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NBME 22 Answers

nbme22/Block 1/Question#2 (52.2 difficulty score)
A 28-year-old man has recurrent pancreatitis ...
Decreasing VLDLπŸ”

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submitted by hyperfukus(76),
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os I hnkti if ouy rfoget caault udrgs on het emartk tath we knwo of dan woh eyht korw, the itnuesqo is lpyesroup nto gksina oyu htat uyo flpi ti ni royu ahed ot ktihn waht eth olbrpme is htat dslea to icn TG sti eubsaec fo LLDV eterehofr tehy adis gidmasinitnre a GRDU tiwh hchiw of het onliwfglo FEEFCTS is TMOS aitpEeCD-apI-EgoGN&Rtpr;rSA- LDVL /cb h'astt teh cpiulrt

ghAouhlt sgdur ew nokw of hvae eht rtheo hrtacccsta,sirie ofr shit ,gyu ew uwdlo eb ikoonlg ofr eht tefecf of DLLV yenthvgeir sele si a ides ihngt ttah 'otesdn yrdlicte sdredas ish iotcnndio

submitted by dr.xx(150),
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etbaFisr ceeasedr rcyriidseetlg yb nucdeirg eht pticodnuro fo LDVL.

submitted by gh889(125),
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heT wensra is due to an ptxnceioe duneiotl erhe erehw innaci is udes in pst o/w beaseitd how ahev reyatrcofr yrtmeeelghryidcarpii ta ihhg iskr ro ash a xh fo an.acritsitep

I geaer htat tfsebari ear rfsit niel da(n os odes that artc)iel btu BMEN asw nhonig in on a icpecfis tncieoxpe taht nnicia nac olsa be usde ecsni LDVL dna GTs aer ihhg ni ecidrehmaglptire.iryy

Teh "u"elc hyet adh was nrrur"etec "inrstiaapcte ichwh si ppsulysdoe a elad owrdats

I lsao upt ieraesnc ..DLH..

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 7Ξ±-hydroxylase. +  
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.. +2  
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) +2  
hyperfukus  @impostersyndrome1000 literally that's the ONE thing i remembered and i went YOLO lol cuz i was staring for a while +  
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 +1  
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. +  
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. +  

submitted by armymed88(47),
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'uSlndoth hte ttrnamtee orf yGprhTe eb a trsea?ibf chihW odulw iadticen teh sreanw ot be icngseanri LDH 7(2A0F1. p)306

I see erngdaiecs VLLD as a fucniont of cnian,i ichwh reessv to eaesrcde iaphetc V.L.LD

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! +2  
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. +  
lordxrequiem  but fibrates also decrease bile acid production by inhibiting 7alpha hydroxylase, which is how they cause increased cholesterol gallstones. +2  

submitted by monique(8),

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 .

submitted by fleurmuxlin(1),
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Frtis idA eaPg 94

ypTe 4 mirhagcryeyl-edetpiri is cuedsa yb teHapic rodoonceriptuv of V.LLD If ew tjus oicdsern het impyrar su,sei then it is esya ot ees why egesdiarnc VLLD uwldo be het asrn.we

u(fll ordisculess, I loas asw hintk obuta eht eptys of idmeanicto atth ousdhl be d)eus

submitted by biteme(1),

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.

submitted by adong(97),

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

submitted by syoung07(27),

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)

submitted by 2weekstomyexamaah(0),
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fAert I did tish NBE,M I got IQD 661 gnowr (I put ii)ac;nn dna wno m'I ton ures icwhh is eth htrig yaw ot tihnk aoubt it. In ,166 het tp sha hyerTGp dan rawsne is to etrta him hwit efibsatr to eenvrpt crucnseeerr - ikd fi nnyaoe slee dah hits ocsoinfu.n