Dyslipidaemias Flashcards
What is the drug class of choice for treating hypercholesterolaemia and moderate hypertriglyceridaemia?
Statins
What lipid-regulating drug is given in addition to statins for severe hypercholesterolemia or hypertriglyceridemia?
Ezetimibe
- oral: 10 mg daily
What drug class is more effective than statins at reducing triglyceride concentration?
Fibrates (e.g. fenofibrate)
What drug would you add to statin therapy if triglycerides remain high even after the LDL-cholesterol concentration has been reduced adequately?
Fenofibrate
- Oral capsules: maximum 200 mg daily with concomitant statin
- Oral tablets: 160 mg daily
Fibrates are more effective than statins in reducing triglyceride concentration
Patients with familial hypercholesterolaemia are at high risk of premature (?)
coronary heart disease
What is the definition of ‘high-intensity statin’?
The dose at which a reduction in LDL-cholesterol of greater than 40% is achieved
What is first-line therapy in all patients with familial hypercholesterolemia?
High-intensity statin
+ lifestyle changes
What is the target reduction of LDL-cholesterol concentration in a patient with familial hypercholesterolemia?
Greater than 50% from baseline
For patients with primary heterozygous familial hypercholesterolaemia who have contra-indications to, or are intolerant of statins, what drug is the used as monotherapy?
Ezetimibe
- Oral: 10 mg daily
For patients with familial hypercholesterolaemia and in whom statins or ezetimibe are inappropriate, what two other drug classes can be considered?
Fibrates (fenofibrate)
Bile acid sequestrant (e.g. colestyramine or colestipol hydrochloride)
Which side effect is a patient taking a combination of statin with a fibrate at increase risk of?
Muscle-related side-effects (including rhabdomyolysis)
Should be used under specialist supervision
Which drug should NOT be combined with a statin because of the very high risk of rhabdomyolysis?
Gemfibrozil
Which two drugs can be considered for patients with primary heterozygous familial hypercholesterolemia whose LDL-cholesterol has NOT been adequately controlled on maximum tolerated lipid-lowering therapy?
Alirocumab
Evolocumab
What reduction of LDL cholesterol would you expect in the patient is taking 20 mg daily dose of atorvastatin?
43%
What reduction of LDL cholesterol would you expect in the patient is taking 80 mg daily dose of atorvastatin?
55%
Why is high-dose simastatin (80mg) NOT considered in the majority of patients?
Increased risk of myopathy
The 80 mg dose should be considered only in patients with severe hypercholesterolaemia and high risk of cardiovascular complications who have not achieved their treatment goals on lower doses, when the benefits are expected to outweigh the potential risks.
(drug?) and (drug?) bind to a pro-protein involved in the regulation of LDL receptors on liver cells; receptor numbers are increased, which results in increased uptake of LDL-cholesterol from the blood.
Alirocumab
Evolocumab
Alirocumab and evolocumab bind to a pro-protein involved in the regulation of (?) receptors on liver cells; receptor numbers are increased, which results in increased uptake of LDL-cholesterol from the blood.
LDL
Alirocumab and evolocumab binds to a pro-protein involved in the regulation of LDL receptors on liver cells; receptor numbers are increased, which results in increased uptake of (?) from the blood.
LDL-cholesterol
What are the two indications for the use of alirocumab?
- Primary hypercholesterolaemia or mixed dyslipidaemia in patients who have not responded adequately to other appropriate measures
- Established atherosclerotic cardiovascular disease
- Subcutaenous injection: Initially 75 mg every 2 weeks; increased if necessary to 150 mg every 2 weeks, alternatively 300 mg every 4 weeks, patients requiring an LDL-C reduction of greater than 60% may be initiated on 150 mg every 2 weeks or 300 mg every 4 weeks, dose adjustments should be made at 4 to 8 weekly intervals.
What are the common side effects of alirocumab?
- Nasal complaints
- Oropharyngeal pain
- Pulmonary reaction
- Skin reactions
Can alirocumab be used during pregnancy?
No unless clinical condition requires treatment
Maternal toxicity in animal studies
What is the route of administration of alirocumab?
Subcutaneous injection
What are the 4 indications for use of evolocumab?
- Primary hypercholesterolaemia or mixed dyslipidaemia in patients who have not responded adequately to other appropriate measures
- Established atherosclerotic cardiovascular disease
- Homozygous familial hypercholesterolemia
- Homozygous familial hypercholesterolemia in patients on apheresis
What is the route of administration of evolocumab?
Subcutaneous injection
What are the common side effects of evolocumab? (6)
- Arthralgia
- Back pain
- Hypersensitivity
- Increased risk of infection
- Nausea
- Skin reactions
Can pregnant women take evolocumab?
No unless essential
Should patients with moderate to severe hepatic impairment use evolocumab?
Use with caution
Risk of reduced efficacy
Name two bile acid sequestrants
Colestipol hydrochloride
Colestyramine
(drug class?) act by binding bile acids, preventing their reabsorption; this promotes hepatic conversion of cholesterol into bile acids; the resultant increased LDL-receptor activity of liver cells increases the clearance of LDL-cholesterol from the plasma.
