Hyperlipidaemia

Question 1

list the individuals who are at high risk of developing cardiovascular disease (5)

Answer 1

1) Diabetes
2) CKD (eGFR <60mL/min and/or albuminuria
3) Familial hypercholesterolaemia
4) Obesity
5) Aged 85 years or over
↳ very high risk of developing CVD because of age alone, especially smokers and people with high blood pressure

Question 2

1) list two cardiovascular risk assessment calculators and state which one is recommended by NICE
2) which patients should risk calculators not be used in?

Answer 2

1) QRISK (recommended by NICE) and JBS3 (calculation of lifetime risk)
2) should not be used in those aged ≥80 years and NICE advises not to use, in those with type 1 diabetes

Question 3

Both QRISK and JBS3 assess cardiovascular risk on the basis of lipid profile. State what factors these calculators take into account when calculating a risk score (9)

Answer 3

1) Systolic BP
2) Gender, Age, Ethnicity, BMI
3) Smoking status
4) CKD
5) Diabetes
6) AF
7) Treated hypertension
8) Rheumatoid artharitis
9) Family history of premature CV disease

Question 4

Risk assessment tools can underestimate risk in patients with additional conditions or medication. Outline which patients would have their risk underestimated (6)

Answer 4

1) Serious mental disorder
2) Autoimmune disorders
3) Antiretroviral treatment
4) Medication causing dyslipidaemia as a SE: e.g. antipsychotics, corticosteroids or immunosuppressents
5) Triglyceride conc > 4.5mmol/L
6) Already taking antihypertensive or lipid-regulating drugs and in those who have recently stopped smoking

Question 5

All patients at high risk of CV disease should be advised to make lifestyle modifications. List the lifestyle measures that should be provided to patients for primary prevention

Answer 5

1) Diet
2) Exercise
3) Weight management
4) Alcohol consumption
5) Smoking

Question 6

1) What drug should be offered as first-line IF lifestyle modifications are inappropriate or ineffective in primary prevention?
2) how does this differ with advice for secondary prevention?

Answer 6

1) if lifestyle + diet measures fail: statins (Combine with lifestyle and diet measures)
2) Statins should be offered to all patients, including the elderly with CV disease
↳ initiation of lipid-regulating drug should not be delayed to manage modifiable risk factors and must be combined with diet & lifestyle measures

Question 7

Before starting statins secondary causes of dyslipidaemia should be addressed. List some of the causes of secondary dyslipidaemia

Answer 7

1) Uncontrolled diabetes
2) nephrotic syndrome
3) excessive alcohol consumption
4) hypothyroidism- should receive adequate replacement therapy prior to commencing statin, as this may in itself resolve the lipid abnormality
↳ untreated hypothyroidism increases risk of myositis with lipid-regulating drugs

Question 8

NICE groups statins into 3 different intensity categories according to the percentage reduction in LDL-cholesterol they achieve. Outline these 3 catogeries and in general state which lipid regulating drugs and doses fall into each. (3)

Answer 8

1) low intensity if the reduction is 20% to 30%
↳ simvastatin 10mg, parvastatin
2) medium intensity if the reduction is 31% to 40%
↳ Aorvastatin 10mg, simva 20-40mg, Rosuvastatin 5mg
3) high intensity if the reduction is above 40%.
↳ Atorvastatin >20mg, Rosuvastatin > 10mg, simvas 80mg

Question 9

which lipid-regulating drug and dose should be offered to those with a QRISK of ≥ 10% for primary prevention of CV disease?

Answer 9

Atorvastatin 20mg OD (unlicensed) (high intensity statin)

↳ patients aged 85 or over may also benefit to reduce risk of non-fatal MI

Question 10

which lipid-regulating drug and dose should be offered for secondary prevention of CV disease?

Answer 10

Atorvastatin

↳ patients already taking low-medium lipid regulating therapy should speak to GP about switching to high intensity

Question 11

1) with regards to those with diabetes, who should be offered a statin?

