Cardiovascular- HIGH Flashcards
1
Q
When is amiodarone initiated for patients?
A
ONLY under specialist supervision, usually in secondary care (HIGH RISK DRUG)
2
Q
What is amiodarone indicated for?
How does it act on the heart?
A
Arrhythmias- where past treatment has failed
Acts on both supraventricular and ventricular arrhythmias
3
Q
What is the initial dosing schedule for amiodarone?
What is the maintenance dose?
A
Initial: 200mg TDS for 1 week, then 200mg BD for 1 week, then maintenance dose
Maintenance: 200mg OD
4
Q
What potential adverse effects may be brought on by amiodarone therapy?
A
- Corneal microdeposits- rarely interfere with vision but drivers may be dazzled by headlights at night
- Phototoxicity- skin sensitive to sun light. Advise patients to use wide spectrum sunscreen
- Hyper/hypothyroidism- contains iodine (S&S- weight loss, palpitations and insomnia)
- Slight grey skin discolouration (very common)
5
Q
What are the monitoring requirements for amiodarone?
A
- Thyroid function test- every 6 months
- LFTs- before treatment and every 6 months thereafter (any signs of hepatotoxicity- STOP TREATMENT)
6
Q
What might a new/progressive SoB or cough indicate in amiodarone-taking patients?
A
Pneumonitis (inflammation of lungs)
7
Q
With which other drugs does amiodarone INCREASE the risk of arrhythmias
A
- Amitriptyline
- Lithium
- Quinines
- Erythromycin
- Haloperidol
8
Q
Is amiodarone safe in pregnancy and BF?
A
Pregnancy- possible risk of neonatal goitre (doffuse of nodular enlargement of the thyroid gland). Only use if no alternative
BF- Avoid; present in milk in significant amounts; theoretical risk of neonatal hypothyroidism from release of iodine
9
Q
What is the mode of action of beta blockers?
A
Reduce cardiac output by BLOCKING beta-receptors in the heart
Also act on beta-receptors in the liver, bronchi and pancreas
10
Q
When are beta blockers contraindicated?
A
Uncontrolled heart failure
11
Q
What kind of beta blocker should asthma and COPD patients recieve?
Examples?
A
Cardio-selective BBs
Atenolol, bisoprolol, Metoprolol, nebivolol and acebutolol
12
Q
What are the side effects of beta blockers?
A
- GI upset
- Headache, dizziness, fatigue
- coldness of extremities
- Sleep disturbances (nightmares)
- Affect carbohydrate metabolism- causing hypoglyacemia
13
Q
When should beta blockers be avoided where possible?
A
- Asthma and COPD- action on bronchi can cause bronchospas
- Diabetes- action on pancreas and liver can reduce cardbohydrate metabolism and induce hypo/hyperglycaemia (use with caution)
14
Q
Where should beta blockers be used in caution?
A
Diabetic patients- can mask hypoglyceamia
Cardioselective BB may be preferred
15
Q
Wht are beta blockers indicated for?
A
- Angina- reducing workload of heart and prevent recurrence of MI
- Anxiety symptoms
- Migraine prophylaxis
16
Q
Examples of cardioselective beta blockers
A
- Acebutol
- Atenolol
- Betaxolol
- Bisoprolol
- Celiprolol
- Metoprolol
- Nebivolol
17
Q
Examples of non-selective beta blockers
A
- Carvedilol
- Labetalol
- Nadolol
- Oxprenolol
- Pinolol
- Propranolol
- Stotalol
- Timolol
18
Q
What is the mode of action of digoxin?
A
Increase the force of myocardial (heart muscle) contraction and reduced contractivity of the AV node
19
Q
What is digoxin indicated for?
A
- Atrial fibrillation
- Heart failure
20
Q
What is the dosing schedule for digoxin?
What is their dose determined by ?
A
Long half life so OD dosing
However, if patient not feeling effects then can be BD
Dose determined by renal function
21
Q
If required, when should bloods be taken for digoxin monitoring?
A
At least 6 hours after a dose
22
Q
What are the S&S of digoxin toxicity?
A
- N&V
- Blurred/yellow vision
- Weight loss
- Anorexia
- Palpitations
- Hallucinations
- Abdominal pain
23
Q
How is digoxin toxicity treated?