Bile acid sequestrants
Bile acid sequestrants act by binding bile acids, preventing their (?); this promotes hepatic conversion of cholesterol into bile acids; the resultant increased LDL-receptor activity of liver cells increases the clearance of LDL-cholesterol from the plasma.
reabsorption
Bile acid sequestrants act by binding bile acids, preventing their reabsorption; this promotes hepatic conversion of (?) into (?); the resultant increased LDL-receptor activity of liver cells increases the clearance of LDL-cholesterol from the plasma.
Cholesterol into bile acids
Bile acid sequestrants act by binding bile acids, preventing their reabsorption; this promotes hepatic conversion of cholesterol into bile acids; the resultant increased (?) activity of liver cells increases the clearance of LDL-cholesterol from the plasma.
LDL-receptor
What is the only indication for the use of colestipol hydrochloride?
Hyperlipidaemias, particularly type IIa, in patients who have not responded adequately to diet and other appropriate measures
- Oral: Initially 5 g 1–2 times a day, increased in steps of 5 g every month if required, total daily dose may be given in 1–2 divided doses; maximum 30 g per day.
Which type of hyperlipidaemia are colestipol hydrochloride and colestyramine particularly useful for treamtent?
Type IIa
Familial hypercholesterolaemia
- Elevated LDL-cholesterol
What supplements are required if a patient is taking long-term bile acid sequestrants?
Vitamins A, D, K and folic acid
Bile acid sequestrants interfere with the absorption of fat-soluble vitamins
Bile acid sequestrants interfere with the absorption of (?)
Fat-soluble vitamins
Supplements of vitamins A, D, K, and folic acid may be required when treatment is prolonged
What are the common side effects of bile acid sequestrants?
Constipation GI discomfort Headache Nausea Vomiting
Why should bile acid sequestrants be used with caution in pregnancy and breastfeeding?
May cause fat-soluble vitamin deficiency on prolonged use
What is the mode of administration of bile acid sequestrants?
Oral
- sachet should be mixed with water, fruit juice, skimmed milk or thin soup
Colestipol hydrochloride - mixed with 100 mL of liquid
Colestyramine - mixed with 150 mL of liquid
What are the indications for use of colestyramine? (5)
- Hyperlipidaemias, particularly type IIa, in patients who have not responded adequately to diet and other appropriate measures
- Primary prevention of coronary heart disease in men aged 35-59 years with primary hypercholesterolemia who have not responded to diet and other appropriate measures
- Pruritis associated with partial biliary obstruction and primary biliary cirrhosis
- Diarrhoea associated with Crohn’s disease, ileal resection, vagotomy, diabetic vagal neuropathy, and radiation
- Accelerated elimination of teriflunomide
What is the contra-indications for the use of colestyramine?
Complete biliary obstruction
Not likely to be effective
Should bile acid sequestrants be taken at the same time as other drugs?
NO
Take other drugs at least 1 hour before or 4 hours after
What is the mode of action of ezetimibe?
Inhibits the intestinal absorption of cholesterol
If used alone, it has a modest effect on lowering LDL-cholesterol, with little effect on other lipoproteins.
What are the indications for the use of ezetimibe?
- Adjunct to dietary measures and statin treatment in primary hypercholesterolaemia
- Adjunct to dietary measures and statin in homozygous familial hypercholesterolaemia
- Primary hypercholesterolaemia (if statin inappropraite)
- Adjunct to dietary measure in homozygous sitosterolaemia (body stores plant sterols)
What are the common side effects of ezetimibe? (4)
- Asthenia
- Diarrhoea
- GI discomfort
- GI disorders
Fibrates act by decreasing serum (?); they have variable effect on LDL-cholesterol.
triglycerides
(drug class?) act by decreasing serum triglycerides; they have variable effect on LDL-cholesterol.
Fibrates (e.g. fenofibrate)
What are the indications for the use of the drug fenofibrate? (3)
- Adjunct to diet and other appropriate measures in mixed hyperlipidaemia if statin contraindicated or not tolerated
- Adjunct to diet and other appropriate measures in severe hypertriglyceridaemia
- Adjunct to statin in mixed hyperlipidaemia if triglycerides and HDL-cholesterol inadequately controlled in patients at high cardiovascular risk
What is the route of administration of fenofibrate?
Oral using capsules or tablets
What are the contra-indications for the use of fenofibrate? (4)
- Gall-bladder disease
- Pancreatitis (unless due to severe hypertriglyceridaemia)
- Photosensitivity to fibrates
- Photosensitivity to ketoprofen
What condition needs to be corrected before initiating treatment with fenofibrate?
Hypothyroidism
What are the common side effects of the drug fenofibrate? (5)
Abdominal pain Diarrhoea Flatulence Nausea Vomiting
Why must caution be taken when prescribing fenofibrate to patients with renal disease?
