Hyperlipidaemia Flashcards
Hyperlipidaemia
is defined by having high levels of cholesterol,triglyceride or both in blood.
Hyperlipidaemia can manifest into
cardiovascular disease, Hyperlipidaemia causes atherosclerosis and in turn:
- Coronary heart disease(angina, myocardial infarction)
- Strokes and transient Ischaemic attacks(TIA)
- Peripheral arterial disease
Prevention of Cardiovascular disease:
1) Primary prevention in patients that have…
- Type 2 Diabetes Mellitus only if CVD risk is greater than 10%
○ Risk calculators(eg.QRISK2): 10 year CVD risk greater than 10%
○ Chronic kidney disease or albuminuria
○ Familial hypercholesterolaemia
○ 85 years and above(reduce risk of non fatal myocardial infarction)
Secondary prevention in patients that have…
- Established CVD(Coronary heart disease -Angina,MI, cerebrovascular disease-stroke/TIA and peripheral arterial disease
The risk calculators:
- Qrisk2 is recommended by NICE, it assess cardiovascular risk in 84 years and under
10 year CVD risk score of greater than 10% then offer primary prevention
Unsuitable in patients at high cardiovascular risk(score will be underestimated)
This include patients that have:
- Type 1 diabetes Mellitus
- Established cardiovascular disease
- Over 85 years of age
- CKD(eGFR less than 60 ml/min)
- Familial hypercholesterolemia
Cholesterol Targets:
Hyperlipidaemia diagnosis - 6mmol/L total cholesterol
- Less than or equal to 5mmol/L total cholesterol for healthy adults - Less than or equal to 4 mmol/L total cholesterol for high risk adults - Less than or equal to 3 mmol/L LDL for healthy adults - Less than or equal to 2 mmol/L LDL for high risk adults
What are the causes of Hyperlipidaemia:
Drugs:
- Antipsychotics
- Immunosuppressants
- Corticosteroids
- Antiretrovirals(HIV Drugs)
Conditions that can cause hyperlipidemia
- Hypothyroidism
- Liver or kidney disease
- Diabetes Mellitus
- Family history of high cholesterol
- Lifestyle factors: smoking,excess alcohol consumption, obesity and poor fatty diet.
Before starting statins condition we need to address the causes of what???
- Address any secondary causes of dyslipidaemia
○ Hypothyroidism
○ Uncontrolled diabetes Mellitus
○ Nephrotic syndrome(albuminuria)
○ Liver disease eg. Alcoholic cirrhosis
First choice of hyperlipidaemia are….
Statinnnssssssssssssssssssss
If statin is not tolerated or contraindicated -hyper cholesterolameia
if Statin not tolerated or contra- indicated =Ezetimibe can be given)
Moderate hypertriglyceridaemia- if statin not tolerated of contra
(If statin not tolerated or contra indicated = Fibrate can be given)
Specialist supervision
- If severe Hyperlipidaemia - add on ezetimibe
- If triglyceride still high after LDL reduced: Add fibrate OR nicotinic acid (also lowers LDL)
Primary prevention - 10 year cardiovascular risk >=10% OR most type of T1D or CKD if eGFR <60ml/min
Atorvastatin 20mg OD
- If non-HDL has fallen by >= 40% then consider titrating up to 80mg
Secondary prevention - knows ischaemic heart disease or cerebra vascular disease or peripheral artierial disease
Atorvastatin 80mg OD
The risk calculators:
- Qrisk2 is recommended by NICE, it assess cardiovascular risk in 84 years and under
10 year CVD risk score of greater than 10% then offer primary prevention
Lipid regulating Drugs:
The steps
1)Hyperlipidaemia - Statin is the first choice
2) Primary hypercholesterolaemia and Familial Hypercholesterolaemia(High intensity statin - if Statin not tolerated or contra- indicated =Ezetimibe can be given) 3) Moderate hypertriglyceridaemia(If statin not tolerated or contra indicated = Fibrate can be given)
Specialist supervision
- If severe Hyperlipidaemia - add on ezetimibe
- If triglyceride still high after LDL reduced: Add fibrate OR nicotinic acid (also lowers LDL)
Dyslipidaemia- Lipid lowering agents should be offered in:
Patients that are…..age and a 10 year of what?? Greater 10%( 5 groups)
- Patients under 85 with a 10 year risk of CVD greater than 10%
- Pts with type 2 diabetes - with a greater than 10% risk of CVD
- All type 1 dbts patients - age over 40,diabetes for over 10 years,established nephropathy
Patients with chronic kidney disease
Patients with familial hyper cholesterol anemia
Statins - Atrovastatin and Rosuastatin - anytime during the day - others at night
Why is that? What is the strongest dose of atorvastatin that can be given??? What kind of t… do we need to manage before statins?? Patients at high risk of what should have what measured before starting a statin??? This is done every 3 month
- Cholesterol is produced at night - where there’s more cholesterol being produced
- Atorvastatin 80mg - strongest dose - used in secondary prevention
- Any thyroid disorder - hyperthyroidism - manage before statin
- Patients with high risk of diabetes - should have fasting blood glucose conc or HB1AC measured before starting statin-
- Every 3 months
Monitoring LFTS 3-12 need to be monitored how often??? When would we need to discontinue??? If what rises by how much???
Liver function and full lift and thyroid function and creatinine kinase measured
- 3months - 12 months
- Discontinue if serum transminases are raised by more than 3 times the upper limit
If patient has muscle aches and their Creatnine Kinase is ….
- If measurement is 5 times higher than upper limit- re measure in 7 days
- If still higher than 5x the limit - do not initiate statins
- If levels are raised but under 5 times the limit - start at a lower dose
SIDE EFFECTS- myopathy, rhabdo, interstitial lung disease, teratogenic
Myopathy and Rhabdomyolysis
- Muscle toxicity - seek medical advice if the develop muscle symptoms (pain tenderness, weakness) - medical advice straight away
- Interstitial lung disease
Seek medical attention - if pt develops disposes,cough and weight loss
Teratogenic -
Stating should be avoided in pregnancy - discontinue 3 months before conceiving
INTERACTION - Statins - REDUCE
CYP450 enzyme inducers - reduces the concentration of statins
CRAp GPS
Carbamazepine, rafampacin, alcohol, grapefruit juice, phenytoin, gracofluvin,phenobarbital and St John’s wart
Statinsssss increase CONC of what???
CYP450 inhibitors sick face. Com
- Increases the conc of statins - increased risk of rhabdomyolysis
- Patients prescribed with macro life’s should stop taking the statin during their treatment
- Avoid drinking grapefruit juice
Fusidic acid - oral
- Stop statin during treatment - restart 7 days after last dose
Maximum doses -
Amiodarone + Simvastatin= 20mg
Amlodipine+ Simvastatin= 20 mg
Diltiazem/verapamil + Simvastatin = 20mg
Ticagrelor + Simvastatin= 40mg
Cyclosporine + atorvastatin = 10mg
Tipranovir + atorvastatin = 10mg
Other lipid lowering agents -
Ezetimibe - Statin + Eztimide - increased risk of rhabodomyolsis
Fibrates: do what?
What are examples of them? What can they cause in renal impairment???What do they do??? How often do we measure lfts first year, statins+ vibrates increase the risk of what?
- Lower lipid profile
- Bezafibrate ciprofibrate fenofobrabe gemfibrozil
- Myotoxicity in renal impairment
- LFTs every 3 months for the first year
- Statins + fibrates = increased risk of muscle related side effects
