2. Hyperlipidaemia Flashcards
What is
Hyperlipidaemia
Hyperlipidaemia is the presence of elevated plasma concentrations of lipids including cholesterol, triglycerides and lipoproteins. It is an important modifiable risk factor for cardiovascular disease (CVD).
Hyperlipidaemia
Can be the cause of: (4)
Artherosclerosis
Coronary heart disease like:
Angina
MI
stroke
Peripheral arterial disease
Hyperlipidaemia
CVD prevention
Primary prevention: (6) cases
Give meds?
Yes give statins!
Diabetic type 1
Diabetic type 2 CVD risk >10%
Risk calculator QRISK2 results in >10% CVD
Chronic kidney disease or albuminuria
Familial hypercholesterolaemia
Age 85+
Hyperlipidaemia
Secondary prevention
Stabilised CVD
Angina MI Stroke TIA transient ischamic attack (mini stroke) Peripheral arterial disease PAD
Note: REGARDLESS OF THEIR SERUM CHOLESTEROL
Stat 80mg atorvastatin
What is
Peripheral arterial disease (PAD)
Peripheral arterial disease (PAD) is a common condition where a build-up of fatty deposits in the arteries restricts blood supply to leg muscles.
What is the QRISK2 calculator
A risk calculator recommended by NICE
It gives a score of how high a persons risk of developing CVD over the next 10 years
The score determine to give statins or not
Age group 84 and less
Scores of >10 %
Require intervention and lifestyle advice
QRISK2
Not suitable for
:
(5)
As it under estimates the real risk
1 Type 1 diabetic 2 Established CVD 3 Over 85 4 CKD (eGFR <60ml/min/1.73m2) 5 Familial hypercholesterolaemia
Cholesterol targets
Hyperlipidaemia diagnosis :
6 mmol/L and above
In total cholesterol
Hyperlipidaemia
Total cholesterol target in
HEALTHY ADULT
5 mmol/L or less
Hyperlipidaemia
Total cholesterol target in
High risk adults
4mmol/L or less
Hyperlipidaemia
LDL= low density lipoprotein
Bad ❌
LDL target in healthy adults
3mmol/L or less
Hyperlipidaemia
LDL= low density lipoprotein
Bad ❌
LDL target in high risk adults
3mmol/L or less
Hyperlipidaemia
HDL: high density lipoprotein
Good
HDL target in all adults
1mmol/L or more
The higher this number the better
Hyperlipidaemia
Triglycerides target in all adults
1.7mmol/L or less (less is better)
Drugs that cause hyperlipidaemia
10
Antipsychotics Immunosuppressants Corticosteroids Antiretrovirals (HIV drugs) Diuretics retinoids oral oestrogen beta-blockers antidepressants anticonvulsants
Conditions causing hyperlipidaemia
high-fat diets, a sedentary lifestyle, obesity Diabetes. Hypothyroidism Liver disease Kidney disease
There are also genetic causes. Familial hypercholesterolemia, one form of hyperlipidemia, is the most common dominantly inherited genetic disorder in humans worldwide.
Hyperlipidaemia
Tx is to prevent CVD
Before starting a stating which underlying conditions must be treated first (3)
Liver disease
Hypothyroidism-hyperthyroidism
Nephrotic syndrome (albuminuria)
When are statins best taken
Any exemptions?
At night!
Except atorvastatin
High intensity statins
What does that mean and which ones are they? 3
They are statins that proxy a greater LDL reduction than
SIMVASTATIN 40mg
Atorvastatin
Primary prevention: 20mg OD
Secondary prevention: 80mg OD
Rosuvastatin 10mg +
⚠️Simvastatin 80 only give if absolutely necessary
High intensity statin
Statin CI what to do?
- Reduce dose of high intensity statin
- Switch to lower intensity statin
- If pt intolerant of all 3 statins -> specialist
Hyperlipidaemia
Hypercholesterolaemia
Tx
- Statins
- High intensity statins
3 statins CI ezitime
Primary
Familial cholesterolaemia
In SEVERE hyperlipidaemia ADD ezitime to statin
Hyperlipidaemia
Hyper triglyceridaemia
Tx
Moderate
Severe
- Statin
- high intensity statin
3 statin CI give FIBRATE
Or if triglycerides still high abs LDL reduced
Add (to the statin) FIBRATE ( except: gemfibrozil)
Or
add (to statin) nicotinic acid
Statins
Pts MUST REPORT:
Symptoms Muscle pain, decreased urination Brown urine Pain in lower back thighs and shoulders Tiredness SOB
Myopathy
Myositis
⚠️Rhabdomyolysis
is a serious syndrome due to a direct or indirect muscle injury. It results from the death of muscle fibers and release of their contents into the bloodstream. This can lead to serious complications such as renal (kidney) failure. This means the kidneys cannot remove waste and concentrated urine
Statins
Increased risk of muscle toxicity in
(Conditions 4)
Personal/ family history of muscle disorders
Increase alcohol intake
Renal impairment
Hypothyroidism
Statins :
Caution
Concomitant use of statin +
(3)
Avoid statin with
- Ezetimibe
- fibrates especially (gemfibrozil)
- Systemic fusidic acid ( restart statin 7 days AFTER last dose of fusidic acid; risk of RHABDOMYOLYSIS)
(avoid unless specialist prescribed)
Statins
SE
SOB
COUGH
WEIGHLOSS
Asthenia (abnormal physical weakness or lack of energy)
constipation; diarrhoea; dizziness; flatulence; gastrointestinal discomfort; headache; myalgia; nausea; sleep disorders; thrombocytopenia
Statin
Caution BNF
Elderly; high alcohol intake; history of liver disease; hypothyroidism; known genetic polymorphisms—consult product literature; patients at increased risk of muscle toxicity, including myopathy or rhabdomyolysis (e.g. those with a personal or family history of muscular disorders, previous history of muscular toxicity and a high alcohol intake)
Statins
monitoring BNF
Hypothyroidism
Hypothyroidism should be managed adequately before starting treatment with a statin.
