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bnf 2021 > 2. Hyperlipidaemia > Flashcards

2. Hyperlipidaemia Flashcards

1
Q

What is

Hyperlipidaemia

A

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).

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2
Q

Hyperlipidaemia

Can be the cause of: (4)

A

Artherosclerosis

Coronary heart disease like:
Angina
MI

stroke

Peripheral arterial disease

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3
Q

Hyperlipidaemia

CVD prevention

Primary prevention: (6) cases

Give meds?

A

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+

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4
Q

Hyperlipidaemia

Secondary prevention

A

Stabilised CVD

Angina
MI
Stroke 
TIA transient ischamic attack (mini stroke) 
Peripheral arterial disease PAD

Note: REGARDLESS OF THEIR SERUM CHOLESTEROL

Stat 80mg atorvastatin

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5
Q

What is

Peripheral arterial disease (PAD)

A

Peripheral arterial disease (PAD) is a common condition where a build-up of fatty deposits in the arteries restricts blood supply to leg muscles.

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6
Q

What is the QRISK2 calculator

A

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

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7
Q

QRISK2
Not suitable for
:

(5)

As it under estimates the real risk

A 
1 Type 1 diabetic 
2 Established CVD
3 Over 85
4 CKD (eGFR <60ml/min/1.73m2)
5 Familial hypercholesterolaemia
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8
Q

Cholesterol targets

Hyperlipidaemia diagnosis :

A

6 mmol/L and above

In total cholesterol

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9
Q

Hyperlipidaemia

Total cholesterol target in

HEALTHY ADULT

A

5 mmol/L or less

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10
Q

Hyperlipidaemia

Total cholesterol target in
High risk adults

A

4mmol/L or less

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11
Q

Hyperlipidaemia

LDL= low density lipoprotein
Bad ❌

LDL target in healthy adults

A

3mmol/L or less

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12
Q

Hyperlipidaemia

LDL= low density lipoprotein
Bad ❌

LDL target in high risk adults

A

3mmol/L or less

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13
Q

Hyperlipidaemia

HDL: high density lipoprotein
Good

HDL target in all adults

A

1mmol/L or more

The higher this number the better

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14
Q

Hyperlipidaemia

Triglycerides target in all adults

A

1.7mmol/L or less (less is better)

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15
Q

Drugs that cause hyperlipidaemia

10

A 
Antipsychotics 
Immunosuppressants
Corticosteroids 
Antiretrovirals (HIV drugs) 
Diuretics 
retinoids
oral oestrogen
beta-blockers
antidepressants
anticonvulsants
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16
Q

Conditions causing hyperlipidaemia

A 
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.

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17
Q

Hyperlipidaemia

Tx is to prevent CVD

Before starting a stating which underlying conditions must be treated first (3)

A

Liver disease

Hypothyroidism-hyperthyroidism

Nephrotic syndrome (albuminuria)

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18
Q

When are statins best taken

Any exemptions?

A

At night!

Except atorvastatin

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19
Q

High intensity statins

What does that mean and which ones are they? 3

A

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

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20
Q

High intensity statin

Statin CI what to do?

A
  1. Reduce dose of high intensity statin
  2. Switch to lower intensity statin
  3. If pt intolerant of all 3 statins -> specialist
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21
Q

Hyperlipidaemia

Hypercholesterolaemia
Tx

A
  1. Statins
  2. High intensity statins
    3 statins CI ezitime

Primary
Familial cholesterolaemia

In SEVERE hyperlipidaemia ADD ezitime to statin

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22
Q

Hyperlipidaemia

Hyper triglyceridaemia

Tx

Moderate

Severe

A
  1. Statin
  2. 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

23
Q

Statins

Pts MUST REPORT:

A 
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

24
Q

Statins

Increased risk of muscle toxicity in

(Conditions 4)

A

Personal/ family history of muscle disorders

Increase alcohol intake

Renal impairment

Hypothyroidism

25
Q

Statins :

Caution

Concomitant use of statin +
(3)

