Dyslipidaemia

Question 1

Cholesterol and CHD relationship

Answer 1

Decreasing cholesterol always decreases CHD - no ‘safe’ level
1% decrease in cholesterol results in 2% decrease CHD

Question 2

Treatment of Hyperlipidaemia - Severe CVS risk

Answer 2

In severe CVS risk do not wait for lipid results and treat empirically with a high intensity statin (atorvastatin 20mg/simvistatin 80mg)
If statins are not tolerated consider fibrates, nicotinic acids, anion exchange resins or ezetimibe

Question 3

Treatment of hyperlidipaemia - secondary prevention

Answer 3

In secondary risk (pts with clinical evidence of CVD)
start 40mg simvastatin without waiting for other lifestyle modifications to be put in place.
Double this if cholesterol stay >4 and LDL >2.
If statins continue to be ineffective or not tolerated consider further therapies

Question 4

Treatment of hyperlidipaemia - Primary prevention

Answer 4

In pts over 40 with a 20%> CVS risk in the future offer 4mg simvastatin as part of a larger risk management strategy
In primary prevention there is no aim, but if not tolerated consider further therapies (not nicotinic acid)

Question 5

Nicotinic Acid

Answer 5

AKA Niacin, used to treat pellagra and lowering cholesterol and LDL. Consider as an further treatment for secondary prevention and in pts with severe CVS risk.

Question 6

Statins

Answer 6

Lower cholesterol by inhibiting HMG-CaA reductase, blocking production + reducing LDL uptake and improving endothelial function. They have been found to be useful in secondary prevention but lack evidence for primary preventative use.

Question 7

Anoin exchange resins (Cholestyramine)

Answer 7

a bile acid sequestrant which prevents reabsorbsion of cholesterol, lowering the blood levels.
It is also used to treat diarrhoea in post-surgical crohn’s and IBS

Question 8

Ezetimibe

Answer 8

Lowers cholesterol by decreasing cholesterol absorption from the intestine. It decreases cholesterol but hasnt been found to improve CVS disease outcomes. Can be used alone or in with statins

Question 9

Fibrates

Answer 9

Chemicals which increase HDL and decrease LDL by a variety of mechanisms. They are used in combination with statins but not alone, They reduce the number of non-fatal MIs but do not decrease all-cause mortality

Question 10

Statin drug interactions

Answer 10

There is an increased risk of rhabdomyolysis when combined with other cholesterol lowering drugs (atorvastatin is lowest risk)
HIV pts taking protease inhibitors should use atorvastatin, pravastatin or fluvastatin
pt taking cyclosporin should use pravastatin or fluvastatin to reduce interaction risk

Question 11

Statins with Warfarin

Answer 11

There are not interactions but warfarin dose may need to be decreased as the effect may be increased by statins