Chapter 2 - Dyslipidaemia Flashcards
What are the causes of hypercholestsrolaemia and hypertriglyceridaemia?
Inherited (familial hypercholestsrolaemia)
Alcohol
Fatty food
Poor glycaemic control
Smoking
Obesity
Medication - corticosteroids, immunosuppressants, antipsychotics
What are the aims in hypercholestsrolaemia?
Total cholesterol <5mmol/L
LDL <3mmol/L
HDL >1mmol/L
Triglycerides <2.3mmol/L
Give examples of high intensity statins
Atorvastatin 20, 40, 80
Rosuvastatin 10, 20, 40
Simvastatin 80
How much do high intensity statins reduce LDL cholesterol by?
> 40%
Give some examples of medium intensity statins
Atorvastatin 10
Rosuvastatin 5
Simvastatin 20, 40
Fluvastatin 80
How much do medium intensity statins reduce LDL cholesterol by?
30-40%
Give examples of low intensity statins
Simvastatin 10
Fluvastatin 20, 40
Pravastatin 10, 20, 40
How much do low intensity statins reduce LDL cholesterol by?
<30%
What is familial hypercholestsrolaemia and when should this be suspected?
This is inherited hypercholestsrolaemia
If should be suspected history
Total cholesterol is >7.5mmol/L
There is a personal or family histrionic of CHD
What is the lifestyle advice associated with familial hypercholestsrolaemia?
Stop smoking
Lose weight
Reduce alcohol consumption
This should be given to every patient affected
What is the first line treatment for familial hypercholestsrolaemia?
High intensity statin e.g. atorvastatin 20mg
What drugs can be considered if a statin is contraindicated, not tolerated or not effective as monotherapy?
Ezetimibe
Fibrates (when TG >10mmol/L)
Lipid modifying drugs
In hypercholestsrolaemia, who should primary prevention be given to?
Anyone with familial hypercholestsrolaemia
Anyone with type 1 diabetes
Anyone with CKD
Anyone with a 10 year CVD risk of >10% (QRISK score)
What is first line for primary hypercholestsrolaemia?
Atorvastatin 20mg
When is secondary prevention given in hypercholestsrolaemia?
In patients with established CVD e.g. MI, angina, stroke, TIA
What is the first line drug treatment for secondary hypercholestsrolaemia?
Atorvastatin 80mg
What type of cholesterol are statins best at reducing?
LDL-C
They are not as effective at reducing triglycerides
What type of cholesterol are fibrates good at reducing?
Triglycerides
They are usually given when TG levels are high (>10mmol/L) even after LDL-C had been reduced
What monitoring needs to be done before lipid modifying therapy is started?
TC
HDL-C
Non HDL-C
TG
Creatinine kinase (in patients with an increased risk of myopathy or unexpected muscle pain) Renal function LFTs (then measure at 3 and 12 months) Thyroid function HbA1c
What is rhabdomyolysis?
This is a serious syndrome caused by direct muscle injury
The muscle fibres die and release their contents into the bloodstream
This can lead to serious complications e.g. renal failure
What are the symptoms of rhabdomyolysis?
Muscle pain
Muscle weakness of trouble moving
Dare red or brown urine, or decreased urination
What is the mechanism of action of statins
They competitively inhibit HMG-CoA reductase
Which controls the synthesis of cholesterol in the liver
What are the cautions associated with statins?
Elderly
Liver disease
Increased risk of myopathy
What increases the risk of myopathy associated with statins?
High dose High alcohol consumption Hypothyroidism Renal impairment Personal or family history or muscle disorders
What are the side effects of statins?
Common - myalgia, thrombocytopenia
Uncommon - hepatic disorders
Rare - myopathy, rhabdomyolysis, interstitial lung disease
Can statins be given in pregnancy?
No
Discontinue statins 3 months before attempting to conceive
The patient should be on adequate contraception during treatment and for 1 month afterwards
What patient counselling should be given for statins?
