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Competency > Hyperlipidaemia > Flashcards

Hyperlipidaemia Flashcards

1
Q

What is considered very high risk which requires secondary prevention?

A

ASCVD

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2
Q

What is considered very high/high risk which requires primary prevention?

A

Familial hypercholesterolaemia (FH), DM, CKD

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3
Q

What should you do if there are no very high or high risk factors?

A

Calculate 10 year risk score using SG-FRS

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4
Q

Using the SG-FRS, what risk score is considered:
- high risk
- intermediate risk
- borderline risk
- low risk

A
  • high risk: > 20%
  • intermediate risk: 10-20%
  • borderline risk: 5-<10%
  • low risk: <5%
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5
Q

If no comorbidities and LDL-C < 4.9, what is the target LDL-C for patients of:
- high risk
- intermediate risk
- borderline risk
- low risk

A
  • high risk < 1.8 mmol/L
  • intermediate risk < 2.6 mmol/L
  • borderline risk: < 3.4 mmol/L
  • low risk: < 3.4 mmol/L
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6
Q

If no comorbidities and LDL-C < 4.9, what is the preferred treatment for patients of:
- high risk
- intermediate risk
- borderline risk
- low risk

A
  • high risk: maximally-tolerated statin +- ezetimibe
  • intermediate risk: moderate-intensity statin esp if risk enhancers present
  • borderline risk: risk-benefit discussion for a statin if risk enhancers present
  • low risk: lifestyle intervention, risk-benefit discussion if LDL-C persistently > 4.1
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7
Q

If ASCVD & LDL-C > 4.9, what is the target LDL-C? (different conditions)

A
  • with ACS (MI, unstable angina): < 1.4 mmol/L
  • without ACS: < 1.8 mmol/L
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8
Q

If ASCVD & LDL-C > 4.9, what is the preferred treatment?

A
  • maximally-tolerated statin +- ezetimibe
  • PCSK9 inhibitor if LDL-C ≥ 1.8 despite first option, esp post-ACE, recurrent ASCVD, polyvascular disease or FH
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9
Q

If FH & LDL-C > 4.9, what is the target LDL-C? (different conditions)

A
  • if >40y or additional CV risk factor (DM, HTN, smoking etc): < 1.8 mmol/L
  • if ≤40y & no additional CV risk factor: < 2.6 mmol/L
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10
Q

If DM & LDL-C > 4.9, what is the preferred treatment? (different conditions)

A
  • additional DM-specific risk factors (CKD, multiple microvascular complications, DM > 10y, glycemic level persistently above target despite optimal tx): maximally-tolerated statin +- ezetimibe
  • no additional DM-specific risk factors: at least moderate-intensity statin
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11
Q

If CKD & LDL-C > 4.9, what is the preferred treatment?

A

moderate-intensity statin +- ezetimibe in non-dialysis dependent pts

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12
Q

If FH & LDL-C > 4.9, what is the preferred treatment?

A
  • maximally-tolerated statin +- ezetimibe
  • PCSK9 inhibitor if LDL-C ≥ 2.6 despite first option
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13
Q

If DM & LDL-C > 4.9, what is the target LDL-C level? (diff conditions)

A
  • additional DM-specific risk factors (CKD, multiple microvascular complications, DM > 10y, glycemic level persistently above target despite optimal tx): < 1.8 mmol/L
  • no additional DM-specific risk factors: < 2.6 mmol/L
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14
Q

If CKD & LDL-C > 4.9, what is the target LDL-C?

A

eGFR < 60 +/ ACR ≥3: < 2.6 mmol/L

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15
Q

If LDL-C > 4.9 but not FH (no other comorbidities), what is the target LDL-C?

A

Calculate 10y SG-FRS to determine target

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16
Q

If LDL-C > 4.9 but not FH (no other comorbidities), what is the preferred treatment?

A

at least moderate-intensity statin

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17
Q

How much do the following statins reduce LDL-C by:
- high-intensity statin
- moderate-intensity statin

and give examples

A
  • high intensity: ≥50% reduction (atorvastatin 40-80mg, rosuvastatin 20-40mg)
  • moderate intensity: 30-49% (atorvastatin 10-20mg, lovastatin 40-80mg, rosuvastatin 5-10mg, simvastatin 20-40mg)
18
Q

MOA of statins?