Does the formulation affect the dose?
A
A digoxin specific antibody e.g. Digifab
YES- liquid and tablets have different bioavilabilities
24
Q
What is tranexamic acid indicated for?
Dosing schedule?
A
- Prevent bleeding associated with excessive fibronylosis e.g. surgery, dental extraction
- Management of menorrhagia
- 2-3 500mg tablets BD/TDS
25
What is the mode of action of tranexamic acid?
Inhibits excessive fibrinolysis (prevents blood clots from being broken down)
26
What is venous thromboembolism (VTE)?
| Which two conditions come under this?
Thrombus (clot) formation in a vein
| Deep-vein thrombosis (DVT) + Pulmonary Embolism (PE)
27
Which patient groups are at greater risk of venous thromoelmbolism?
* > 60 years old
* Limited mobility (secondary care- long stay!)
* Obesity
* Malignant disease
* Thrombophilic disorder
* History of VTE
28
What is pulmonary embolism?
Blocking of a vein from the heart to the lungs
29
How is VTE managed?
Prophylaxis with Low Molecular Weight Heparin (LMWH) e.g. apixaban
30
How is VTE managed in patients with renal failure?
Unfractionated heparin
31
What is given to patients if suffering with a haemorrhage while taking unfractionated heparin?
Protamine- given to reverse effects of unfractionated heparin
Only partially effective for LMWH
32
Can heparin be given in pregnancy?
| What else may be preferred?
Yes- it doesn't cross the placenta
However, LMWH preferred due to reduced risk of osteoporosis and heparin-induced thrombocytopenia (low platelet count)
33
What are the side effects of heparin?
* Thrombocytopenia (reduced platelet count)
* Hypokalaemia (low potassium)
34
What is the dosing schedule for a LMWH?
Duration of action is longer so is OD
35
What is warfarin indicated for?
* Atrial fibrillation
* Deep vein thrombosis (DVT)
* Pulmonary embolism (PE)
36
What is the mode of action of warfarin?
| How long before effects are felt?
Vitamin K antagonist (needed to produce clotting factors)
Usually takes at least 48-72 hours to feel full effect
If effect is needed sooner, use a heparin
37
How are doses calculated for warfarin?
| What are the target ranges for AF, DVT, PE and mechanical aortic valves
Dose calculated based on patients INR
Targets:
* AF, DVT and PE = **2.5**
* Mechanical aortic valve = **3.5**
38
What are the counselling points for warfarin?
Ensure dose taken at **same time each day**
39
How often should INR be monitored?
| Initially and then once stable?
Initially- daily or alternate days
Stable- longer durations up to 12 weeks apart
40
What patient changes may affect INR and require more frequent monitoring?
* Decreased liver function
* Medication changes
* Diet
* Smoking
* Alcohol intake
* Recent weight loss
* Acute illness
* Diarrhoea and vomiting
41
What is the main adverse effect of warfarin?
| and how is it managed?
Haemorrhage (bleeding)
Warfarin stopped immediately and patient started on vitamin K
42
What is the management if no bleeding present but INR > 8
| What if INR is 5-8
Give vitamin K orally, and withhold warfarin
| Just withhold warfarin (no vitmain K)
43
How is warfarin therapy managed around elective surgery
| and patients at particularly high risk of VTE
Stopped 5 days prior to surgery
Restarted almost immediately after the procedure
If high risk VTE, given 'bridging' therapy with LMWH- should be stopped 24h before surgery and restarted 48 hours after
44
How are warfarin patients managed during emergency surgery?
Given vitamin K with prothrombin complex depending on timescale
45
Which regimen has a greater bleeding risk?
Aspirin + Warfarin
or
Clopidogrel + Warfarin
Clopidogrel + Warfarin
46
Can warfarin be given in renal impairment?
Yes- increased frequency of INR monitoring needed in severe impairment
47
What is aspirin typically indicated for?
Secondary prevention of cardiovascualr disease (75mg OD)
can be given with prasugrel/ticagralor for prevention of thrombotic events in acute coronary syndrome (sudden reduced blood flow to heart)
48
What is the dosing regimen for rapid digitalisation in digoxin therapy?