Answer 11

1) Considered for all adults with type 1 particularly those aged over 40 years
2) Those who have had diabetes for more than 10 years
3) Those who have established nephropathy or other risk factors for CV disease
4) Those with type 2, assess risk using risk calc and treat for primary prevention if necessary

Question 12

What are the monotoring requirements for those starting treatment with a high intensity statin?

Answer 12

Total cholesterol, HDL and non-LDL concentrations should be checked 3 months after starting treatment

Question 13

1) what % reduction in non-HDL cholesterol concentration is recommended by NICE?
2) what should be ensured if this target is not achieved?

Answer 13

1) reduction in non-HDL concentration greater than 40%
↳JBS3 recommends target non-HDL below 2.5mmol/L
2) if not achieved ensure lifestyle modifications are optimised and consider increasing dose of statin if started on dose < 80mg of atorvastatin and the patient is judged to be at high risk

Question 14

1) Are fibrates recommended for primary and secondary prevention of hyperlipidaemia?
2) what about bile acid sequestrants and omega-3 fatty acid compounds?

Answer 14

1) should not be routinely used for primary and secondary prevention
2) not recommended at all in primary or secondary prevention

Question 15

Statins are also the first line treatment for hypercholesterolaemia, hypertriglyceridaemia and familial hypercholesterolaemia. what additional agent can be given if cholesterol levels still remain high despite using maximum dose of statins?

Answer 15

Ezetimibe- supervised by specialist

Question 16

1) when should fibrates and nicotinic acid be added to statin therapy?

Answer 16

1) Fenofibrate can be added to statin therapy if triglycerides remain high even if LDL concentration has been reduced adequately; nicotinic acid may also be used to lower triglyceride and LDL concentration further
↳fibrates can also be used in those whose serum-triglyceride conc is greater than 10mmol/l or in those who cannot tolerate statin

Question 17

1) what can concomitant therapy with statins + fibrates + nicotinic acid cause?
2) what should be monitored?

Answer 17

1) increase risk of SE, including rhabdomyolysis- so use under specialist
↳ gemfibrozil + statin should not be used together as there is significant risk of rhabdomyolysis
2) consider monitoring liver function and creatine kinase

Question 18

what is meant by the term high-intensity statin ?

Answer 18

A high-intensity statin is one that produces a greater LDL-cholesterol reduction than simvastatin 40mg

Question 19

what is the recommended reduction in LDL-concentration that should be achieved in familial hypercholesterolaemia with the use of statin therapy?

Answer 19

more than 50% from baseline

in familial hypercholesterolaemia a high intensity statin should be used e.g. rosuvastatin

Question 20

how do statins compare to other lipid regulating drugs and fibrates, with regards to effectiveness at reducing cholesterol levels?

Answer 20

Statins more effective than other lipid regulating drugs at lowering LDL cholesterol concentrations. BUT they are LESS effective than fibrates in reducing triglyceride concentrations

Question 21

Bile acid sequestrants are effective at reducing LDL-cholesterol. When should they be considered to treat hyperlipidaemia?

Answer 21

May be appropriate under a specialist if statins and ezetimibe are inappropriate and when when LDL cholesterol is severely raised e.g. in familial hypercholesterolaemia.
↳ (they can aggrivate hypertriglyceridaemia)

Question 22

nicotinic acid is used by specialists in combination with statins if the statin alone cannot control dyslipidaemia. However its use is limited mainly due to which side effect?

Answer 22

vasodialation

↳Acipimox has fewer S/E but not as effective

Question 23

Is there evidence that omega-3 fatty acid compounds reduce the risk of CV disease?

Answer 23

No

Question 24

what is Alirocumab and Evolocumab licensed to treat?

Answer 24

Primary hypercholesterolaemia or mised dyslipidaemia as an adjunct to dietary measures. can be added to statin therapy

Question 25

Why does the MHRA recommends that simvastatin 80mg should only be considered in patients with severe hypercholesterolaemia and those at high risk of CV complications

Answer 25

Increased risk of myopathy associated with high dose simvastatin