Dys/Hyperlipidaemias & Statins

Question 1

Background

Answer 1

Cholesterol can build up on arteries walls and become plaques causing narrow arteries which would restrict blood flow to organs like heart or brain.
- Plaques can rupture and cause blood clots.
- High cholesterol can cause atherosclerosis and increase risk of MI, Coronary arteries disease, stroke.

Cholesterol uses:
makes bile acid, steroid hormones, fat soluble vitamins (A,D,E,K)

Question 2

High cholesterol causes

Answer 2

Gender women r higher than men, Family Hx.

Pregnancy

Diabetes - damaged arteries lining making cholesterol more likely to stick and make plaque.

Liver/ Kidney disease High TC, low HDL more likely to have reduced GFR

PCOS

Hypothyroidism

Drugs: contraceptives, diuretics, beta-blockers, anti-depressants, antipsychotic (mainly 1st gen) (BC weight gain), anti-retrovirals, steroid

HIGH RIKS PTs:
T1DM, T2DM (if CVD risk>10%), CKD, Family Hx, older, 10 year risk of CVD >/= 10%, CVD Pts.
- GIVE statin to them regardless of levels.

Question 3

Hypercholesterolaemia and hypertriglyceridaemia (BNF)

Answer 3

1st line - Statin for hypercholesterolemia and moderate hypertriglyceridaemia. & Lifestyle

Severe forms NOT controlled with MAX statin dose CAN + other lipid drugs like EZETIMIBE.

NOTE: If Pts have secondary causes ie hypothyroidism address that 1st. Thyroid low = LDL build up. (HYPO = Hippo = Weight gain)

Statin more effective than other lipid regulating drugs at lowering LDL conc.
BUT less effective than Fibrates (fenofibrate, bezafibrate) at reducing triglyceride.
- Can ADD fenofibrate to statin if triglyceride stay high after LDL is reduced well.

COMBO Interactions:
Statin + Fibrate/nicotinic acid can increase risk of AEs eg rhabdomyolysis.
- Monitor LFT and creatine kinase.

Statin + Gemfibrozil - Increases risk of rhabdomyolysis ALOT. AVOID COMBO.

Question 4

Familial hypercholesterolaemia (FH)

Answer 4

Lifelong lipid-modifying therapy and lifestyle advice should be offered to all patients with FH.

FH treatment
1st line High intensity statin
- Titrate up.
ALT ezetimibe alone. IF BOTH not suitable REFER.

Ppl with heterozygous FH
IF MAX statin dose fails/ Statin change THEN OFFER statin + ezetimibe.
- ALT with fibrate or a bile acid sequestrant (colestyramine or colestipol) Considered (specialist) if statin or ezetimibe inappropriate.

Primary heterozygous FH where everything above fails - Alirocumab and evolocumab.

Homozygous FH only done with specialist.

Question 5

Cholesterol ideal ranges

Answer 5

Total cholesterol - <5mmo/L
LDL C - <3.5mmol/L
HDL C - >1mmol/L
Triglycerides - <1.7mmol/L

Higher risk people:
Total - <4mmol/L
LDL C - 2mmol/L

Question 6

Other times statins used

Answer 6

NICE - (GPHC Q)
Primary prevention
- For ppl with 10 yrs risk of CVD >10% - Atorva 20mg OD.
- High intensity statin to be used.
- ALSO use in >85 yrs old - helps reduce risk of non fatal MI.

Secondary prevention:
CVD - usually atorva 80mg OD but if CKD atorva 20mg.
ALSO use:
- low dose aspirin, clopidogrel or dipyridamole (stroke prevention)
- Antihypertensive if >140/90
- atorva>simva

Statin is give to ALL with T1DM.
- Check lipid profile (TC, LDL-C, HDL-C &Triglycerides) 3 months after starting statin
AIM FOR reduction in non HDL >40% (target for non-HDL <2.5) non HDL C

AVOID fibrates, nicotinic acid, bile acid sequestrants, omega 3 fatty acid for primary and 2ndry prevention.

Question 7

Statin basic info

Answer 7

GPHC NEED TO KNOW:
Timing, monitoring, patient counselling, Pregnancy, interactions, Intensity/CVD treatment.
MOA:
They inhibit HMG COA reductase so reduce cholesterol production as MG CoA helps produce cholesterol.

• Statin reduce CVD and total mortality.

YOUNGER PTS - statins only used if there’s target organ damage poor glycaemic control (HbA1c >9%), low HDL levels, Raised triglyceride conc., HTN OR family Hx of premature CVD

Pregnancy and BF
STOP statins during these stages.
- Discontinue 3 months before attempting to conceive.
- Adequate contraception during treatment and 1 month after.

Hepatic impairment
CAUTION with liver disease.
- AVOID in active liver disease or when there’s unexplained elevation in serum transaminases

Renal
STOP if elevated creatine kinase (sign of myopathy[term to describe any condition affecting muscles that connect to bones or skeletal muscles)

Patient and carer advise
REPORT Unexplained muscle pain, tenderness or weakness. Signs of rhabdomyolysis.

AES
Rhabdomyolysis can occur with dose increase.

Question 8

Statins

Answer 8

DOSE TIMING
ONLY Atorva and rosuva can be given any time BC longer duration of action.

• SIMVA 80 dangerous MHRA warning = rhabdomyolysis

GPHC Q: - High intensity statin is one that reduces LDL by >40%.

KNOW RANGES - ON phone pics.

CAN ADD or change statin to ezetimibe if statin not doing enough. specialist can suggest other drugs.

Question 9

Statin MORE INFO

Answer 9

MHRA warning on doses:
Higher doses are off label to serious AEs (same applies to simva 80)

ATORVA + Ciclo - MAX 10mg
SIMVA + Fibrate - MAX 10mg
SIMVA + (amlodipine, amiodarone, Rate limiting CCBs, Ranolazine) - MAX 20mg
ROSUVA + Clopidogrel - MAX 20mg

MONITORING (EXAM Q)
Leg cramps - check creatine kinase (if 5X above upper limit dont give statin)
Liver (LFT)- Monitor within 3 months then at 12 months. (if 3X above upper limit dont give statin)

PIC IN PHONE. B4: lipid, LFT, Creatine kinase, HbA1c/FPG (IF AT HIGH RISK OF DM), Hypothyroidism, renal function.
AFTER: LFT, HbA1c/FPG.

KEY INTERACTIONS
Amiodarone, colchicine, nicotinic acid, fibrates- Increase rhabdomyolysis risk.

Carbamazepine - Increase risk of Hepatotoxicity.

Clarithro/eryhtro, Grapefruit juice, ketocon/miconazole - Increase exposure to statin.

Amlodipine - Increase risk of AEs

NOTE: For doses of atorva and rosuva. learn atorva and divide by 2 to get rosuva 1s. (intensity based stuff)