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Let’s start our USMLE Review with Drugs of Choice from the Gold Standard USMLE Step 2 Audio Review program.
Play USMLE Audio MP3 20 05 Drugs of Choice CHD and LDL, HDL Below
In terms of coronary heart disease, associated with hyperlipoproteinemia, what are the 2 primary risk factors?
- Elevated LDL or decreased HDL.
Trials have shown that lowering total cholesterol reduces risk for coronary heart disease; specifically what part of total cholesterol when it is lowered, causes the greatest reduction in risk?
Generally, for every 1% reduction in total cholesterol or LDL-C, what reduction in risk occurs?
- There is a 2% reduction in risk for every 1% reduction in total cholesterol or LDL-C.
What level of HDL-C is also a risk factor for coronary heart disease?
- Levels below 35 mg/dL.
What level of HDL-C reduces the risk of coronary heart disease?
- HDL-C higher than 60 mg/dL.
In terms of drug therapy to lower the level of triglycerides or LDL or cholesterol, what class of drugs are most widely used?
- The HMG-CoA Reductase Inhibitors.
From highest relative potency to lower relative potency, what are the 4 HMG-CoA Reductase Inhibitors currently in use?
- Simvastatin, Lovastatin, Pravastatin, Fluvastatin.
What is the trade name for Simvastatin?
And what is the trade name for Lovastatin?
And what is the trade name for Pravastatin?
And finally, the trade name for Fluvastatin?
What is the most important side effect of the HMG-CoA Reductase Inhibitors?
- Transaminase elevations, which appear to be clinically significant.
How common are these?
- These are quite rare.
And how long do they last?
- They are usually transient.
Very rarely, what are 2 serious side effects of the HMG-CoA Reductase Inhibitors in addition to the transaminase elevations?
- Myositis, rhabdomyolysis.
What is the class of drugs used to help lower cholesterol which work by helping with the elimination of cholesterol through the feces?
- Bile acid sequesterants.
And what are the 2 currently used?
- Cholestyramine, Colestipol.
And the trade name for Cholestyramine?
And the trade name for Colestipol?
Why are the bile acid sequesterants considered to be very safe?
- Because they are not absorbed systemically from the bowel.
About how much reduction in LDL-C expected from the use of HMG-CoA Reductase Inhibitors?
- 20-40% reduction.
What level of reduction can usually be achieved with the bile acid sequesterants?
- Only about 10-30% at best reduction.
What process or loop is interfered with by the bile acid sequesterants?
- The entero-hepatic circulation of bile acids is decreased.
What effect does this have on the liver?
- The liver puts out more LDL-C receptors in order for the liver to absorb more LDL-C from the blood because its internal content of cholesterol has been lowered.
What is the most common side effect of the bile acid sequesterants?
Can the bile acid sequesterants be used with other lipid-lowering drugs?
- Yes, they can be used in combination with all of the other classes of lipid lowering drugs.
While the bile acid sequesterants may be used by themselves for a modest reduction in LDL-C, they’re most frequently used in combination with what other class of drug?
- With the HMG-CoA Reductase Inhibitors.
What adverse effect can the bile acid sequesterants have on serum lipids?
- They can increase triglyceride levels.
So, in what patients do you not use bile acid sequesterants?
- Patients who have a triglyceride level of 250mg/dL or greater
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