Before starting treatment with statins, at least one full lipid profile (non-fasting) should be measured, including total cholesterol, HDL-cholesterol, non-HDL-cholesterol (calculated as total cholesterol minus HDL-cholesterol), and triglyceride concentrations, thyroid-stimulating hormone, and renal function should also be assessed.
Liver function
There is little information available on a rational approach to liver-function monitoring; however, NICE suggests that liver enzymes should be measured before treatment, and repeated within 3 months and at 12 months of starting treatment, unless indicated at other times by signs or symptoms suggestive of hepatotoxicity (NICE clinical guideline 181 (July 2014). Lipid Modification—Cardiovascular risk assessment and the modification of blood lipids for the primary and secondary prevention of cardiovascular disease).
Those with serum transaminases that are raised, but less than 3 times the upper limit of the reference range, should not be routinely excluded from statin therapy. Those with serum transaminases of more than 3 times the upper limit of the reference range should discontinue statin therapy.
Creatine kinase
Before initiation of statin treatment, creatine kinase concentration should be measured in patients who have had persistent, generalised, unexplained muscle pain (whether associated or not with previous lipid-regulating drugs); if the concentration is more than 5 times the upper limit of normal, a repeat measurement should be taken after 7 days. If the repeat concentration remains above 5 times the upper limit, statin treatment should not be started; if concentrations are still raised but less than 5 times the upper limit, the statin should be started at a lower dose.
Diabetes
Patients at high risk of diabetes mellitus should have fasting blood-glucose concentration or HbA1C checked before starting statin treatment, and then repeated after 3 months
Statins
Monitoring 6
1 baseline lipid profile
2 renal function
3 thyroid function
4 HbA1c if at high risk developing diabetes
5 creatine kinase if 5x the normal STOP!
6 liver function if 3x the normal STOP!
“Liver transaminases
List
Fibrates
Fenofibrate
Bezafibrate
Ciprofibrate
Fenofibric acids
Gemfibrozil AVOID WITH STATINS!!!
Fibrates
SE
Abdominal pain; diarrhoea; flatulence; nausea; vomiting
Fibrates
Cautions
Gall bladder disease; pancreatitis (unless due to severe hypertriglyceridaemia);
photosensitivity to fibrates;
photosensitivity to ketoprofen
Statins
metabolism REDUCED
by enzyme inhibitors
such as: 10
Rate limiting CCB
verapamil and diltiazem
Amiodarone
Amlodipine
Ciclosporin
Grapefruit juice
Itraconazole
Clarithromycin
Setraline
Sildenafil
Dose adjustments
Simvastatin with
FIBRATE
Amiodarone, amlodipine, CCB
MAX 10mg simvastatin
MAX 20mg simvastatin
Dose adjustment
Atorvastatin
And
Ciclosporin
Max 10mg if atorvastatin
Dose adjustment
Rosuvastatin
And
Clopidogrel
Initially 5mg - MAX 20 of rosuvastatin
Alternative to
Statins what can be given?
hyper triglyceridaemia
FIBRATE
What to give if statins CI
In pts
Hyperlipidaemia
Ezetimibe
Statins and pregnancy
Contraception
Stop statins 3 months before trying to conceive
Contraception during treatment
Contraception 1 month after treatment
Restart AFTER Breastfeeding
Tx for
Hypercholesterolaemia
Bike acids
What are they?
Bile acid sequestrants act by binding bile acids, preventing their reabsorption; this promotes hepatic conversion of cholesterol into bile acids; the resultant increased LDL-receptor activity of liver cells increases the clearance of LDL-cholesterol from the plasma
Bike acids
Initiated by specialist
List
When & how to take
cholestyramine. colesevelam. (4hrs before n 4 after) Colestipol Colestid. LoCholest. Prevalite. Questran. Questran Light.
“1 hr before food or 4 hrs after”
Impair absorption of Fat soluble vits ADEK
Bile acids sequestrates
SE
Constipation; gastrointestinal discomfort; headache; nausea; vomiting
Hyperlipidaemia
Omega 3 fatty acids
No evidence for use
Name 3 long 1/2t statins
Can be taken at anytime of the day
Atorvastatin
Rosuvastatin
Pitavastatin
Name 3 statins
that have a short half life
have to be taken at NIGHT only
Simvastatin
Lovastatin
Fluvastatin
Lipophilic statins
Increased risk of developing myalgias
atorvastatin,
simvastatin,
fluvastatin,
Hydrophobic
Statins
Less risk of developing myalgias
rosuvastatin
pravastatin
Fluvastatin
Statins
and
impaired renal function
Best statin to give
Atorvastatin
Or
Fluvastatin
Statins
and
impaired renal function
Statin to AVOID:
Rosuvastatin
Statins
and
CYP3A4
Drug interaction
AVOID those 2 statins
Simvastatin
And
Atorvastatin
Statins
and
CYP3A4
Drug interaction
To give:
Pravastatin
Or
Rosuvastatin
Statins
List
atorvastatin fluvastatin pravastatin rosuvastatin simvastatin
TLD
THIAZIDES LIKE DIURETICS
In renal impairment
Not effective ❌
Therefore give LOOP DIURETICS
Furosemide
Bumetanide
