Hyperlipidaemia Flashcards
First line medication for treating hypercholesterolaemia
Statins
What drug class is better at lowering triglyceride concentration than statins?
Fibrates
What drug can be added to statin therapy if TG remain high?
Fenofibrate
What heart condition are patient with familial hypercholesterolaemia at high risk of?
premature coronary heart disease
What should be offered to patients with familial hypercholesterolaemia?
- Statin therapy
2. Lifestyle advice
What is defined as a high intensity statin?
Where the reduction in LDL-cholesterol is greater than 40%
What should be offered to patients with primary heterozygous familial hypercholestererolaemia who are contra-indicated to be on a statin?
Ezemtibe monotherapy
If the maximum tolerated dose of statin fails to provide adequate control of LDL cholesterol what can be tried?
- Statin + Ezemtibe
- different statin
- bile acid sequestrant or fibrate (under specialist input)
- Evolocumab or Alirocumab
What is a side effect that could happen when being on a fibrate and a statin?
muscle related side effects ( Rhabdomyolysis risk)
Can Gemfibrozil be given with a statin?
No- considerable risk of Rhabdomyolysis
Examples of high intensity statins?
Atorvastatin (20mg, 40mg, 80mg)
Rosuvastatin (10mg, 20mg, 40mg)
Simvastatin (80mg)
Medium intensity statin examples
Atorvastatin (10mg)
Fluvastatin (80mg)
Rosuvastatin (5mg)
simvastatin (20mg, 40mg)
Examples of low intensity statins
Fluvastatin (20mg, 40mg)
Pravastatin (10mg, 20mg, 40mg)
Simvastatin (10mg)
MHRA adivce about simvastatin 80mg
High risk of myopathy associated wiht 80mg simvastatin. The 80mg dose should only be considered in patients with severe familial hypercholesterolaemia and high risk cardiovascular complications who have not reached their treatment goals on lower doses
Mechanism of action of bile acid sequestrants
bind to bile acid, preventing their absorption, this promotes hepatic conversion of cholesterol into bile acids; the resultant increased LDL-receptor activity of the liver cells increases the clearance of LDL cholesterol from the plasma
What needs to be noted about bile acid sequestrants affect on fat soluble vitamins?
BA sequestrants interfere with the absorption of fat soluble vitamins (ADEK and folic acid)
Examples of bile acid sequestrants
Colesevlam hydorchloride, Colestipol hydrochloride, Colestyramine
What needs to be monitored when a patient is on Colesevelam and ciclosporin?
Ciclosporin levels before, during and after treatment with colesevelam
What is the guidance for administration of Colestipol and can patients take other medications at the same time?
mix contents of each sachet with 100mL of water or other suitable liquid. Avoid other drugs at the same time
What drug works by inhibiting the intestinal absorption of cholesterol?
Ezetimibe
How does Benfibrate work?
Acts by decreasing serum triglycerides; they have a variable affect on LDL cholesterol
What are the 2 reasons Benzafibrate may be stopped?
- mytotoxicity suspected
2. if CK level increases significantly
How should Benzafibrate be taken?
Swallow whole with food
What does reduction is required for Ciprofibrate in moderate renal impairment?
100mg on alternate days
What gastro-intestinal disorder are fibrates contra-indicated in?
Gall bladder disease
What is the monitoring requirement for Fenofibrate?
- hepatic transaminases every 3 months during the first 12 months of treatment and periodically thereafter - discontinue if treatment levels increase to more than 3 times the ULN
- serum creatinine levels during firs 3 months and periodically thereafter - interrupt treatment if creatinine levels is >50% of ULN
Examples of nicotinic acid derivatives
Nicotinic acid, Acipimox
Common side effect with nicotinic acid derviatives
Prostaglandin mediated flushing - typically within an hour of dosing and lasting for 15 - 30 mins ( particularly with the inital dose). Taking after aspirin or before food minimizes this
How do Statins work?
competitively inhibit 3-HMG CoA reductase and enzyme involved in cholesterol synthesis, especially in the liver
At what creatinine kinase concentrations are patients at risk of muscle effects?
5 times the ULN
If a patient developed myalgia and has a raised CK on a statin - wha does the BNF suggest to do?
Stop the statin. If symptoms resolve and CK comes back to normal can start a statin back at a lower dose. Statins should not be restarted if there is an increase in blood glucose conc as the benefits continue to outweigh the risks
If a patient has symptoms such as dysponea, cough and weight loss on a statin - what could this be?
Intersitual lung disease
How long is contraception needed during statin therapy?
Throughout therapy and for 1 month post
What patient population should statins be avoided in?
Pregnancy (discontinue 3 months before conception)
What blood monitoring is needed before statin statin therapy?
- full lipid profile (non fasting) including total cholesterol, HDL, non HDL, TG
- TFT
- Renal function
- LFTs - before and reeat within 3 monthd then annually
- Creatine kinase - in patients who have persistant, generalised muscle pain
- Blood glucose - patients who are at high risk of DM should have fasting glucose / HbA1c checked before starting and at 3 months
If a patient is on Ciclosporin therapy and needs to be started on atorvastatin - what is the maximum dose?
10mg OD
What is the maximum dose of atorvastatin when given alongside anion-exchange resin for heterozygous familial hypercholesterolaemia?
40mg OD
What is the maximum dose of atorvastatin + elbasvir/grazoprevir/sofosbuvir?
20mg OD
Maximum dose of Simvastatin + fibrate
10mg OD
Maximum dose of Simvastatin + amiodarone / amlodipine / ranolazine?
20mg OD
If simvastatin is given concurrently with CYP3A4 inhibitors e.g. Verapamil, what is the max recommended dose?
20mg OD
Which statin and what dose can be sold to the public to reduce the risk of first coronary event in individuals at moderate risk of CHD?
Simvastatin 10mg, 28 pack size
What drug class do Alirocumab and Evolocumab belong to?
PCSK 9 inhibitors
Work by binding to pro-protein involved in the regulation of LDL receptors on liver cells; receptor numbers increase which results in increased uptake of LDL
How should Evolocumab be stored?
In fridge (2 - 8 degrees)
Which 2 statins need to be given at night?
Pravastatin and Simvastatin
