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Chapter 35: Agents Used in Dyslipidemia

PJ is a 5-year-old boy. At his checkup, the pediatrician notices cutaneous xanthomas and orders a lipid panel. Repeated measures confirm that the patient’s serum cholesterol levels are high (936 mg/dL). Further testing confirms a diagnosis of homozygous familial hypercholesterolemia. Which of the following interventions will be least effective in this patient?

(A) Atorvastatin

(B) Ezetimibe

(C) Lomitapide

(D) Mipomersen

(E) Niacin

Homozygous familial hypercholesterolemia is caused by mutations leading to dysfunctional LDL receptors incapable of taking up LDL from the bloodstream. Options B–E would have a cholesterol-lowering effect. Lomitapide and mipomersen are specifically indicated for patients with familial hypercholesterolemia. Reductase inhibitors such as atorvastatin rely on functional LDL receptors to achieve a LDL-lowering effect and thus will not work in patients with homozygous familial hypercholesterolemia. The answer is A.

A 46-year-old woman with a history of hyperlipidemia was treated with a drug. The chart below shows the results of the patient’s fasting lipid panel before treatment and 6 months after initiating drug therapy. Normal values are also shown. Which of the following drugs is most likely to be the one that this patient received?

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Lipid Measurement Before treatment Six months after starting treatment Normal values
Triglyceride 1000 300 <150
Total Cholesterol  640 280 <200
LDL Cholesterol  120  90 <130
VLDL Cholesterol  500 150 <30
HDL Cholesterol   20  40 >35

(A) Colestipol

(B) Ezetimibe

(C) Gemfibrozil

(D) Lovastatin

(E) Niacin

This patient presents with striking hypertriglyceridemia, elevated VLDL cholesterol, and depressed HDL cholesterol. Six months after drug treatment was initiated, her triglyceride and VLDL cholesterol have dropped dramatically and her HDL cholesterol level has doubled. The drug that is most likely to have achieved all of these desirable changes, particularly the large increase in HDL cholesterol, is niacin. Although gemfibrozil lowers triglyceride and VLDL concentrations, it does not cause such large increases in HDL cholesterol and decreases in LDL cholesterol. The answer is E.

A 35-year-old woman comes in for her annual checkup. Labs are ordered and her lipid values are shown in the table.

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Lipid Patient values Reference range
Cholesterol mg/dL 209 100–240 (<200 desirable)
Triglycerides mg/dL 352 < 150 optimal
HDL mg/dL 37 >60 desirable
LDL mg/dL 102

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