A

Avoid statin with

  1. Ezetimibe
  2. fibrates especially (gemfibrozil)
  3. Systemic fusidic acid ( restart statin 7 days AFTER last dose of fusidic acid; risk of RHABDOMYOLYSIS)

(avoid unless specialist prescribed)

26
Q

Statins

SE

A

SOB
COUGH
WEIGHLOSS
Asthenia (abnormal physical weakness or lack of energy)

constipation; diarrhoea; dizziness; flatulence; gastrointestinal discomfort; headache; myalgia; nausea; sleep disorders; thrombocytopenia

27
Q

Statin

Caution BNF

A

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)

28
Q

Statins

monitoring BNF

A

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

29
Q

Statins

Monitoring 6

A

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

30
Q

List

Fibrates

A

Fenofibrate

Bezafibrate

Ciprofibrate

Fenofibric acids

Gemfibrozil AVOID WITH STATINS!!!

31
Q

Fibrates

SE

A

Abdominal pain; diarrhoea; flatulence; nausea; vomiting

32
Q

Fibrates

Cautions

A

Gall bladder disease; pancreatitis (unless due to severe hypertriglyceridaemia);

photosensitivity to fibrates;
photosensitivity to ketoprofen

33
Q

Statins

metabolism REDUCED

by enzyme inhibitors

such as: 10

A

Rate limiting CCB
verapamil and diltiazem

Amiodarone

Amlodipine

Ciclosporin

Grapefruit juice

Itraconazole

Clarithromycin

Setraline

Sildenafil

34
Q

Dose adjustments

Simvastatin with

FIBRATE

Amiodarone, amlodipine, CCB

A

MAX 10mg simvastatin

MAX 20mg simvastatin

35
Q

Dose adjustment

Atorvastatin

And

Ciclosporin

A

Max 10mg if atorvastatin

36
Q

Dose adjustment

Rosuvastatin

And

Clopidogrel

A

Initially 5mg - MAX 20 of rosuvastatin

37
Q

Alternative to

Statins what can be given?

hyper triglyceridaemia

A

FIBRATE

38
Q

What to give if statins CI
In pts

Hyperlipidaemia

A

Ezetimibe

39
Q

Statins and pregnancy

A

Contraception

Stop statins 3 months before trying to conceive

Contraception during treatment

Contraception 1 month after treatment

Restart AFTER Breastfeeding

40
Q

Tx for

Hypercholesterolaemia

Bike acids
What are they?

A

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

41
Q

Bike acids

Initiated by specialist

List

When & how to take

A 
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

42
Q

Bile acids sequestrates

SE

A

Constipation; gastrointestinal discomfort; headache; nausea; vomiting

43
Q

Hyperlipidaemia

Omega 3 fatty acids

A

No evidence for use

44
Q

Name 3 long 1/2t statins

Can be taken at anytime of the day

A

Atorvastatin
Rosuvastatin
Pitavastatin

45
Q

Name 3 statins

that have a short half life

have to be taken at NIGHT only

A

Simvastatin
Lovastatin
Fluvastatin

46
Q

Lipophilic statins

Increased risk of developing myalgias

A

atorvastatin,
simvastatin,
fluvastatin,

47
Q

Hydrophobic

Statins

Less risk of developing myalgias

A

rosuvastatin

pravastatin

Fluvastatin

48
Q

Statins

and

impaired renal function

Best statin to give

A

Atorvastatin

Or

Fluvastatin

49
Q

Statins

and

impaired renal function

Statin to AVOID:

A

Rosuvastatin

50
Q

Statins

and

CYP3A4

Drug interaction

AVOID those 2 statins

A

Simvastatin

And

Atorvastatin

51
Q

Statins

and

CYP3A4

Drug interaction

To give:

A

Pravastatin

Or

Rosuvastatin

52
Q

Statins

List

A 
atorvastatin 
fluvastatin 
pravastatin 
rosuvastatin 
simvastatin
53
Q

TLD
THIAZIDES LIKE DIURETICS

In renal impairment

A

Not effective ❌

Therefore give LOOP DIURETICS

Furosemide
Bumetanide

bnf 2021 (20 decks)

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