0.75-1.5mg over 24h in divided doses
49
Common Se of digoxin
* Dizziness
* Blurred vision
* Skin rash
50
What can cause increased levels of serum digoxin?
* Renai imapirment (renally cleared)
* Low body weight
* P-glycoprotein transport inhibitors e.g. amiodarone, verapamil, macorlides (-mycin), azole antifungals (fluconazole), ciclosporin
51
Vigorous diuresis may result in...?
Increased risk of acute hypotension (low BP)
52
How is gravitational oedema managed?
Movement alone
53
How is cerebral oedema managed?
Osmotic diuretic i.e. IV mannitol
54
What can be used to manage altitude sickness prophylaxis
Carbonic anhydrous inhibitors e.g. acetazolamide
55
What complication can commonly arise from thiazide-like and loop diuretics?
Hypokalaemia- low potassium
Dangerous in severe CVD, esp in patients on cardiac glycosides e.g. digoxin
56
What can hypokalaemia in heart failure precipitate?
Encephalopathy- reduced blood flow/oxygen to the brain
57
How does hypokalaemia affect magnesium levels?
Increases risk of hypomagnesia (low magnesium)
This can lead to increased risk of arrhythmia in alcoholic cirrhosis
58
What is the mode of action of thiazide-like diuretics?
Inhibits the NaCl channel in proximal segment of the distal convoluted tubule
59
What are thiazide-like diuretics indicated for?
Treat oedema due to chronic heart failure
60
What condition can thiazide-like diuretics exacerbate
Diabetes
Do NOT use in gestational diabetes
61
What are the common side effects of thiazide-like diuretics?
* GI disturbances
* Postural hypotension
* Hypokalaemia (avoid in refractory hypokalaemia)
62
What should be monitored while using thiazide-like diuretics?
U&Es
63
When should thiazide-like diuretics be taken?
Ideally in the morning
Can cause urinary urgency during the night
64
What are the bendroflumethiazide doses for oedema and HTN?
1. Oedema- 5-10mg daily
2. Hypertension- 2.5mg daily
65
What are the indapamide doses for regualr and SR forms?
Regular- 2.5mg OM
SR- 1.5mg OM
66
What is the mode of action for loop diuretics?
Inhibits reabsorption of NaCl in the loop of Henle
Results in increased excretion of water and loss of calcium and magnsium ions
67
What are loop diuretics indicated for?
* Chronic heart failure
* Pulmonary oedema due to left ventricular failure
* often used with anti-hypertensives to increased BP control
68
What are the common side effects of loop diuretics?
* GI upset
* Pacreatitis
* Hepatic encephalopathy
* Postural hypotension
69
Common loop diuretics and thier dosing regimens
1. Bumetanide- 1mg OM
2. Furosemide- 20-40mg daily. MAX 120mg daily (resistant oedema dose)
## Footnote
Both act within 1 hr
70
Are potassium sparing diuretics given for hypertension?
| Why?
No- when given with ACEi or ARBs, increased risk of hyperkalaemia
71
What must not be given with potassium sparing diuretics
Potassium supplementation
72
How should MR potassium supplements be taken?
Whole, with a full glass of water
Whilst sitting/standing
73
What is amiloride indicated for?
| What else is typically given in this regimen?
* Oedema
* Hepatic cirrhosis with ascites
| Given with furosemide (combination drug i.e. Frumil 40mg/5mg tabs)
74
What is the mode of action of aldosterone and subsequently aldosterone antagonists?
| Example?
* Aldosterone sysnthesised by adrenal glands and binds to mineralcorticoid receptors in kidney, colon and sweat glands
* Increases reabsorption of sodium and water and excretion of potassium
* Antagonists reduce this action and decreases sodium reabsoprtion and potassium excretion
| e.g. spironalactone
75
What are the consequences of excess aldosterone in the body?
Pressure on CV system (increased intravascular fluid retention and volume overload)
76
What is spironalactone indicated for?
* Oedema
* Ascites caused by liver cirrhosis
* Hyperaldosteronism
77
Common SE for spironalactone
* GI upset
* Malaise (general unwell)
* Dizziness
* Droswiness
78
What is the maximum daily dose for spironalactone?
400mg daily
79
What is the maximum daily dose for eplerenone?
