Welcome to NP Certification Q&A presented by Fitzgerald Health Education Associates. This podcast is for NP students studying to pass their NP certification exam. Getting to the correct test answers means breaking down the exam questions themselves. Leading NP expert Dr. Margaret Fitzgerald shares her knowledge and experience to help you dissect the anatomy of a test question so you can better understand how to arrive at the correct test answer. So, if you're ready, let's jump right in.
A 65-year-old woman who has hypertension, dyslipidemia, type 2 diabetes, a 50-pack-year cigarette smoking history, currently smoking one-half pack per day, and stage 3B CKD, chronic kidney disease, with a GFR of 37, presents for care. She's currently not taking any dyslipidemia therapy and her LDL is 140. Which of the following represents the most appropriate pharmacologic intervention for the treatment of dyslipidemia in this patient?
A. Owing to age and comorbidity, no further intervention is required.
B. Moderate-intensity statin therapy is the preferred treatment option.
C. Niacin should be prescribed.
D. The use of ezetimibe, or Zetia, will likely be sufficient to achieve dyslipidemia control.
Where do we start with this question? First, what type of question is it?
We are directed to treat her dyslipidemia. Therefore, of course, this is a plan question.
Let's take a look at the background information. Dyslipidemia refers to abnormal levels of circulating total cholesterol, usually with elevated LDL and triglycerides, most often with lower levels of HDL. And if you remember with dyslipidemia, you want your highs high, your HDL high, because that's like the cholesterol vacuum cleaner. You want your lows low because the LDL is what gets people into trouble with atherosclerotic disease.
Contributing factors to dyslipidemia, particularly elevated LDL, include genetic predilection. In other words, strong family history of dyslipidemia, a diet rich in saturated fat, sedentary lifestyle,
and the use of certain medications. For example, higher dose thiazide diuretics, progestins, or anabolic steroids. There are certainly other medications that can cause LDL to rise. Dyslipidemia is quite common in type 2 diabetes, as part of this disease’s pathology, the type 2 diabetes, includes insulin resistance, and once again, the classic pattern of dyslipidemia seen with insulin resistance is low HDL, high LDL, high triglycerides. Of course, prolonged dyslipidemia, if untreated, is associated with a marked increased risk for atherosclerotic cardiovascular disease development,including coronary artery disease, cerebrovascular, as well as peripheral vascular disease.
We're talking here about a woman who has multiple risk factors for the development of ASCVD: Her high blood pressure, the dyslipidemia that we're talking about, her tobacco use, plus her type 2 diabetes. And by the way, peripheral vascular disease is actually pretty uncommon in people who only have high blood pressure and dyslipidemia. But then if you add in the tobacco use, you add in the type 2 diabetes, dramatically increases the risk of poor peripheral vascular disease, particularly peripheral arterial disease.
Treatment of dyslipidemia is an important part of cardiovascular and cerebrovascular risk reduction. While intensive lifestyle changes should be the first-line therapy. Medications are commonly used, particularly in a high-risk situation, as is seen in this patient who has those multiple ASCVD risk factors. The choice of a lipid-lowering agent should be guided by the effect of the agent on the lipid profile.
And you know what this gets back to? This gets back to the adage:
Never ask a drug to do something it can't. Like in this particular situation, we weren't given the choice of using a fish oil derivative,
but it wouldn't have been the right answer anyway, because we're only given her LDL. And what do fish oil derivatives do? Lower triglycerides. In this particular patient we’re given her LDL cholesterol only.
I know, I hear you all now going, “I need more data. Where are the rest of her labs?” I would agree with you on that, in clinical practice.
You actually have enough information to answer this question. Recommendations from the American College of Cardiology and the American Heart Association advise statin treatments for individuals with diabetes age 40 to 75 years of age. The ADA chimes in and advocates this as well. There are certainly other groups where statin therapies are also recommended. So, with that as background information, let's take a look at the question and of course, the answer options.
A 65-year-old woman who has hypertension, dyslipidemia, type 2 diabetes, a 50-pack-year cigarette smoking history, currently smoking one-half pack per day, and stage 3B CKD, with a GFR of 37, presents for care. She's currently not taking any dyslipidemia therapy and her LDL is 140. Which of the following represents the most appropriate pharmacologic intervention for the treatment of this patient’s dyslipidemia?
A. Owing to age and comorbidity, no further intervention is required.
This is incorrect. This patient is presenting with just sky high ASCVD risk, and treatment is recommended per EBP. And that would include the recommendations, one more time, of not only the ADA, but also the ACC and the AHA.
B. Moderate-intensity statin therapy is the preferred treatment option.
One more time, she's at very high risk for ASCVD. While high and statin therapy might be preferred over moderate-intensity therapy. In other words, high-intensity statin therapy that will bring the LDL down by 50% or more, compared to moderate-intensity statin therapy that will bring the LDL down by one-third or more. Given her CKD, she's actually at increased risk for a statin-induced myopathy, including the most feared of all rhabdo. Evidence-based practice dictates that individuals with type 2 diabetes be offered at bare minimum, moderate-intensity statin therapy. We're going to take a look at the other options. But this could be an example of the best choice, maybe not the perfect choice, but the best choice because she is in need of a major LDL reduction and the moderate-intensity statin therapy will bring her LDL down by one-third or more. So, let's just so that I don't embarrass myself by doing the math in my head, let's pretend for a moment that her LDL was 150. That math I can do in my head (hers was actually 140). Bringing it down by one-third or more would bring her under 100, an LDL under 100. And that's considered to be at minimum a first step in the treatment of dyslipidemia, because as I believe we're all aware, the ideal LDL is below 100. And for a higher-risk individual like her, it's actually 70 or below. But one more time we’re going to hold that thought for a moment because this Option B might in fact be the best choice.
C. Niacin should be prescribed. Niacin is not recommended for LDL reduction. It does very, actually, it does very very little to help with LDL reduction. And what niacin can do, though, is boost up HDL and lower triglycerides. At the same time, if you comb through all the dyslipidemia treatment guidelines, you're going to find no mention of niacin in the affirmative. And in fact, you might find notation that niacin should not be used. Part of this is due to the results of the AIM-HIGH and other studies, its use is no longer advocated for any dyslipidemia therapy. In other words, niacin will really never be the right answer when it comes to dyslipidemia treatment.
And option D: The use of Zetia will likely be sufficient to achieve dyslipidemia control. Zetia is a cholesterol blocker. It works at the intestinal lumen level, very well tolerated. But this is not the correct answer. That Zetia will provide about a 20% reduction in LDL, very safe, very well tolerated, its use as a solo product is not advised. However, and I prescribed a lot of it for this reason, it's used as a first-line add-on medication when a person's LDL is not at goal with intensified statin therapy. And so that's really where Zetia shines and beautifully.
So, to recap here, the best option is option B. It might not be the perfect answer. And in fact, I could see somebody could argue and say she's at such high risk, she actually needs high-intensity statin therapy. But guess what, folks? We didn't have that as a choice, did we? We did not. So therefore, the best answer is option B, moderate-intensity statin therapy, since it features a first-line recommended treatment for dyslipidemia, the use of a statin.
Key takeaway: knowing which meds are first-line therapy is key to safe practice and certification success.
Key Takeaway Number two: Sometimes the best answer is not the perfect answer.
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