Increased risk of myotoxicity (rhabdomyolysis)
Discontinue if myotoxicity suspected or creatine kinase concentration increases significantly
In which condition do you need to make dose adjustments for the drug fenofibrate?
Renal impairment
Max. 67 mg daily if eGFR 30-59 mL/minute/1.73m^2
Avoid if eGFR < 30
What needs to be monitored when using the drug fenofibrate?
- Hepatic transaminases (every 3 months during the first 12 months)
- Serum creatinine levels (during the first 3 months and then periodically)
(drug class?) are mainly used in those whose serum-triglyceride concentration is greater than 10 mmol/litre or in those who cannot tolerate a statin (specialist use).
Fibrates
Fibrates are mainly used in those whose serum-(?) concentration is greater than 10 mmol/litre or in those who cannot tolerate a statin (specialist use).
triglyceride
Fibrates are mainly used in those whose serum-triglyceride concentration is greater than (?) mmol/litre or in those who cannot tolerate a statin (specialist use).
10
Fibrates are mainly used in those whose serum-triglyceride concentration is greater than 10 mmol/litre or in those who cannot tolerate a (?) (specialist use).
statin
(drug class?) competitively inhibit 3-hydroxy-3-methylglutaryl coenzyme A (HMG CoA) reductase, an enzyme involved in cholesterol synthesis, especially in the liver
Statins
Statins competitively inhibit (?), an enzyme involved in cholesterol synthesis, especially in the liver.
3-hydroxy-3-methylglutaryl coenzyme A (HMG CoA) reductase
Statins competitively inhibit 3-hydroxy-3-methylglutaryl coenzyme A (HMG CoA) reductase, an enzyme involved in cholesterol synthesis, especially in the (?).
Liver
Which patients are at an increased risk of muscle toxicity if they use a statin? (5)
- Personal or family history of muscular disorders
- Previous history of muscular toxicity
- High alcohol intake
- Renal impairment
- Hypothyroidism
In patients at increased risk of muscle effects, a statin should not usually be started if the baseline (?) concentration is more than 5 times the upper limit of normal
creatine kinase
Some patients may present with an extremely elevated baseline creatine kinase concentration, for example because of a physical occupation or rigorous exercise—specialist advice should be sought regarding consideration of statin therapy in these patients
In patients at increased risk of muscle effects, a statin should not usually be started if the baseline creatine kinase concentration is more than (?) times the upper limit of normal
5
Some patients may present with an extremely elevated baseline creatine kinase concentration, for example because of a physical occupation or rigorous exercise—specialist advice should be sought regarding consideration of statin therapy in these patients
Which medical condition needs to be managed adequately before starting treatment with a statin?
Hypothyroidism
What are the common side effects for all statins?
- Asthenia
- Constipation
- Diarrhoea
- Dizziness
- Flatulence
- GI discomfort
- Headache
- Myalgia
- Nausea
- Sleep disorders
- Thrombocytopenia
What side effects of statins are rare but have serious effects?
Myopathy, myositis and rhabdomyolysis
In addition to all side effects for statins, what are common side effects for atorvastatin?
- Epistaxis
- Hyperglycaemia
- Hypersensitivty
- Joint disorders
- Laryngeal pain
- Muscle complaints
- Nasopharyngitis
- Pain
In women of child bearing potential, what must be prescribed during treatment with a statin and 1 month afterwards?
Adequate contraception
Congenital anomalies have been reported and the decreased synthesis of cholesterol possibly affects fetal development.
How long prior to attempting to conceiving should a woman discontinue taking a statin?
3 months
Congenital anomalies have been reported and the decreased synthesis of cholesterol possibly affects fetal development.
What needs to be measured at least once before treatment with statins is started? (6)
- Full lipid panel (non-fasting) - total cholesterol, HDL-cholesterol, non-HDL cholesterol, triglyceride concentrations
- Thyroid-stimulating hormone
- Renal function
- Liver function (recommended by NICE but no rationale)
- Creatine kinase (in patients who have had persistent, generalised, unexplained muscle pain)
- Fasting blood-glucose (if at high-risk of diabetes)
According to NICE guidelines, how often should liver function tests be performed on a patient taking a statin?
- Before starting treatment
- Within 3 months
- At 12 months of starting treatment
Any other times signs or symptoms suggest hepatotoxicity
Which patients need to have creatine kinase measured before starting treatment with a statin?
Those with persistent, generalised, unexplained muscle pain
If the concentration is more than 5 times the upper limit of normal, a repeat measurement should be taken after 7 days. If the repeat concentration remains above 5 times the upper limit, statin treatment should not be started; if concentrations are still raised but less than 5 times the upper limit, the statin should be started at a lower dose.
What advice needs to be given to all patients who are started on a statin?
Report promptly unexplained muscle pain, tenderness or weakness
What drink should patients taking atorvastatin or simvastatin avoid?
Grapefruit juice
Why should patients taking atorvastatin or simvastatin avoid grapefruit juice?
Reduces the body’s ability to breakdown the statin, increases the risk of side effects
