Feb 14, 2023
Statins and More (gemfibrozil, fenofibrate, niacin, ezetimibe, cholestyramine, PCSK9)
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Hyperlipidemia treatments are really about statins and then what to do if that doesn't work. This episode has a few mnemonics that will help you remember them.
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Welcome to the Memorizing Pharmacology podcast. I’m Tony Guerra, pharmacist and author of The Memorizing Pharmacology book series, bringing you mnemonics, cases, and advice for succeeding in Pharmacology. Sign up for the email list at memorizingfarm.com to get your free suffixes cheat sheet or find our mobile-friendly self-paced online pharmacology review course at residency.teachable.com forward slash P forward slash mobile. Let’s get started with the show.
Okay, today we’re going to talk about statins and more. Statin is an HMG COA reductase inhibitor that will be important as we kind of go through here, that’s how it works. I’ll focus a lot on the statins but I’ll also talk about some agile therapy as well or some other choices.
So really what we’re talking about here is atherosclerosis and coronary artery disease and you’ve probably had physiology where you start with that normal artery and you get that fatty streak, you get a plaque and then a complicated plaque. So statins do a good job of lowering LDL and we can use l for lousy cholesterol or bad cholesterol and move cholesterol from the plaque to stabilize it. Now the evidence is a little bit weak in terms of you know making a plaque smaller but again it stops the madness I guess you would say.
Okay, we’re always looking for lifestyle changes. I use the mnemonic changer Fates so increase fiber, increase food that’s good for you, decrease fat, decrease alcohol or stop Tobacco Stop alcohol exercise gotta increase exercise and then decrease your sodium. So again really the lifestyle changes are the first place that we go but um there are so many good medications for hyperlipidemia that we just go through them now.
Okay so HMG-COA reductase Inhibitors let’s start with the suffix it’s vastatin be careful you’ll probably hear Statin a lot of times and that’ll usually get you by but for example if you look the bottom right Nystatin is not for lipids It’s actually an anti-fungal so just be careful with that.
We’ll talk about this division in a second about how really you can use atorvastatin resuvastatin which are Lipitor and Crestor at higher Doses and then you can use them at lower Doses and that actually means something. And then just like you’re going to have to worry about lfts the liver function tests the other drugs are lfps so Lovastatin fluvastatin pravastatin and Simvastatin.
Alright so let’s just talk about high intensity versus moderate intensity high intensity are the atorvastatin at greater than 20 milligrams and rosuvastatin is at 40 milligrams because once we start increasing those dosages we’re really worried about that myopathy that we’re going to get and liver issues and we’ll talk about adverse effects in a minute but just know that if the patient is more fragile we would use something moderate intensity if they’re less fragile high intensity.
Uh so Lipitor I’m guessing that they were thinking like lipid Gladiator so this is the lipid lion uh that is being slain by the HMG co-a how do we figure out high intensity versus moderate intensity uh we’re really looking at the clinical atherosclerotic cardiovascular disease abbreviated As ascvd and we’re worried about peripheral artery disease myocardial infarction heart attack or a cerebrovascular accident.
So if the patient is greater than 75 we’ll probably go moderate if they’re less than 75 we might go high intensity if their LDL is greater than 190 we’d go high intensity if they’re diabetic 45 to 70 and their ascvd score is less than 7.5 percent then moderate and then higher than 7.5 high intensity.
