Additive hypocholesterolemic effect of psyllium and cholestyramine ...
Podcast (Video Recorded Lecture Series): Lipoprotein...
Transcript of Podcast (Video Recorded Lecture Series): Lipoprotein...
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Podcast (Video Recorded Lecture Series):Lipoprotein Metabolism and Lipid Therapy for the USMLE Step One Exam
Howard J. Sachs, MDwww.12DaysinMarch.com
Email: [email protected]
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Howard J. Sachs, MDwww.12DaysinMarch.com
Email: [email protected]
Tutorial Services(check website for details)
Podcast (Video Recorded Lecture Series):Lipoprotein Metabolism and Lipid Therapy for the USMLE Step One Exam
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Meds:Lipids
Antianginals
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Cholesterol Lowering
HMG CoA Reductase Inh
Cholestyramine
Niacin
Fibrates (gemfibrizol, fenofibrate)
Lots of great questions on cholesterol lowering meds.
MOAWhat or ¯ in response to med?
Adverse effects
Ezetimibe
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Cholesterol Lowering: MOA
Bile Acid Sequestrant
Upregulates LDL receptor (2)
¯ VLDL and lipolysis
Activate PPAR-a ( LPL)
HMG CoA Reductase Inh
Cholestyramine
Niacin
Fibrates(gemfibrizol, fenofibrate)
EzetimibeInhibits cholesterol
absorption and is pretty damn safe and they won’t
ask any questions
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Cholesterol Lowering: AE
Triglyceride elevation
Cholelithiasis
Hyperuricemia (Gout)/IGT
Myalgia+
HMG CoA Reductase Inh
Cholestyramine
Niacin
Fibrates(gemfibrizol, fenofibrate)
Ezetimibe Pretty Damn Safe
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Although we think about lipids in a pathologic sense, their role is fairly innocent by design:
• Chylomicrons and VLDL are designed to provide energy to the tissues (FFA); thus, the role of LPL.
• The metabolism of VLDL generates LDL, which is designed to provide cholesterol to the periphery for membrane and steroid hormone synthesis
• Some cells (including hepatocytes) have the ability to synthesize cholesterol through formation of mevalonic acid by HMG CoA Reductase
These simple principles provide targets for pharmacorx:• ↓ Cholesterol Synthesis• Upregulation of LDL Receptor (for hepatic clearance)• Upregulation of Lipoprotein Lipase
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In setting of pancreatic colipase/lipase, PLA2, cholesterol esterase
FFA & MGCholesterol
TriglyceridesCholesterol Esters
PPLApolipoproteins
Emulsified into Simple Micelles: Bile Salts plus fat droplets
TRIG
Water soluble
MixedMicelle
FFA, MG, Cholesterol, PPLFat Globule
Lacteals ® Thoracic Duct® Subclavian Vein(not the portal vein)
Discussed in video: Chylomicron Formation and Fat Absorptionhttps://youtu.be/KMSEEwEScZc
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Storage, Energy
Exogenous (dietary ) Pathway
- Capillary
Dietary Fat
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VLDLTGCE
‘Hepatic Fat’VLDL
VLDL Remnant
(IDL)
LDL
VLDL
Endogenous (hepatic ) Pathway
Storage, Energy
Peripheral Tissues
‘VLDL is the Chyloµof the Liver’
- Capillary
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Exogenous: dietary chyloµ
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IDL = VLDL remnantEndogenous: Hepatic VLDL
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B-100
IDL = VLDL remnant
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IDL = VLDL remnant
B-100
What happens to:Trigs/VLDL
LDL
If you LPL?If you ¯ VLDL secretion?
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Fibrate(gemfibrozil)
PPAR-a(transcription
receptor)
Because fibrates upregulate LPL via PPAR, they should be considered ‘specialists’ in Triglyceride/VLDL metabolism.
As such, fibrate questions will always address the high triglyceride patient
IDL
B100Trigs
Reduce TrigsRaise HDL
Hepatocyte
VLDL LPL
MOA: increased expression of transcription factor (PPAR)
MOA: decrease VLDL synthesis
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MevalonicAcid
Fibrate(gemfibrozil)
PPAR-aThey will ask about AE (2):
(1) Interaction w/ statin ®rhabdomyolysis
(inhibit CYP3A4 ® statin)
(2) Cholelithiasis
(IDL/LDL returned to liver & ↓ 7-α-OHase activity ®
cholesterol saturation of bile)
Discussed in Bile Metabolism AND Lithogenesis Videos:
https://youtu.be/TF1ADSDHbSg(Bile metabolism)
https://youtu.be/vc9TCZMDofA(Cholelithiasis)
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MevalonicAcid
Fibrate(gemfibrozil)
PPAR-aThey will ask about AE (2):
(1) Interaction w/ statin ®rhabdomyolysis
(inhibit CYP3A4 ® statin)
(2) Cholelithiasis
(IDL/LDL returned to liver & ↓ 7-α-OHase activity ®
cholesterol saturation of bile)
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MevalonicAcid
Fibrate(gemfibrozil)
PPAR-a
That’s it:
MOA (2): PPAR ® LPL, ¯ VLDL synthesis
Result: ¯ TriglycerideAE: Stones
AE: ¯ metabolism of statin ®rhabdomyolysis
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Niacin
MOA: Inhibits VLDL secretion(inhibits intrahepatic TG synthesis)
(lesser effect: inhibition of lipolysisin adipocyte; FYI)
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MevalonicAcid
Inhibits lipolysis (adipocyte)
Niacin pathways: effects of decreasing VLDL synthesis
Niacin: the Perfect Drug?
¯ Triglycerides¯ LDL HDL
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MevalonicAcid
Inhibits lipolysis (adipocyte)
Niacin pathways: effects of decreasing VLDL synthesis
Niacin: the Perfect Drug?
