Cardiovascular Dyslipidaemia

Question 1

Statins

• example
• moa
• SE
• precautions

Answer 1

Example: atorvaatatin, pravastatin, simvastatin

Moa: competitively inhibit hmg-coa reductase, rate limiting step in cholesterol synthesis, increase hep cholesterol uptake, reduce concentration of total cholesterol, LDL and triglyceride,

SE: myalgia, derange LFT, myopathy rhabdomyolysis, renal failure and hepatitis, pancreatitis, gallstones

Precautions: withhold serious illness, increase risk of myopathy, rhabdomyolysis, rf (which increase myopathy and rhabdomyolysis)
Start low dose, monitor rf and ck, ck, LFT, EUC

Atorvaatatin and simvastatin is better and cheaper then pravastatin

Question 2

Bile acid binding resins

• ‘example
• moa
• SE

Answer 2

Example- cholestyramine, cholestipol

Moa- bind bile acids in intestinal lumen, prevent reabsorption, and increase bile acid excretion in faeces -> increase synthesis of bile acid therefore increase demand for cholesterol therefore increase LDL uptake and remove from plasma

SE: GIT, increase trigs (exacerbate hypertriglyceridaema), steatohoea, malnutrition, malabsorption of fat soluable vitamin, constipation, worsen diverticular disease

Question 3

Vibrates

• example
• moa
• SE

Answer 3

Example - gemfibrozil, fenofibrate

Moa- activiate peroxisome proliferator activated nuclear receptor and modulate lipoprotein synthesis and catabolis, reduce plasma triglyceride,

Variable effect on LDL and increase HDL

SE: GIT distrubance, increase creatinine, photosensitive, cholestatic jaundice, gallstones, anaemia, myopathy, rhabdomyolysis

Question 4

Ezetimibe

• moa
• se

Answer 4

Moa - reduce absorption of dietary and biliary cholesterol by inhibiting its transport across the intestinal wall, therefore increase demand for cholesterol and increase LDL uptake

SE: headache, diahrrhoea, dearranged LFT, myalgia, allergy, pancreatitis, myopathy, raise ck

Question 5

Nicotinic acid

• moa
• SE
• cautions

Answer 5

Moa - suppress fatty acid and release from pheripheral tissue

SE: vasodilate (inhibit if take aspirin before), face and neck flush, hypotension, raise ck, LFT , macular edema, rf

Watch out for rf and take with food

Question 6

Rationale
How to start treatment
When to start
Drug choice

Answer 6

Rationale - reduce atherosclerosis, improve survival and risk of mi/stroke, reduce cardiovascular mortality, prevent pancreatitis

Starting treatment - measure fasting plasma lipid profile, consider cv status, rf, treat secondary cause like obesity, diabetes, hypothyroidism, nephrotic syndrome, alcohol
Non pharm - weight reduce, diet change, exercise, reduce smoke and alcohol, dietitian,

Start when : high risk (pre exist IHD),

Drug choice:
Statins most effective, well tolerated , reduce mortality and morbidity
Isolated hypercholesterolemia use bile acid binding resins, may worsen hypertriglycermka
Nicotinic acid - good LDL and triglyceride lowering effect, increase HDL (adverse effect many)
Ezetimibe. - well tolerated
Fibrates - only if previous drugs not well tolerated