be between 18.5-24.9 kg/m2. B. Exercise 2-3 sessions per week, each session lasting 20-30 minutes. C. Saturated fat intake should be 5-6% of total daily calories. D. Consume vegetables, fruits and whole grains. E. Be careful to consume more eggs, bacon, and sausage. ACD