A

Inhibit HMG-CoA reductase -> inhibit cholesterol synthesis in liver -> liver takes up more LDL to be destroyed (up regulation of LDL receptor) -> reduce LDL in bloodstream

19
Q

Should statins be used in pregnancy?

A

No (generally avoided)

20
Q

Lifestyle modifications for lipid management?

A
  • healthy diet (avoid trans fat, replace saturated fat with polyunsaturated fat, reduce calories/refined sugar)
  • physical activity
  • healthy weight
  • smoking cessation
  • limit alcohol intake (abstain if TG ≥ 4.5 or history of pancreatitis)
21
Q

Rank the potency of statins from weakest to strongest

A

lovastatin < simvastatin < atorvastatin < rosuvastatin

22
Q

PCSK9 inhibitors MOA and examples?

A

MOA: inhibit PCSK9 (which breaks down LDL receptors) -> more cellular uptake of LDL from plasma

Examples: evolocumab, alirocumab

23
Q

Rank the potency of lipid therapies from lowest to highest LDL lowering

A

ezetimibe < statin < PCSK9 inhibitor

24
Q

What is considered ASCVD? (8)

A
  • history of ACS (MI, unstable angina)
  • stable IHD
  • ischaemic stroke
  • TIA (transient ischaemic attack)
  • PAD (peripheral artery disease)
  • AAA (abdominal aortic aneurysm)
  • post-CABG (coronary artery bypass graft)
  • post-PCI (percutaneous coronary intervention)
25
Q

Why need to adjust statin dose for advanced CKD and at what eGFR cut-off?

A

Minimise risk of myopathy
eGFR <30

26
Q

At what TG level should fibrates be added and what risk does it lower?

A

TG ≥ 4.5 mmol/L
Lower risk of pancreatitis

27
Q

If patient is on a statin, should fenofibrate or gemfibrozil be added and why? What should patient be monitored for?

A

Fenofibrate, lower risk of DDI resulting in severe myopathy

Monitor liver function due to risk of hepatotoxicity

28
Q

SE of statin?

A
  • statin-associated muscle sx (SAMS)
  • liver transaminase elevation (>3x ULN)
  • new onset DM
29
Q

CK levels of SAMS?

A
  • myalgias: normal CK (<10x ULN)
  • myopathy/myositis: CK >10x ULN
  • rhabdomyolysis: CK >40x ULN
30
Q

If patient has intolerable symptoms (CK ≤3x ULN) or CK >3-≤10x ULN, what are the different options to restart statins?

A
  • reduced dose
  • different statin
  • alternate-day dosing of atorvastatin or rosuvastatin
31
Q

Dose of ezetimibe? (only one)

A

10mg daily

32
Q

SE of ezetimibe?

A
  • URTI
  • joint pain, limb pain
  • diarrhoea
33
Q

Which fibrate is the only one that has been used together with ezetimibe?

A

Fenofibrate

34
Q

What CrCl/eGFR is fibrates contraindicated?

A

CrCl <30 (fenofibrate & gemfibrozil)

35
Q

SE of fibrates?

A

N/V/D, flatulence
fenofibrate: liver transaminases increase
gemfibrozil: skin reactions, constipation

36
Q

Frequency and SE of PCSK9 inhibitors?

A

Frequency: Q2w or Q1m (diff dose)
SE: injection site reaction, URTI, pruritus, arthralgia, back pain

37
Q

Major DDI with statins?

A
  • CYP3A4 inhibitors (atorvastatin, simvastatin): macrolides, azoles, grapefruit & its juice
  • CYP2C9 (rosuvastatin)
  • increase SAMS: colchicine (monitor), fenofibrate (monitor), gemfibrozil (avoid)
38
Q

When to monitor lipids and ALT?

A

8-12w after starting or dose adjustment

39
Q

Statin contraindications?

A
  • pregnancy & lactation
  • active liver disease
  • persistently elevated liver transaminases
40
Q

Which lipid-lowering meds do not require renal dose adjustment?

A

Simvastatin, atorvastatin, ezetimibe

41
Q

Administration of gemfibrozil?

A

Gemfibrozil: take 30min before meals

Competency (30 decks)

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