Dyslipidemia 2

Question 1

Definition

Answer 1

Abnormal lipid profile in serum

Question 2

Classification

Answer 2

Predominant hyperTAG Predominant hypercholesterolemia Mixed

Question 3

What level of hyperTAG + risk pancreatitis

Answer 3

When level >10mmol/l

Question 4

What reduction in total cholesterol reduced CAD risk by 20% after 3 years

Answer 4

A 10% reduction

Question 5

Causes of secondary

Answer 5

Neprhotic Anorexia Hypothyroid T2DM Cholestasis Obesity Kidney impairment Alcohol abuse Smoking

Question 6

Confirmation of diagnosis

Answer 6

Confirm a positive result with a repeat test in 6-8 weeks.

Question 7

Treatment goals

Answer 7

TC <4
LDL <2.5 (<2 in high risk)
HDL >1
TG <2

Question 8

Patients requiring treatment: at what levels

Answer 8

1. CAD->Cholesterol >4 2. High risk->DM, FH, FHx CAD Cholesterol >6.5 or >5.5 + HDL cholesterol >6.5 4. Patients not for above: men 35-75, PM women->Cholesterol >7.5, TAG >4 5. Others->Cholesterol >9, TAG >8

Question 9

Non-pharmacological measure

Answer 9

1. Diet 2. Exercise 3. Smoking 4. Alcohol 5. Cooperation of family 6. Exclude secondary causes Diet therapy reduction in TG and LDL within 6-8 weeks. Continue for at least 6 months before medication, unless high risk

Question 10

Diet measures

Answer 10

Ideal weight Reduce fats Avoid fast food Replace to mono-unsaturated Approved cooking method Avoid busicuts/sweets between meals High fibre fruit and vegetables Complex carbohydrates Drink more water Reduce alcohol Fish oil

Question 11

Pharmacological management of hypercholesterolemia

Answer 11

1. Atorvastatin 10mg nocte (max 80mg) 2. Ezetemibe if statin intolerant (arthralgia, myalgia, liver) 3. Combination ezetemibe + statin 4. Bile acid sequestrating: cholestyramin 4g daily in fruit juice->GIT SE 5. Fibrates->if others not tolerated Second line: Nicotinic acid Probucol

Question 12

Adverse effects of statins and monitoring

Answer 12

Muscle pains Raised liver enzymes GIT Monitor LFTs and CK as baseline Repeat LFTs after 4-8 weeks, then every 6 weeks for 6 months

Question 13

Pharmacological management of mod-severe TG

Answer 13

Gemfibrozil BD or fenofibrate Slow response, monitor LFTs, predisposes to gall stones and myopathy Second line: Nicotinic acid If +++TG Fibrate + fish oil

Question 14

Treatment when mixed

Answer 14

If TG 4: fibrate Consider statin + fish oil, fibrate + resin

Question 15

Should a statin + fibrate be used

Answer 15

Increased risk of myopathy, need specialist supervision for use

Question 16

Follow up investigations

Answer 16

Serum lipids LFTs CK

Question 17

Heirachy of concern when raised CK and raised ALT

Answer 17

1. CK: statin > fibrate > nicotinic acid or ezetimibe 2. ALT: nicotinic acid > ezetimibe > fibrate > statin

Question 18

Baseline elevation in ALT, creatinine

Answer 18

3X ULN ALT and 5X ULN Creatinine–> incidental? (alcohol and exercise–>avoid for few days and retest) Consider delay treatment until normal +Not to 3/5 X normal–> incidental? If starting therapy–> heirachy of concern

Question 19

Reassessment elevation of LFTs

Answer 19

ALT 3XULN, CK 10X ULN or 5X with muscle symptoms–> STop therapy, retest in a month If persistent elevation: consider harm benefit, consider alternative: retest at 1, 6, 12 months, then when symptoms

Question 20

How to manage when elevated not to 3X or 10 X (ALT and CK)

Answer 20

If no muscle: retest 6, 12 months or when symptoms, continue therapy W persistent muscle->encourage ongoing therapy and retest if symptoms ++ Consider heirachy of concern Continue unless muscle symptoms Retest in 6 months

Question 21

Components of CVD risk calculator

Answer 21

Sex Age SBP Smoking TC HDL Diabetes ECG LVH