Seek advice if you develop muscle pain, weakness, tenderness or dark urine/less urine (rhabdomyolysis)
Seek advice if you develop difficulty breathing, a cough or weight loss (interstitial lung disease)
Statins have many interactions with food and medications e.g. grapefruit juice
What time should to take statins and why?
Simvastatin, pravastatin, fluvastatin
Night - cholesterol synthesis is highest when dietary intake is lowest
Atorvastatin, rosuvastatin
Any time - it has a longer half life
When should the dose of rosuvastatin be reduced?
Risk factors for myopathy or rhabdomyolysis
Concurrent use of fibrates, clopidogrel and some antifungals
Patients aged over 70
Patients of an Asian origin
What are the main drug interactions of statins?
Amiodarone, verapamil, diltiazem, amlodipine- increased risk of myopathy
Clarithromycin, erythromycin, ciclosporin - temporarily stop the statin during antibiotic treatment
Grapefruit juice - take 12h apart
At johns wort
Fibrates, ezetimibe
Can simvastatin be sold OTC?
Yes, for primary prevention
Max pack side 28
Max dose 10mg daily
What is the mechanism of action of ezetimibe?
They reduce the intestinal absorption of cholesterol
They have a greater effect on LDL-C than they do on TGs
What are the main side effects of ezetimibe?
Myopathy
Pancreatitis
Are fibrates better at reducing LDL cholesterol or triglycerides?
Triglycerides
They are used when TG levels remain high >10mmol/L
When are fibrates cautioned?
Myopathy
Increased risk of myopathy e.g. renal impairment
Hypothyroidism - correct thyroid levels before initiating
What additional monitoring should be carried out when fibrates and statins are used?
Hepatic function
Creatinine kinase
Can lomitapide be given in pregnancy?
No - it is teratogenic
Give some examples of bile acid suppressants
Colestryramine
Colestipol
Colesevelam
What is the mechanism of action of bile acid sequestrants?
Bind to bile acids and prevent their reabsorption
This promotes the conversion of cholesterol into bile acids
What is an issue associated with the long term use of bile acid sequesterants?
Deficiency of fat soluble vitamins e.g. vitamin A, D, K and folic acid
Which groups of lipid regulating drugs are the most effective at reducing LDL-C?
Statins
What is the main problem associated with bile acid seqesterants in reducing cholesterol?
They can efficiently reduce LDL-C, but can aggregate hypertriglyceridaemia
What is the advice surrounding bile acid sequestrants if a patient is on other medications?
Don’t take them at the same time
Take other drugs 1 hour before or 4 hours after
Bile acid sequestrants can affect the absorption of other medications
Why is it important to treat hypothyroidism before starting lipid modifying therapy?
Hypothyroidism can exacerbate hyperlipidaemia
Treating hypothyroidism may reduce cholesterol and therefore the need for statins
What is the maximum atorvastatin dose when taking ciclosporin?
10mg
What creatinine kinase is a concern in a patient on a statin?
5 times the upper limit
What is the maximum dose of atorvastatin if a patient is also taking ciclosporin?
10mg
Can a statin and gemfibrozil be used together?
No - increased risk of myopathy and rhabdomyolysis
If a patient is on a statin, what LFT level would you stop the statin?
3 times the upper limit
In what patient groups would you offer statins without assessing them?
Type 1 diabetes
CKD eGFR<60
Familial hypercholestsrolaemia
Who do we offer lipid modifying therapy to?
QRISK >10% (CV event in the next 10 years)
Type I diabetics
CKD
Familial hypercholestsrolaemia
What cardiovascular risk assessment calculators do we use?
QRISK2
QRISK3 - considers additional factors e.g. migraines, corticosteroid use
JBS3 - long term assessment
What is used for the secondary prevention of CV events
Lipid modifying therapy e.g. statin
Aspirin if atherosclerotic disease
Why do we tend to avoid high dose simvastatin (80mg)
Risk of myopathy and rhabdomyolysis
