NBME 22 Decreasing VLDL (NBME Answers)

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Retired NBME 22 Answers

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A 28-year-old man has recurrent pancreatitis ...
Decreasing VLDL 🔍 / 📺 / 🌳 / 📖
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submitted by ∗hyperfukus(111)

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so I think if you forget actual drugs on the market that we know of and how they work, the question is purposely not asking you that specifically...If you flip it in your head to think what the problem is that leads to inc TG its because of VLDL therefore they said administering a DRUG with which of the following EFFECTS is MOST appropriate--->DECREASING VLDL b/c that's the culprit

Although drugs we know of have the other characteristics, for this guy, we would be looking for the effect of VLDL everything else is a side thing that doesn't directly address his condition

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an1 Pancreatitis is due to Type 1 (high chylomicrons, TG, cholesterol) or Type 3 ( chylomicrons, VLDL). Increasing chylomicrons would not be helpful, best approach is to reduce VLDL. Increasing HDL would be protective again MI, pancreatitis is occurring due to excess ‘fat’ so the best approach is to reduce it +

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submitted by ∗dr.xx(176)

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Fibrates decrease triglycerides by reducing the production of VLDL.

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submitted by ∗gh889(154)

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The answer is due to an exception outlined here where niacin is used in pts w/o diabetes who have refractory hypertriglyceridemia at high risk or has a hx of pancreatitis.

I agree that fibrates are first line (and so does that article) but NBME was honing in on a specific exception that niacin can also be used since VLDL and TGs are high in hypertriglyceridemia.

The "clue" they had was "recurrent pancreatitis" which is supposedly a lead towards niacin.

I also put increase HDL....

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wutuwantbruv Correct, you would not want to give fibrates to someone with recurrent pancreatitis since fibrates increase the risk of cholesterol gallstones due to inhibition of cholesterol 7α-hydroxylase. +2

kernicterusthefrog FYI @gh889 can't follow your link w/o an NYIT username and password, unless there's a more tech-savvy way around that.. I appreciate the info, though. Niacin rx for familial hypertriglyceridemia w/ recurrent pancreatitis. Now I know.. +4

impostersyndromel1000 Great points, very in depth knowledge taking place here. Also, familial hypertriglyceridemia (per FA 2019 pg 94) has hepatic overproduction of VLDL so picking this would have been the easiest answer (in retrospect) +4

hyperfukus @impostersyndrome1000 literally that's the ONE thing i remembered and i went YOLO lol cuz i was staring for a while +2

osler_weber_rendu @gh889 I agree niacin is the answer, but even niacin causes increase in HDL. As if getting to the drug wasnt tough enough, NBME puts two of its actions in the options! What a shit question +3

mtkilimanjaro I forget where I saw (maybe UWorld), but I always thought increasing HDL is never really a primary form of lipid control. You want to lower the bad cholesterol etc. since increasing good cholesterol wont change LDL VLDL etc. +2

jaramaiha @mtkilimanjaro I believe it was in BnB. Dr.Ryan mentioned that there hasn't been enough evidence that raising HDL would be beneficial as far as lipid control goes. Better studies were done on statins hence why they are usually first line Tx. +

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submitted by ∗armymed88(49)

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Shouldn't the treatment for hyperTG be a fibrates? Which would indicate the answer to be increasing HDL (FA.2017 p306)

I see decreasing VLDL as a function of niacin, which serves to decrease hepatic VLDL..

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keycompany Fibrates inhibit VLDL secretion (by inhibiting 7-a Hydroxylase) and they increase HDL. However, this patient has chronic pancreatitis, which decreases enzymes that allow for fat absorption. Because a large portion of HDL is synthesized in enterocytes from newly absorbed fat, HDL content is unlikely to increase in patients with chronic pancreatitis from any of the lipid-lowering agents. Hope this helps! +3

mr_haib fibrates cause decreased VLDL as well as niacin. They increase the activity of LpL by activating PPARa causing increase catabolism of VLDL and chylomicrons. since VLDL are rich in triglycerides, this is how they decrease triglycerides. +1

lordxrequiem but fibrates also decrease bile acid production by inhibiting 7alpha hydroxylase, which is how they cause increased cholesterol gallstones. +3

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submitted by monique(10)

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Fibrates, used for hypertriglyceridemia, act by upregulating LPL, which on its way transforms VLDL ( and CHYLOMICRONS) in free fat acid that will be stored in adipose tissue> therefore DECREASING VLDL LEVELS .

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submitted by ∗biteme(1)

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Other than chylomicrons, VLDL have the highest triglyceride content of any of the lipoproteins. Since decreasing chylomicrons isn't an option, decreasing VLDL is your only choice to keep it out of circulation.

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submitted by 2weekstomyexamaah(0)

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After I did this NBME, I got QID 166 wrong (I put niacin); and now I'm not sure which is the right way to think about it. In 166, the pt has hyperTG and answer is to treat him with fibrates to prevent recurrences - idk if anyone else had this confusion.

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submitted by fleurmuxlin(0)

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First Aid Page 94

Type 4 -hypertriglyceridemia is caused by Hepatic overproduction of VLDL. If we just consider the primary issue, then it is easy to see why decreasing VLDL would be the answer.

(full disclosures, I also was think about the types of medication that should be used)

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submitted by ∗imgdoc(183)

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Guys, there are two ways to go about this question:

You recognize this guy has familial hypertriglyceridemia.

You recognize that chylomicrons and VLDL are the only two triglyceride molecules in this entire list. This narrows it down to 1 answer, decreasing VLDL, because the other answer choice was to increase chylomicrons. Boom, this is one way of answering it.
You recognize that we give fibrates for hypertriglyceridemia. They have 1 MOA, which is to active peroxisome proliferator activator alpha, and that increases HDL levels, decreases VLDL levels, and upregulates Lipoprotein lipase. This also narrows it down to two options, increase in HDL and decrease in VLDL levels. Whats the function of HDL? it leads to CETP upregulation and decreases cholesterol levels. It isn't useful in the reduction of triglycerides. Boom, your answer is still decreasing VLDL.

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submitted by ∗adong(144)

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from uworld: fibrates activate PPAR-alpha to increase LPL and decrease VLDL production

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submitted by ∗syoung07(58)

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familial HyperTG is is due to overproduction of VLDL. It's familial dyslipidemia type 4. Annoying to keep all of those straight but check out FA p.94 (2018)

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