2. GI distress (cramping, bloating, fart) 3. Constipation CONTRAINDICATIONS Bowel obstruction TG induced pancreatitis TG > 400mg/dL Dysbetalipoproteinemia Relative - TG > 200 mg/dL 1. Ezetimibe (Zetia) Adverse 1. Myopathy 2. Rhabdomyolysis 3. Hepatitis 4. Pancreatitis 5. HA, GI discomfort CONTRAINDICATIONS 1. Moderate to severe liver injury PCSK-9 Inhibitors None known Adverse 1. Lipid Panels 1. Myalgia 3. Injections reactions 4. Nasopharyngitis (stuffy nose) 5. Influenza Adverse 2. HYPOtension 4. Hepatotoxicity 5. Hyperglycemia Therapeutic Lifestyle Changes (TLC) 1. Diet - reduce saturated fat intake, reduce cholesterol intake 2. Weight Managmeent - Gocal BMI <= 25kg/m2, initial goal to decrease body weight by 10% over 6 months, no more than 1-2 lbs loss per week 3. Increase physical activity - exercise 30 minutes most days of the week 4. Smoking Cessation - quitting smoking can reduce CHD risk within months Treatment of Dyslipidemia - Pharmacotherapy (should always include TLC) 1. Firstline - STATINS 2. Second Line - reserved for patients with tolerability issues and hypertriglyceridemia a. Bile acid sequestrants b. Cholesterol absorption inhibitors c. PCSK - 9 inhibitors d. Niacin, Nicontinic acid e. Fibrates f. Omega 3-fatty acids g. Misc. agents THERAPUTIC CLASS PREGNANCY LACTATION ADVERSE EFFECTS/ CONTRAINDICATIONS MONITORING PARAMETERS ANTI- HYPERLIPIDEMICS 1. Lovastatin (Mevacor) - Med/Low 2. Lovastatin ER (Altoprev) 3. Pravastatin (Pravachol) - Med/Low 4. Simvastatin (Zocor) - Med/Low 5. Fluvastatin (Lescol) - Med/Low 6. Fluvastatin XL (Lescol XL) - Med 7. Atorvastatin (Lipitor) - High/Med 8. Rosuvastatin (Crestor) - High/Med 9. Pitavastatin Sodium (Nikita) - Med/Low 10. Pitavastatin Calcium (Livalo) - Med/Low 11. Pitavastatin Magnesium (Zypitamag) - Med/Low 1. Inhibit HMG-CoA reductase, reducing cholesterol synthesis 2. Increase # LDL receptors on hepatocytes, increasing #LDL removed from blood 1. Do not combine with statins with fibrates or niacin due to increased risk of muscle (rabdomylsis), liver or kidney injury 2. Ue caution if combine a statin with ezetimibe 3. CYP3A4 inhibitors (-azole antifungals, grapefruit juice) can raise levels of lovastatin, simvastatin and atorvastatin 4. CYP2C9 & CYP2C19 inhibitors may raise levels of fluvastatin, pitavastatin, and rosuvastatin 5. Potent inducers may reduce statin levels ABSOLUTE NO - have patients document use of contraception. NO BREASTFEEDING 1. LFT (12 wks, every 6 months after) 2. Cr 3. CK (if at risk) baseline or if patients experience muscle symptoms 4. Hb A1C if diabetes status unknown 5. Lipid paramenters PK: Hepatic metabolism followed by excretion in bile Reduce dosage in patients with renal impairment due to significant excretion in urine for pravastatin, pitavastatin, simvastatin, lovastatin SPECIAL CONSIDERATIONS - dosage reduction for rosuvastatin recommended in Asian patients, patients with untreated hypothyroidism or ANYONE over 65 Patients with active hepatic disease or unexplained levels of LFTs Bile Acid Sequestrants 1. Cholestyramine 2. Colestipol 3. Colesvelam 1. Increase LDL receptors (reduces LDL) 2. Prevents reabsorption of bile- acids 3. Raise HDL
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- Spring '14