Hyperlipidaemia Flashcards
What are the first choice for treating hypercholesterolaemia or moderate hypertriglyceridaemia?
Statins
What should be done in the case of severe hypercholesterolaemia or hypertriglyceridaemia?
After trying max dose statin, may need to add another lipid regulating drug e.g. ezetimibe (specialist supervision)
What med is most effective for lowering LDL-cholesterol conc?
Statins
What med is most effective for lowering triglyceride conc?
Fenofibrate- added to statin if TGs high even after LDL reduced
What is the risk with familial hypercholesterolaemia?
Puts patients at high risk of premature coronary heart disease
What should be offered to patients with FH?
Lifelong lipid modifying therapy and advice on lifestyle changes
What is 1st line treatment for FH?
> High intensity statin (dose where reduction of LDL greater than 40% is achieved)
Dose to be titrated to achieve reduction of LDL greater than 50% from baseline
What is an alternative to a statin if it is not tolerated?
> In primary heterozygous FH can give ezetimibe as monotherapy
Combo of statin and ezetimibe can be given if max tolerated statin dose fails to reduce LDL
What should be considered if statin and ezetimibe not appropriate?
A fibrate or bile acid sequestrant (cholestyramine or colestipol hydrochloride) [specialist advice]
What is the risk of combining fibrate and statin?
Increased risk of rhabdomyolysis
Which fibrate should not be given with statins at all and why?
Gemfibrozil–> together it increases risk of rhabdomyolysis considerably
What is one of the last treatment steps in FH if all else fails?
Alirocumab and evolocumab
What are some examples of high intensity statins?
> Atorvastatin: 20mg, 40mg, 80mg
Rosuvastatin: 10mg, 20mg, 40mg
Simvastatin: 80mg
What is the MHRA advice regarding Simvastatin 80mg?
There is an increased risk of myopathy–> only considered in severe hypercholest and high risk of CVD (benefits outweigh risk)
What is the definition of hyperlipidaemia?
High blood levels of cholesterol, triglycerides or both
How does HL manifest?
> Cardiovascular disease --> it causes atherosclerosis which causes: > CHD > Strokes and TIAs > Peripheral arterial disease
When is primary prevention indicated?
- T1DM
- T2DM (only if CVD risk >10%)
- QRisk >10%
- CKD or albuminuria
- FH
- 85+
When is secondary prevention indicatied?
In established CVD:
Angina, MI, Stroke, TIA and peripheral arterial disease
What is the risk calculator recommended by NICE?
QRISK3: assesses CVD risk in 84 and under
if over 10% then offer primary prevention
Which patients is QRISK inaccurate in?
> T1DM > Established CVD > Over 85 years > CKD (eGFR <60) > FH
What level would cholesterol be for hyperlipidaemia diagnosis?
6mmol/L total cholesterol
What are the total cholesterol targets for a healthy adult and high risk adult?
<5mmol/L HEALTHY
<4mmol/L HIGH RISK
What are the LDL targets for a healthy adult and high risk adult?
<3mmol/L healthy
<2mmol/L high risk
What are the HDL and triglycerides target?
> 1mmol/L HDL (higher the better)
<1.7mmol/L TG
What drugs can cause hyperlipidaemia?
> Antipsychotics
Immunosuppressants
Corticosteroids
Antiretrovirals (HIV drugs)
What conditions can cause hyperlipidaemia?
> Hypothyroidism > Liver or kidney disease > Diabetes > Family history > Lifestyle (smoking, excess alcohol, obesity, fatty diet)
How do statins work?
They lower LDL synthesis by the liver via inhibition of HMG-CoA reductase)
What are the atorvastatin doses for primary and secondary prevention?
Primary= 20mg OD Secondary= 80mg OD
What needs to be considered before starting a statin?
Any secondary causes of dyslipidemia:
- Hypothyroidism
- Uncontrolled diabetes
- Nephrotic syndrome
- Liver disease
What are some common side effects of statins?
> Myopathy, myositis, rhabdomyolysis (Tell patient to report tender, weak and painful muscles)
Interstitial lung disease (report SOB, cough, weight loss)
Diabetes (can raise HbA1c)
What patients have a higher risk of muscle toxicity?
> Personal or fam history of muscle disorder
High alcohol intake
Renal impairment
Hypothyroidism (treat before giving statin)
In what instances are there increased risk of myopathy?
> Concomitant ezetimibe or fibrates (esp gemfibrozil)
> Concomitant fusidic acid (restart statin 7 days after ast dose)
What monitoring is required with statins?
> Baseline lipid profile
Renal function
Thyroid function
HbA1c if high risk of developing diabetes
When should you consider discontinuing therapy?
> Severe muscle symptoms
Creatine kinase–> is 5X normal
Liver function–> if 3X normal
What happens if statin levels increase?
Increased myopathy risk
What meds can increase statin levels?
- Amiodarone
- Grapefruit
- CCB
- Imidazole/triazole antifungals
What interactions can occur with statins and what should be done?
- Macrolides (e.g.clarith): stop statin until abx course done
- Ezetimibe/fibrate: AVOID
- Fusidic acid: restart statin 7 days after (oral) dose
What are some simvastatin dose adjustments needed for interactions?
- Max 10mg w/fibrate
- Max 20mg w/Amiodarone, amlodipine, diltiazem and verapamil
What are some atorvastatin dose adjustments needed for interactions?
Max 10mg w/ ciclosporin
What are some rosuvastatin dose adjustments needed for interactions?
Initially 5mg, max 20mg w/clopidogrel
Can statins be taken in pregancy?
No- they are teratogenic
When should statins be stopped in pregnancy?
3 months before conceiving and restart after breastfeeding
What is ezetimibe mechanism of action?
Reduces blood cholesterol by inhibiting abs of cholesterol from small intestine
What is the mechanism of action for fibrates?
Lowers TG levels by reducing liver’s production of VLDL (what carries TG around blood) and also speeds up TG removal from blood
What is the mechanism of action of bile acid sequestrants?
Binds and sequesters bile acids. Liver then makes more bile acid which uses cholesterol to do so- reducing LDL in blood
What is important to factor with bile acid sequestrants?
Imparis abs of fat sol vitamins (ADEK) and other drugs.
Take other drugs 1 hour before (4h for coleveselam) or 4h after.