¯ Triglycerides¯ LDL HDL
Many Adverse EffectsDidn’t hold up in contemporary clinical trials
Better alternatives
Q-bank Cautionary Tales:Best agent for RR → statinsBest agent to HDL → niacin
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MevalonicAcid
Inhibits lipolysis (adipocyte)
Niacin pathways: effects of decreasing VLDL synthesis
Niacin: the Perfect Drug?
¯ Triglycerides¯ LDL HDL
Many Adverse EffectsDidn’t hold up in contemporary clinical trials
Better alternatives
Q-bank Cautionary Tales:Best agent for RR → statinsBest agent to HDL → niacin
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Niacin:
MOA: Inhibits VLDL secretion \¯ LDL as well
Inhibits lipolysis in adipose
Patient profile: high triglycerides
Distinguish from fibrate by MOA and AE
Focus AE (3):
Flushing (PG « ASA)Hyperuricemia (‘podagra on rx’)Hyperglycemia (diabetic w/ high
trigs; which agent to avoid?)
Hepatotoxic
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Binding Resins(cholestyramine)
Decrease enterohepatic circulation of bile salts
10-fold increase in bile salt production (leading to cholesterol excretion)
Upregulation of LDL receptor(need cholesterol)
Increased production of VLDL →hypertriglyceridemia
Used to rx bile-salt induced diarrhea (s/p CCY – 10%)
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Zetia
MOA:Inhibits Niemann-Pick C1-like-1 protein located
on luminal side of the small intestine.
It binds to the transmembrane loop of NPC1L1 inhibiting internalization/endocytosis
AE: nothing important
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PCSK9 Inhibitors:
PCSK9 agents interfere with recycling of the LDL receptor.
Patients with genetic deficiency of PCSK9 have low LDL cholesterol and low rates
of CAD
Monoclonal antibodies against PCSK9 increase LDL receptor and lower cholesterol values.
Clinical trials pending on CAD reduction.Cost is an issue.
siRNA oligonucleotides are in study.Oral inhibitors are in development.
Stay tuned!
siRNA
PCSK9 ® Target the LDL receptor for degradation
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Statins: 1st agent was Mevacor. Pay attention to the Meva in Mevacor
If you inhibit this enzyme:
What happens to Mevalonate level?What happens to LDL receptor?
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Statins: 1st agent was Mevacor. Pay attention to the Meva in Mevacor
LDL Receptors
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AE (2): Myalgia PLUS Drug Intax
Be familiar with the inhibitors of statin metabolism(i.e. they increase drug level and risk for rhabdo)
E-mycin & ketoconazole most likely to be seen.
Fibrates increase risk as well…
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Cholesterol Lowering: MOA
Bile Acid Sequestrant/LDL- R
Upregulates LDL receptor
¯ VLDL and lipolysis
Activate PPAR-a/ LPL
HMG CoA Reductase Inh
Cholestyramine
Niacin
Fibrates(gemfibrizol, fenofibrate)
EzetimibeInhibits cholesterol
absorption via NPC1L1 transmembrane protein
PCSK9 Inhibitors ® LDL receptor (protect against degradation)
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Cholesterol Lowering: AE
Triglyceride elevation
Cholelithiasis/Rhabdo
Hyperuricemia (Gout)/IGTFlushing (PG mediated)
Myalgia+HMG CoA Reductase Inh
Cholestyramine
Niacin
Fibrates(gemfibrizol, fenofibrate)
Ezetimibe Pretty Damn Safe
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Your patient is diagnosed with metabolic syndrome. You start a medication to manage his dyslipidemia. He calls the clinic
complaining about acute onset of severe pain, redness and swelling of his foot. Physical exam confirms swelling and redness of the
first metatarsal joint. Which medication was most likely to precipitate this condition?
A. SimvastatinB. NiacinC. FenofibrateD. CholestyramineE. Ezetimibe
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Your patient is diagnosed with HTN. You start a medication to manage his HTN. He calls the clinic complaining about acute onset
of severe pain, redness and swelling of his foot. Physical exam confirms swelling and redness of the first metatarsal joint. Which
medication was most likely to precipitate this condition?
A. SimvastatinB. HCTZC. FenofibrateD. CholestyramineE. Ezetimibe
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The patient is a 65 y.o. male who develops classic anginal symptoms. He refuses angiogram. He does agree to maximize his medical
management. You decide to start him on pravastatin. The treatment is most likely to result in which of the following adaptive responses
at the cellular level?
A. Decreased transcription of HMG-CoA reductaseB. Increased mevalonic acid degradationC. Increased mevalonic acid synthesisD. Increased hepatic expression of LDL cholesterol receptors
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The patient is a 65 y.o. male who develops classic anginal symptoms. He refuses angiogram. He does agree to maximize his medical
management. You decide to start him on pravastatin. The treatment is most likely to result in which of the following adaptive responses
at the cellular level?
A. Decreased transcription of HMG-CoA reductaseB. Increased mevalonic acid degradationC. Increased mevalonic acid synthesisD. Increased hepatic expression of LDL cholesterol receptors
Increased
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Given the patient’s CAD, lipid lowering drug therapy is initiated. Upon repeat testing, his triglycerides are noted to be elevated.
Which of the following drugs, when used as monotherapy, would be most likely to increase the triglyceride level?
A. AtorvastatinB. NiacinC. GemfibrozilD. CholestyramineE. Ezetimbe
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Howard J. Sachs, MDwww.12DaysinMarch.com
Email: [email protected]
Podcast (Video Recorded Lecture Series):Lipoprotein Metabolism and Lipid Therapy for the USMLE Step One Exam