50mg daily
80
Which AF medication should be used in sedentary patients?
Digoxin- only effective for controlling ventricualr rate at rest
81
What are the causes of Torsade de points (prolonged QT interval)
* Drug induced
Can also be precipitated by:
* Hypokalaemia
* Bradycardia
82
What is flecanide indicated for?
SE?
Dosing schedule and max daily?
* Treat supraventricular and ventricular arrhythmia
* Usually conserved for rapid control in heavy built patients
* SE: Dizziness, pro-arrhythmic effects, fatigue
* 50-100mg BD (MAX: 400mg daily)
83
What is dronedarone indicated for?
SE?
Dosing schedule and max daily?
* Controlling sinus rhythm after cardioversion (previous treatment failure
* Initiated under specialist supervision
* Increased risk of hepatic disorders and heart failure
* 400mg BD
84
Counselling points for dronedarone
Recognition of liver disorder e.g. jaundice, fever, malaise
Recognition of new-onset or worsening heart i.e. oedema, dyspnoea (SoB)
85
Can beta blockers be used in pregnancy?
Avoid- may cause intr-uterine growth restriction, neonatal hypoglyacemia and bradycardi
Risk is greater in severe hypertension
86
Caution for Labetalol use?
Liver damage reported with use - STOP at any sign of liver dysfunction and do not restart
87
Propranolol max daily dose?
320mg daily
88
Cautions for sotalol use?
Dosing schedule?
* Prolongs QT interval (ECG monitoring required)
* 80mg initially- may be adjusted every 2-3 days to allow monitoring of QT intervals
89
Target clinic BP?
< 140/90 mmHg
90
Complications of HTN in T2DM?
Increased risk of macro and microvascular complications
91
Complications of HTN in T1DM?
Usually indicated diabetic nephropathy
92
What effect can the rapid reduction of BP have on patients?
Can cause:
* Reduced organ perfusion
* Blindness
* Myocardial infarction
93
What are the treatment steps for HTN in patients under 55 y/o
STEP 1: ACEi or ARB
STEP 2: (ACEi or ARB)+ (CCB or Thiazide)
STEP 3: (ACEi or ARB) + CCB + Thiazide
STEP 4: (ACEi or ARB) + CCB + Thiazide + (Low dose spiro../alpha blocker or BB)
94
What are the treatment steps for HTN in patients over 55 y/o /Africa/Carribean
STEP 1: CCB
STEP 2: CCB + (ACEi or ARB or Thiazide)
Step 3: CCB + Thiazide + (ACEi or ARB)
Step 4: CCB + Thiazide + (ACEi or ARB) + (Low dose spiro../alpha blocker or BB)
95
Treatment options for primary prevention of CVD when statins are contraindicated?
* Ezetimibe
OR
* Bile acid sequestrants e.g. colestyramine or colestipol
96
Typical regimen for secondary prevention of CVD?
* Low dose aspirin (clopidogrel if aspirin contraindicated)
* Antihypertensive therapy
* High intensity statin e.g. 80mg atorvastatin
* If LDL cholesterol remains high- consider ezetimibe or bile acid sequestrants e.g. colestyramine and colestipol
97
What is clonidine indicated for?
Cautions?
Dosing?
* Indicated for HTN, migraine, tourette syndrome
* Sudden withdrawal can cause severe rebound hypertension
* 50mcg BD
98
99
What is methyldopa indicated for ?
Cautions?
Dosing?
* Indicated for HTN- has been used for HTn in pregnancy
* Many patients will experience sedation in early treatment
* 250mg TDS for 2 days. Adjusted no less than every two days to MAX daily dose of 3g
100
What is doxazosin indicated for?
Cautions? SE?
Dosing (MAX?)
* Indicated for HTN and BPH
* May affect performance of skilled tasks
* Usually given with a PDE5 inhibitor (e.g. sildenafil, tadalafil)
* SE: coughing, fatigue, vertigo, sleep disturbances
* MAX 16mg daily
101
What is indoramin indicated for?
Contraindications?
Dosing (MAX?)
* Indicated for HTN and treating utinary outflow obstruction due to BPH
* Contraindicated in heart failure
* MAX dose 200mg daily
102
What is prazosin indicated for?
