USMLE Step 2 Review 20 06 Drugs of Choice Niacin

USMLE Step 2 Review 20 06 Drugs of Choice Niacin

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Begin 20 06 Drugs of Choice Niacin Transcription

What vitamin can be used to lower triglycerides and LDL and to increase HDL?

  • Nicotinic acid.

And nicotinic acid is what type of vitamin?

  • It is a B vitamin.

And what is the other name for nicotinic acid?

  • Niacin.

What dose per day of Niacin can increase HDL-C by 25% or more and also cause a modest decrease in triglycerides and LDL-C?

  • 1.5 grams per day.

What dosage can decrease LDL-C by 25-30% and decrease triglycerides by half?

  • 3- 4.5 grams per day.

Especially as the patient gets over the dosage level of 1.5 g per day, there are 2 side effects of Niacin that, while they are not harmful, usually cannot be tolerated by the patient. What are they?

  • Cutaneous flushing and itching, and gastrointestinal symptoms.

What form of Niacin may reduce these symptoms?

  • Sustained release Niacin, however, there is a real problem with sustained release Niacin.

What is it?

  • There is increased risk of hepatotoxicity.

What are the 3 worrisome adverse effects of Niacin, which may occur?

  • Hepatitis, hyperglycemia, hyperuricemia.

What medication given to post-menopausal women will usually cause a modest drop in LDL-C and a modest increase in HDL-C?

  • Estrogen.

Unfortunately, what additional hormone negates the possible increase in HDL-C?

  • Progestin.

And in what type of post-menopausal woman is progestin in combination with estrogen required?

  • A woman who still has a uterus.

And why must progestin be given to the woman with a uterus in combination with estrogen?

  • The progestin helps prevent endometrial cancer, which estrogen unopposed would cause an 8-fold increase in risk for.

And what class of lipid-lowering drug as, as its main effect, increasing lipoprotein lipase activity?

  • These are the fibric acid derivatives.

There is only 1 approved for use in the United States; What is it?

  • Gemfibrozil.

And the trade name for Gemfibrozil?

  • Lopid.

There was another fibric acid derivative being used in the United States, but has been discontinued due to toxicity. Which one is this?

  • Clofibrate.

And the trade name for Clofibrate?

  • Atromid-S.

In what type of patient is Gemfibrozil (trade name Loprid) most effective?

  • Patients who do not have elevated triglycerides.

In these patients, the positive benefits are a modest decrease in LDL-C and a modest increase in HDL-C. What are the 2 serious side effects of Gemfibrozil (trade name Lopid)?

  • Increased risk of cholelithiasis and when administered with another lipid lowering drug, there is increased risk of myopathy.

And what is the other lipid lowering drug that, when this is given in combination with it, increases the risk of mypoathy?

  • The HMG-CoA Reductase Inhibitors.

Finally, what lipid lowering agent, which is also an antioxidant, has recently been taken off the market?

  • Probucol.

And what is the trade name for Probucol?

  • Lorelco.

Why was it taken off the market?

  • Because it lowers HDL-C.

All right, let’s take a look at applying these different drugs to different situations.

What is the first-line drug of choice for patients who have low HDL-C levels, that is, below 35 mg/dL, but whose LDL-C levels are not elevated?

  • For these people, crystalline Niacin is the drug of choice for increasing HDL-C.

What additional non-drug strategy can be added to the use of Niacin for even more beneficial raising of HDL-C?

  • The obese patient losing weight.

What is the drug of choice for the patient with low HDL-C levels, but where their triglycerides are so high that Niacin is contraindicated?

  • Gemfibrozil.

And the trade name for Gemfibrozil?

  • Lopid.

Going back to the patient who has low HDL-C levels but whose triglycerides are not elevated, if this patient cannot tolerate the high levels of Niacin, what is the next best alternative?

  • The HMG-CoA Reductase Inhibitors.

When the patient has both elevated LDL-C and triglycerides, and the HDL-C may or may not be low, what class of lipid lowering agents is used first?

  • The HMG-CoA Reductase Inhibitors.

And again, in order of potency, what are the 4 HMG-CoA Reductase Inhibitors?

  • Simvastatin, Lovastatin, Pravastatin, Fluvastatin.

And the trade name for Simvastatin?

  • Zocor.

And the trade name for Lovastatin?

  • Mevacor.

And the trade name for Pravastatin?

  • Pravachol.

And the trade name for Fluvastatin?

  • Lescol.

Now, while these HMG-CoA Reductase Inhibitors are the first step in treatment, what general principle is true of these patients with elevated LDL and triglycerides?

  • These patients usually need double or triple combination therapy.

What drug should be added next after initiating HMG-CoA Reductase Inhibitors?

  • Niacin.

Now, if high enough levels of Niacin are not tolerated, what alternative may be considered to adding to the HMG-CoA Reductase Inhibitor?

  • Gemfibrozil.

And the trade name for Gemfibrozil?

  • Lopid.

However, by using Gemfibrozil (trade name Lopid) in combination with HMG-CoA Reductase Inhibitors, what serious side effect is the patient at greater risk for?

  • Myopathy.

What serum level may you wish to monitor periodically to monitor for the possiblilty of myopathy?

  • Creatine kinase (CK).

In these patients, once the triglyceride level has been brought down to normal, what additional agent may be considered?

  • A bile acid sequesterant,

in order to lower what other level?

  • The LDL-C even further.

And again, the 2 bile acid sequesterants? Cholestyramine and Cholestipol.

And the trade name for Cholestyramine?

  • Questran.

And the trade name for Colestipol?

  • Colestid.

Finally, what class of drug is the first consideration for patients who have elevated LDL but whose triglycerides are normal?

  • Again, the HMG-CoA Reductase Inhibitors.

Now, for these patients with elevated LDL but normal triglycerides, what agent is often added to HMG-CoA Reductase Inhibitors?

  • The bile acid sequesterants.

Finally, in these patients with elevated LDL but normal triglycerides, if the HDL-C is low, what other drug may be added into the mix?

  • Niacin.



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