HYPERLIPIDAEMIA Flashcards
Total cholesterol
5 or below
HDL (good cholesterol)
1 or above
LDL (bad cholesterol)
3 or below
Non-HDL (bad cholesterol)
4 or below
Triglycerides
2.3 or below
Hyperlipidaemia
High blood levels of cholesterol, triglycerides or both
Lipid lowering agents should be offered in
Lipid Lowering agents should be offered in:
Patients under 85 with a 10-year risk of CVD greater than 10%
Patients with type 2 diabetes 10-year risk of CVD greater than 10%
All type 1 diabetic patients with:
* Age over 40
* Diabetes for over 10 years
* Established nephropathy
Patients with chronic kidney disease
Patients with familial hypercholesterolaemia
QRISK2
Assesses cardiovascular risk in those aged 84 or under.
QRISK score > 10% = offer primary prevention.
Unsuitable in those at risk of CVD:
- Type 1 diabetes
- Established CVD
- 85+
- CKD (eGFR <60)
- Familial hypercholesterolemia
Primary prevention
Actions taken to prevent the onset of high cholesterol levels before they occur.
Given to high risk groups:
- Type 1 diabetes
- Type 2 diabetes (if CVD risk >10%)
- QRISK score >10%
- CKD or albuminuria
- Familial hypercholesterolaemia
- 85+ (reduces risk of non-fatal MI)
Secondary prevention
Aimed at individuals who have already been diagnosed with hyperlipidemia or have experienced CVD events:
- CHD (angina, MI)
- Cerebrovascular disease (stroke/TIA)
- Peripheral arterial disease
Statins examples
Atorvastatin Rosuvastatin Simvastatin Fluvastatin Pravastatin
What time of the day should you take statins?
Atorvastatin and Rosuvastatin can be taken any time during the day
Cholesterol synthesis is greater at night, therefore it will be more effective.
Prevention of CVD
High intensity statin.
Atorvastatin:
- Primary prevention = 20 mg
- Secondary prevention = 80mg
Hyperlipidaemia - primary hypercholesterolaemia
High-intensity statin
If statin not tolerated or contra-indicated give ezetimibe.
Hyperlipidaemia - familial hypercholesterolaemia
High-intensity statin
If statin not tolerated or contra-indicated give ezetimibe.
Hyperlipidaemia - moderate hypertriglyceridaemia
If statin not tolerated or contra-indicated give fibrate
Severe hyperlipidaemia
Add on ezetimibe
Resistant hyperlipidaemia
Triglycerides still high after LDL reduced
- Add fibrate or nicotinic acid (also lowers LDL)
atorvastatin 80mg
strongest
used in secondary prevention (heart attack)
Hypothyroidism and statins
Hypothyroidism should be managed before starting statin
Patients at high risk of diabetes mellitus
should have fasting blood-glucose concentration or HbA1C checked before starting statin
Repeat after 3 months
Monitoring
Before initiation
full lipid profile
thyroid function
renal function
liver function
creatine kinase
Monitoring - liver function
Liver enzymes measured: before treatment → 3 months → 12 months
Discontinue if serum transaminases are raised by more than 3 x UL
Monitoring - Creatine kinase
Measured in patients who have previously had persistent muscle aches
If measurement 5 x more than UL - remeasure in 7 days
If still higher than 5 times the limit - do not initiate statins
If levels are raised but under 5 times the limit - start at lower dose
Statins - side effects
Myopathy and Rhabdomyolysis
Interstitial Lung Disease
Teratogenic
Myopathy and Rhabdomyolysis
Muscle toxicity → seek medical advice if they develop muscle symptoms (pain, tenderness, or weakness)
Interstitial Lung Disease
Seek medical attention if patient develops dyspnoea, cough, and weight loss
Teratogenic
Statins should be avoided in pregnancy (discontinue 3 months before conceiving)
Statins - interactions
CYP450 Enzyme Inducers
CYP450 Enzyme Inhibitors
Fusidic Acid (oral)
Interactions - CYP450 Enzyme Inducers
Reduces the concentration of statin
Interactions - CYP450 Enzyme Inhibitors
CYP450 Enzyme Inhibitors
Increases the concentration of statin → increased risk of rhabdomyolysis
Patients prescribed macrolides should stop taking their statin during treatment
Avoid drinking grapefruit juice
Interactions Fusidic Acid (oral)
Stop statin during treatment → restart 7 days after last dose
Clari and atorvastatin
tell pt stop statin whilst on clarity
Statin max doses
Amiodarone + Simvastatin = 20mg
Amlodipine + Simvastatin = 20mg
Diltiazem / Verapamil + Simvastatin = 20mg
Ticagrelor + Simvastatin = 40mg
Ciclosporin + Atorvastatin 10mg
Tipranavir + Atorvastatin = 10mg
Amlodipine + Simvastatin = 20mg
important interaction
statin may not exceed 20mg
amlodipine increases levels of simvastatin
increased risk of rhabdomyolysis
statin + ezetimibe
increased risk of rhabdomyolysis
Fibrates
Bezafibrate Ciprofibrate Fenofibrate Gemfibrozil
Fibrates - side effects
Myotoxicity in renal impairment
Fibrates - monitoring
LFTs every 3 months for first year
Statin + Fibrates =
increased risk of muscle related side-effects
rhabdomyolysis
Statin + gemfibrozil (do not use together)
Bile Acid Sequestrants - MOA
Binds to and sequesters bile acids.
Liver then produces more bile acids to replace those lost.
Body uses cholesterol to make bile acids = reduced LDL cholesterol circulating in the blood.
Bile Acid Sequestrants - examples
Colesevelam
Colestipol
Colestyramine
Bile Acid Sequestrants - initiation
Must be initiated by a specialist
Bile Acid Sequestrants - interactions
Impairs absorption of fat-soluble vitamins (ADEK) and other drugs
Bile Acid Sequestrants - administration counselling points
Take other drugs 1 hour before (4 hours for colesevelam) or 4 hours after bile sequestrant.
Nictoinic acid - examples
Acipimox
Nicotinic acid
Omega-3 fatty acid
Nicotinic acid - MOA
Lowers cholesterol and triglyceride concentrations by inhibiting synthesis.
Increases HDL cholesterol
Nicotinic acid - indication
Adjunct to statin OR alone if statin not tolerated
Nicotinic acid - CI
Active peptic ulcer disease
Arterial bleeding
Omega-3 Fatty Acids - Indication
Used in adjunct to statin/diet.
Not be used alone
No evidence for use
Omega-3 Fatty Acids - cautions
Anticoagulant treatment
Haemorrhagic disorders
- Has natural anticoagulant properties so can thin the blood
Omega-3 Fatty Acids - side effects
AF
Burping
Constipation
GI distubrances
N + V