Contraindications?
Dosing (MAX?)
* Indicated for HTN, congenital HF, Raynauds and BPH
* Contraindicated in those with history of postural hypotension
* MAX daily dose 20mg
103
What is terazosin indicated for?
Contraindications?
Dosing (MAX?)
* Indicated for HTN and BPH
* Usual dose: 5-10mg daily (MAX 20mg)
104
What is the RAAS system?
The Renin-Angiotensin-Aldosterone System (RAAS) is a hormone system, essential for regulating blood pressure and fluid balance
Primarily regulted by the rate of renal blood flow
105
Which two classes of drugs are the basis for treatment of chronic heart failure?
## Footnote
In what circumstances mya this regimen be altered?
ACEi + BB
## Footnote
If ACEi not tolerated i.e. dry cough, ARB + BB is suitable
105
What is the mode of action of ace inhibitors (ACEi)?
Inhibit the conversion of angiotensin I to angiotensin II Angiotensin II narrows blood vessels)
Blocks aldosterone and increases K+ accumulation
105
What are the main indications that ACEi are used for?
* Heart failure
* HTN
* Diabetic nephropathy
* Prophylaxis of CVD events
106
Points to consider before starting a patient on an ACEi
Risk of hyperkalaemia- stop K+ sparing diuretics and supplements
First dose can cause hypotension (diuretic dose may need to be reduced/stopeed 24 hours before
107
Monitoring requirements for ACEi
Renal function
Discontinue if jaundice or elevted liver enzymes e.g. ALT, AST etc
108
What are the two most common drug class interactions with ACEi
ACEi + NSAID = increased risk of renal damage
ACEi + K+ sparing diuretis = increased risk of hyperkalaemia
109
What is captopril indicated for?
MAX dose?
* Indicated for essential HTN and HF with diuretics
* Max dose 150mg daily
110
Maximum daily dose of enalapril?
40mg
111
MAX daily dose of lisinopril?
40mg
112
Typical dose for perindopril?
Instructions for administration?
5mg daily, increased to 10mg OD in the morning before meal
113
Typical dose for quinapril?
Usually 20-40mg daily
114
Typical ramipril dose?
MAX daily dose?
Initial: 2.5mg daily
MAX 10mg daily
115
What is the mechanism of action of angiotensin receptor blockers (ARBs)?
Blocking AT1 receptors found in the heart, blood vessels and kidneys
Blocking the action of angiotensin II helps reduce BP and reduce damage to heart and kidneys
116
Why are ARBs often a suitable alternative to ACEi?
Potentially tolerated better because they don't inhibit breakdown of kinins (reduced risk of dry cough SE)
117
Common SE of ARBs
* Hyperkalaemia
* Hypotension
* Dizziness
118
MAX daily dose of candesartan
32mg (highest strength tab remember!)
119
Typical dosing for eprosartan
600mg OD
120
Typical dosing and MAX daily for ibersartan
Initially 150mg daily increased to 300mg (MAX)
121
Maximum daily dose for losartan
MAX 150mg daily
122
Typical dosing and MAX daily for olmesartan
Usually 10-20mg (MAX 40mg daily)
123
Typical dose and MAX daily for telmisartan
Usually effective at 40mg daily (MAX 80mg daily)
124
Typical dose in HF for valsartan and MAX daily
160mg BD (MAX 320mg daily)
125
Mechanims of action for nitrates
Coronary vasodilator
Direct relaxant effect on vascular smooth muscle, and dilation of coronary vessels to improve oxygen supply to the heart
126
What are nitrates primarily indicated for?
Angina
127
What is angina pain?
Tight pain in chest/neck/arm area
Comes from the heart muscle and is a sign that part of it is not getting enough oxygen to maintain its workload
128
When are patients on nitrates more susceptible to developing tolerance?
