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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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so I nihkt if ouy tgfero cuatal gudrs on eth mkerat htat we kwno fo dan owh heyt ,work teh siequton si yepospurl not sgkina ouy that Ic..el.fafspiicyl uyo fpli ti in uryo dahe to tknih atwh het prmbleo is ttha lsdae ot cni GT tis ecbeusa fo LVLD rfhroeeet yteh idsa daetniniisgrm a UGRD tiwh cihhw fo teh lwfonilgo TSEFCEF is MSTO aEg-CopRD;SGprtNeA-&-irtIpaE DLLV c/b 'satht eht urlitcp

hltoguhA dsurg we wkno fo aevh the hoert iecthrcs,citaras rof hsti ,uyg we lwudo be iolokgn rfo the eftfec fo DLLV ytnigeherv esle is a edsi gnhit thta deto'sn cdyeirtl dsedasr ihs cdnitnoio

submitted by dr.xx(150),
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batFiesr eeercsad ldiiseyegcrtr yb ndgcirue the conuidropt of L.VLD

submitted by gh889(125),
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The nreasw si deu to an potncxeei notieldu ehre where incnai si desu ni pst o/w dbaeseit who eavh rrycareotf medriiarrpeyceghylti ta hhgi irks ro has a hx fo seacinri.tatp

I rgeae tath irfaesbt rea frsti leni dan( os osde atth rcai)tle tub EBNM was nogihn ni on a ecisicpf ptnocexei that nainic anc lsao be duse sicen VDLL adn GTs era ighh in ihmiayrrdteigery.pcel

heT "c"elu hyet dha wsa r"ertuercn asna"reipictt chhiw si pusdylsepo a lead adrswot nna.cii

I alos put nseirace .D..L.H

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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l'hutdSno hte nmatertet for GprehyT be a afirbs?et cihWh wdoul ciaetdni eth esnraw to be garciinesn DHL 0(27.F1A )3p60

I ees sincgreead VLLD sa a nunoctif of nnaic,i hiwch severs to ecdaeesr phatiec LD.LV.

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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tisFr iAd agPe 94

eTpy 4 yaeihltgperyci-erdimr is ausced by ctipHea recunpriootovd fo .DVLL fI we tsuj ncoredis the imrayrp ,essiu enht it si saye ot see why nrcsedeiga VLLD lodwu eb eht ernas.w

f(llu esscuodlirs, I laos was hnitk oatbu het pytes of mtdinieoac htta sdouhl eb )deus

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(25),

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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ftreA I did tshi MEB,N I tog IQD 616 wrogn I( tup in;ianc) and now Im' ont seru hhiwc si hte hgrit wya to ikthn batuo .ti In 616, het tp sah yrepThG adn wnsear is to eratt hmi hiwt sreifabt to eventpr eeecnsrrurc - kdi if eannyo sele dha thsi ciusofno.n