Question 1

A patient who has diabetes is taking simvastatin (Zocor)80 mg daily to treat LDL cholesterol level of 170 mg/dL.The patient has a body mass index of 29.At a follow-up visit,the patient's LDL level is 120 mg/dL.The primary care NP should consider:

A) increasing the simvastatin to 80 mg twice daily.
B) adding nicotinic acid to the patient's drug regimen.
C) changing the medication to ezetimibe/simvastatin (Vytorin).
D) referring the patient to a dietitian for assistance with weight reduction.

Accepted Answer

Patients with diabetes have a goal LDL of less than 100 mg/dL.If maximum-dose statin is unable to achieve the goal LDL,a combination product such as a statin plus ezetimibe is recommended.The maximum recommended dose is 80 mg daily,so increasing the dose to 80 mg twice daily is incorrect.

Question 2

The primary care nurse practitioner (NP)sees a patient for a physical examination and orders laboratory tests that reveal low-density lipoprotein (LDL)of 100 mg/dL,high-density lipoprotein (HDL)of 30 mg/dL,and triglycerides of 350 mg/dL.The patient has no previous history of coronary heart disease.The NP should consider prescribing:

A) ezetimibe (Zetia).
B) gemfibrozil (Lopid).
C) simvastatin (Zocor).
D) nicotinic acid (Niaspan).

gemfibrozil (Lopid).

Accepted Answer

Fibric acid derivatives,such as gemfibrozil,are indicated for reducing the risk that coronary heart disease may develop in patients without a history of coronary heart disease who have low HDL cholesterol levels and elevated triglyceride levels.This patient's LDL is within normal limits,so a 3-hydroxy-3-methylglutaryl coenzyme A (HMG-CoA)reductase inhibitor,such as simvastatin,is not indicated.Ezetimibe is a selective cholesterol absorption inhibitor,used to reduce total and LDL cholesterol.Nicotinic acid is used to treat hyperlipidemia in patients who have failed dietary therapy.

Question 3

A primary care NP sees a 46-year-old male patient and orders a fasting lipoprotein profile that reveals LDL of 190 mg/dL,HDL of 40 mg/dL,and triglycerides of 200 mg/dL.The patient has no previous history of coronary heart disease,but the patient's father developed coronary heart disease at age 55 years.The NP should prescribe:

A) atorvastatin (Lipitor).
B) gemfibrozil (Lopid).
C) cholestyramine (Questran).
D) lovastatin/niacin (Advicor).

atorvastatin (Lipitor).

Accepted Answer

HMG-CoA reductase inhibitors are used to treat hyperlipidemia when the LDL is the primary lipid elevation.This patient has risk factors of being a man older than 45 years,with a positive family history of coronary heart disease before age 55 in a male first-degree relative.Gemfibrozil is used for patients with elevated triglycerides and low HDL.Bile acid sequestrants are used as adjunctive and not first-line therapy for reducing LDL.A combination product is not indicated for first-line therapy.

Question 4

A 55-year-old woman has a history of myocardial infarction (MI).A lipid profile reveals LDL of 130 mg/dL,HDL of 35 mg/dL,and triglycerides 150 mg/dL.The woman is sedentary with a body mass index of 26.The woman asks the primary care NP about using a statin medication.The NP should:

A) recommend dietary and lifestyle changes first.
B) begin therapy with atorvastatin 10 mg per day.
C) discuss quality-of-life issues as part of the decision to begin medication.
D) tell her there is no clinical evidence of efficacy of statin medication in her case.

Accepted Answer

This woman would be using a statin medication for secondary prevention because she already has a history of MI,so a statin should be prescribed.Dietary and lifestyle changes should be a part of therapy,but not the only therapy.She is relatively young,and quality-of-life issues are not a concern.There is no clinical evidence to support use of statins as primary prevention in women.

Question 5

A patient who has hyperlipidemia has been taking atorvastatin (Lipitor)60 mg daily for 6 months.The patient's initial lipid profile showed LDL of 180 mg/dL,HDL of 45 mg/dL,and triglycerides of 160 mg/dL.The primary care NP orders a lipid profile today that shows LDL of 105 mg/dL,HDL of 50 mg/dL,and triglycerides of 120 mg/dL.The patient reports muscle pain and weakness.The NP should:

A) order liver function tests (LFTs).
B) order a creatine kinase-MM (CK-MM) level.
C) change atorvastatin to twice-daily dosing.
D) add gemfibrozil (Lopid) to the patient's medication regimen.

Accepted Answer

Hepatotoxicity and muscle toxicity are the two primary adverse effects of greatest concern with statin use.Patients who report muscle discomfort or weakness should have a CK-MM level drawn.LFTs are indicated with signs of hepatotoxicity.It is not correct to change the dosing schedule.Gemfibrozil is not indicated.

Question 6

A patient who has type 2 diabetes mellitus will begin taking a bile acid sequestrant.Which bile acid sequestrant should the primary care NP order?&#10;A) Colesevelam (Welchol)&#10;B) Colestipol (Colestid)&#10;C) Cholestyramine (Questran)&#10;D) Cholestyramine (Questran Light)

Accepted Answer

All bile acid sequestrants are equally effective.Colesevelam has an additional indication to improve glycemic control in adults with type 2 diabetes and so should be selected when prescribing a bile acid sequestrant for this patient.

Question 7

A patient with primary hypercholesterolemia is taking an HMG-CoA reductase inhibitor.All of the patient's baseline LFTs were normal.At a 6-month follow-up visit,the patient reports occasional headache.A lipid profile reveals a decrease of 20% in the patient's LDL cholesterol.The NP should:

A) order LFTs.
B) order CK-MM tests.
C) consider decreasing the dose of the medication.
D) reassure the patient that this side effect is common.

Accepted Answer

LFTs should be performed at baseline,12 weeks after initiation of therapy,and only periodically thereafter.Headaches are common side effects,but do not raise concern about hepatotoxicity.CK-MM tests are indicated if patients report muscle pain or weakness.It is not necessary to decrease the medication.

Question 8

A patient who has primary hyperlipidemia and who takes atorvastatin (Lipitor)continues to have LDL cholesterol of 140 mg/dL after 3 months of therapy.The primary care NP increases the dose from 10 mg daily to 20 mg daily.The patient reports headache and dizziness a few weeks after the dose increase.The NP should:

A) change the atorvastatin dose to 15 mg twice daily.
B) change the patient's medication to cholestyramine (Questran).
C) add ezetimibe (Zetia) and lower the atorvastatin to 10 mg daily.
D) recommend supplements of omega-3 along with the atorvastatin.

Accepted Answer

When used in combination with a low-dose statin,ezetimibe has been noted to produce an additional 18% reduction in LDL.Because this patient continues to have elevated LDL along with side effects of the statin,the NP should resume the lower dose of the statin and add ezetimibe.Atorvastatin is given once daily.Cholestyramine and omega-3 supplements are not indicated.

Deck 24: Antihyperlipidemic Agents