When using long acting transdermal nitrate patches
If tolerance is suspected, leave patch off for 8-12 hours
Modified release forms of isosorbide mononitrate should be given OD
129
Common SE of nitrates
* Flushing
* Headache
* Dizziness
* Postural hypotension
130
What are the different forms of GTN indicated for? (sublingual, injection and transdermal)
* Sublingual: prophylaxis and treatment of angina
* Injection: control hypertension, myocardial infarction
* Transdermal: angina prophylaxis
131
Counselling points for GTN spray
At onset of attack:
* 1-2 sprays under tongue
* If symptoms not resolved, repeat at 5 min intervals for MAX 3 doses
* If not resolved after 3 doses, seek medical attention
132
Counselling points for GTN transdermal patch
* Cange application site to prevent skin irritation
* A patch-off period (8-12 hours) each 24 hours is recommended to avoid tolerance
* If a patch loosens, replace with a new patch
* MAX 2 transdermal patches daily
133
Counselling points for isosorbide mononitrate (Elantan)
* Have a "nitrate low" period (usually sleeping) when no tabs are taken to avoid tolerance
* Do not use to treat angina attack
* Avoid alcohol- can increase effect of Elantan and lower BP too much
134
Mechanim of action of calcium channel blockers (CCBs)
Blocks movement of calcium into the heart, reducing contractility and electrical implses in the heart
135
What may withdrawal from CCBs exacerbate?
Angina
136
Common SE for CCBs
* Ankle swelling
* Flushing
* Palpitations
* Constipation (if taking verapamil)
137
Typical dosing regimen for amlodipine
Points to consider?
5-10mg daily
Strongly affected by CYP3A4 inhibitors
138
MAX daily dose of diltiazem
Points to consider?
MAX 360mg daily
Different MR forms available so prescriber must specify brand
139
MAX daily dose for felodipine
MAX 10mg daily
140
MAX daily dose of lercanidipine
MAX 20mg daily
141
What is ivabradine indicated for?
Dosing schedule? MAX daily?
Indicated for angina in normal sinus rhythm, and mild-severe chronic HF
Taken twice a day with meals, morning and evening- usually 5mg BD (MAX 7.5mg BD)
142
Dosing schedule for nicorandil
When is this offered to patients
Initially 10mg BD (MAX 40mg BD)
For patients who are intolerant to first line antianginal therapies
143
Dosing schedule for ranolazine (Ranexa)
SE?
375-500mg BD
SE: dizziness, headache, constipation, vomiting and nausea
144
What is claudication indicated for?
Cautions?
SE?
Dosing?
Points to consider?
* Indicated for intermittnent claudication (muscle pain due to lack of oxygen triggered by activity)
* SE: GI upset and dyspepsia
* Dose: 100mg BD
* Half the dose if patient on CYP3A4 inhibitor i.e. clarithromycin or CYP2C10 inhibitor i.e. erythromycin, omeprazole
* Counsel patient on recognising blood disorders i.. bleeding, bruising, sore throat, fever
145
What is the mechanism of action of adrenaline?
Acts on both alpha and beta receptors of the sympathetic nervous system, resulting in:
* Increased HR and contractility (Beta1)
* Peripheral vasodilation (Beta2)
* Vasoconstriction (Alpha)
146
Where do inotropic sympathetics act?
Act on Beta1 receptors, increasing contractility i.e. dobutamine
147
What is the mechanims of action of dopamine
When is it used in clinical setting
A vasocontrictor sympathomimetic acting on Alpha receptors, increasing BP
May be used in an emergency to treat low BP, low HR and cardia arrest
148
What is the mechanims of action of fibrinolytics
Activates plasminogen into plasmin which breaks down fibrin (clotting agent)
149
What may be added to statins if lipids remain high?
Fenofibrate of nicotinic acid
150
What does the combination of a statin and fenofibrate/nicotinic acid increase the risk of?
Increased risk of rhabdomyolysis
151
What are the symptoms of rhabdomyolysis?
* Severe muscle aching or swelling, especially in shoulders, thighs or lower back
* Muscle weakness or stiffness
* Dark urine (tea or cola coloured)
152
What causes rhabdomyolysis?
Occurs when damagedmuscle tissue releases its proteins and electrolytes into the blood
These substances can damage the heart and kidneys and cause diability or permenant death
153
What can be used in high lipid patients if intolerant to statins?
Ezetimibe
154
What is the mechanism of action of statins
Act as competitive inhibitors of the enzyme HMG CoA reductase, preventing an early rate limiting step in biosythesis of cholesterol
155
When are statins used in caution/avoided?
