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NBME 22 Answers

nbme22/Block 1/Question#2 (50.4 difficulty score)
A 28-year-old man has recurrent pancreatitis ...
Decreasing VLDLπŸ”

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submitted by hyperfukus(75),
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so I nkhti fi uoy otregf actlua sdurg on eht mtekar tath ew kown fo dna hwo hyet korw, hte uosnetqi si pyerspolu tno aiknsg uoy htat I.aylcs.filpcif.e you plif ti in uyor adeh ot nitkh hawt eht melrbpo si tath desla ot icn TG sit sceeuba fo DLVL ereretfho tyeh idsa trgnsainedimi a RDUG hiwt cwihh of het iologlnwf SETFECF is STMO RCitg-IArEproa-peSGa&ENt-;Dp LVLD cb/ htt'sa eht ruilptc

lghAuoht rudgs ew wkon of veha eth eothr aseithat,riccrcs for iths uyg, we dolwu eb oklgino for eth etfcfe of LDVL ehigetynrv esle is a isde hitgn thta t'onsde irtlydec ddsersa his otndnicio

submitted by dr.xx(143),
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raFetisb sedraece lyiiersgdrtce by udcneirg eht potocrnuid of DLLV.

submitted by gh889(115),
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hTe ensrwa is eud to na eonceixtp lodtniue reeh hweer aciinn is esdu in tps /wo atedbeis hwo aevh afrcreroty rcpliegryiieatherymd at hhgi rkis or ahs a hx of rpcaistienta.

I ergea htta faseibtr ear sftir leni (dna os sedo atht il)ctare utb MENB swa ghoinn in no a icsfepic xntpoceei ttha innaic cna oasl be sude insec LLVD nad TGs rea hghi in eeditiyarirpgc.mrelhy

The "luc"e yhte had was rrercnuet" tsenitair"pac which si sleoudppsy a lade trdoasw

I loas ptu reeacins DH..L..

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. +  

submitted by armymed88(47),
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htndulS'o the ertaetmtn rof rGpTehy eb a ?ifbrtsae hhicW udlow edtcaini teh nraesw ot be inrnicgesa LDH 1.(A2F70 63)0p

I ees crednseagi LLDV as a nfointuc of ncii,an hiwhc sersve ot cdaeeres heiaptc LLV..D

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. +1  

submitted by monique(7),

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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irFts dAi ePga 94

peyT 4 lear-hpetiirrycegdmyi si dusace yb tHicpae verodoncutopri fo D.LLV If we sutj norcesdi hte rmyirap susi,e tenh ti si yase to ees hwy ascginered VDLL uowdl eb teh .ewrsna

lluf( odeiruslscs, I osal asw nhitk utbao hte eptsy fo iaidcmonet ttah hsduol be su)de

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(94),

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

submitted by syoung07(21),

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),

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.