And then 45 to 70 we would go greater than 7.5 percent moderate intensity so again it’s really just figuring out what their risk is of a coronary event and how these medications can help um you might see a bunch of Statin mnemonics there are a number of things that you kind of want to watch out for with statins uh first s skip the grapefruit juice there is an issue with so the grapefruit juice increases the Here is the corrected version of your text:
“Statin level in your body and um some they say that some statins don’t have this effect and some do but you’ll be hard-pressed to not find somebody that’s going to say just go ahead and skip the grapefruit juice. The big one is toxic to muscles and joints and maybe Rhabdomyolysis is an unfamiliar term but if you work out too much too fast this will happen as well but it can be toxic to the muscles and joints and really it’s myopathy that we’re going to see first. A for alt AST monitoring so the lfts or liver function tests for liver injury uh and then T tints the eyes yellow uh again kind of going from that liver injury. I how does it work well it for lack of a better term it just inhibits cholesterol production and then n um one of the add-ons that we’ll talk about is niacin which is an add-on when the triglycerides are just not getting lowered enough so s skip grapefruit juice T toxic to muscles a a l t a s t t 10 size yellow I inhibits cholesterol production and niacin add-on for triglycerides uh atorvastatin or Lipitor it’s this is our big dog uh so hyperlipidemia and cardiovascular risk is the indication and mechanism it is an hmg-coa reductase inhibitor so the big things that we’re worried about are this that muscle myopathy that Rhabdomyolysis which is uh you know progression from the myopathy and then the yellowing eyes which comes from a progression from the liver issue so contraindications would be liver disease pregnancy and then the things that you really want to watch for as a healthcare professional you know so looking for that myopathy and I just put the Three L’s so you can think about lifting weights so it’s really more about the muscles than lifting weights lifestyle and the lfts uh Jim fry Brazil and which is lopid and fenofibrates tri-core these are not statins but they’re really important because they’re also good for hyperlipidemia and high triglycerides especially and so they can decrease cholesterol production and they can also cause myopathy Rhabdomyolysis and then the liver issues and especially with gemfibrazil we’re going to see that myopathy effect is more additive so when you have someone on a Statin engine for Brazil you’re going to see that that myopathy more often uh contraindications well liver disease and pregnancy and then again the The Three L’s the lifting the lifestyle and the lft is really just a way to remember the muscles are part of all this so the next piece we get to is kind of that combination therapy and we say okay well we haven’t decreased their LDL enough so it’s a Statin and so maybe it’s a Statin and niacin okay so niacin blocks the enzyme for making cholesterol and this would be good if we’re you know have those elevated triglycerides but also LDL to some extent uh the big thing with the niacin is that flushing and you can give the aspirin 30 minutes prior and then maybe exacerbation of gout because of its effect on uric acid so adding fluids uh blocking cholesterol absorption so acetamin or zedia against four cholesterol but it’s an absorption inhibitor so both acetamine and cholesterolamine those are going to block that cholesterol absorption and you’re going to see myopathy but with that blocking of cholesterol absorption you’re also going to see fat soluble vitamins D, E, A and K are going to be blocked as well. I always thought of it as a person named Deke, D-E-A-K, that’s how I remember the fat soluble vitamins but blocking those vitamins in addition to the cholesterol is a concern. Then cholestyramine which is question, this is not only for cholesterol but also if you have chronic diarrhea this can work as a bile acid sequesterant and again that the Deep vitamins are an issue here because it is blocking um those that cholesterol absorption blocks the enzyme that regulates the number of cholesterol receptors. So the reason I said it that way was because the real name is proprotein convert a subtilicin kexin type 9 which we abbreviate for good reason as PCSK9 Inhibitors so allerocumab which is probably and evolokumab which is repatha both of those are monoclonal antibodies that we would use for a specific type of cholesterol issue they’re like Uber expensive like super expensive combination therapy. So if we’re now trying to decrease triglycerides rather than LDL we would add the niacin for Brazil again just the way that they work they do a good job with those triglycerides and if we’re thinking of decreasing triglycerides and increasing HDL or just increasing HDL again niacin gem for Brazil are our choice there. So um kind of brings us back to this last slide which is a really expensive situation where somebody does need one of those PCSK 9 Inhibitors or they’ll go through the Rems to get them if omersin these are for familiar familial hypercholesterolemia so if somebody fails the high high dose statins then the alarokimab and evolution might be something you add on and then nipomeracin requires a Rems because of its liver damage but it works way differently it just binds to the messenger RNA of this really important protein LDL and VLDL and fails to translate so you get less of it but okay so again this is for informational purposes only it’s not medical advice if you have a medical question contact a medical professional.
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