Caution: liver disease
Avoid in pregnancy- present in breats milk and can affect foetel development
156
What is the management of muscle symptoms in statin use
Consider all potential causes:
* Rigorous exercise increases creatinine kinase (CK)- could cause muscle weakness/pain
* Hypothyroidism
* Infection
* Trauma before statin
If statin is cause of muscle SE, disontinue immediately. If symptoms resolve and CK levels return to normal, return to statin at low dose and monitor
157
What are the SEs of statins?
* Myalgia, myopathy, rhabdomyolsis
* Hepatitis, jaundice
* Headache
* Dizziness
158
Which factors increase risk of myopathy in statin use
* Hypothyroidism
* Family history
* High dose
* Drug combinations
159
Which drug combinations result in greater risk of myopathy in statin therapy
* Statin + fusidic acid (contraindicated- stop statin and restart 7 days after last fusidic acid dose)
* Statin + fibrate
* Statin + nicotinic acid
* Statin + macrolides
160
MAX dose of atorvastatin
80mg daily
161
MAX dose of Fluvastatin
80mg daily
162
MAX dose of pravastatin
40mg daily
163
MAX dose of rosuvastatin
20mg daily
164
MAX dose of simvastatin
80mg daily
165
What is the mechanism of action of bile acid sequestrants?
Bile acid sequestrants are highly positively charge molecules that bind to the negatively charge bile acids in the intestine, inhibiting their lipid solubilizing activity and thus blocking cholesterol absorption
166
What is a biproduct of bile acid sequestrant's MoA?
How is this issue managed?
Interferes with absorption of fat soluble vitamins A, D, K and folic acid
Management: advise patients take these other drugs 1 hour before/ 4-6 hours after
167
What is the maximum daily dose of the bile acid sequestrant cholestyramine (Questran 4g sachets)
How should they be taken?
MAX 36g daily (9 sachets)
Do not eat dry form. Mix with 150ml suitable liquid i.e. water, fruit juice
168
What is the mechanism of action of ezetimibe?
Inhibits intestinal absorption of cholesterol
169
Ezetimibe is often used adjunct to another medication, which?
What does this combination increase the risk of?
Used with statin, but can be monotherapy
Increased risk of rhabdomyalsis
170
What is the dosing schedule for ezetimibe?
10mg daily
171
What is the healthy amount of LDL cholesterol?
100mg/dl
172
What are the SE of ezetimibe
Very favourable SE profile SEs:
* Nausea
* Diarrhoea
* Fatigue
173
What is the mechanism of action of fibrates?
Decrease serum triglycerides by activating peroxisome proliferator activated receptor alpha (PPARα), increasing lipolysis, activating lipoprotein lipase, and reducing apoprotein C-III.8,11,12 PPARα is a nuclear receptor and its activation alters lipid, glucose, and amino acid homeostasis
174
When are fibrates considered for use in patients with high lipid counts
When statin therapy has failed to reduce triglycerides etc
175
What adverse effect can statin + fibrate use have on patients
Increased risk of myositis (autoimmune response to attack muscles)
176
What is fenofibrate indicated for?
* Hyperlipidaemia
* Hypertriglyceridaemia
177
What is gemfibrozil indicated for?
* Hypertriglyceridaemia
* Hyperlipidaemia
* Hypercholesterolaemia
178
What must be ensured before starting gemfibrozil therapy?
* Hypothyroidism and diabetes meelitus controlled as best as possible
* Patient is on lipid-lowering diet
179
Which adverse effects are associated with gemfibrozil
* Myositis
* Rhabdomyolysis
* Myopathy
180
What does gemfibrozil interact with?
Is an enzyme inhibitor of CYP2C8, CYP2C9, CYP2C19, CYP1A2
181
When is gemfibrozil contraindicated?
Use with simvastatin
182
What is nicotinic acid indicated for and when is it considered for patient use?
Indicated for dyslipidaemia
Adjunct with statin when statin monotherapy has failed to reduce LDL
183
What are omega-3-fatty acids indicated for?
When are they considered for use?
Indicated for hyperlipidaemia
As an alternative for fibrate in addition to statin where monotherapy has failed
184
What is the dosing schedule for omega-3-fatty acids?
Omacor: 2-4 caps daily with food
