HYPERLIPIDAEMIA: PHARMACOLOGICAL TREATMENT

Question 1

Before starting lipid modification therapy for primary prevention of CVD, what must be measured?

Answer 1

ONE measure of full lipid profile (fasting not required):
- Total cholesterol
- HDL cholesterol
- non-HDL cholesterol
- triglycerides

Question 2

What are the normal levels (and targets) for lipids e.g. cholesterol?

Answer 2

1. Serum cholesterol: < 5.0 mmol/L
2. Serum triglyceride: < 2.3 mmol/L
3. Serum HDL cholesterol (“good cholesterol”) > 1.0 mmol/L
4. Serum LDL cholesterol (“bad cholesterol”): < 3.0 mmol/L
5. Serum NON-HDL
   cholesterol: < 4.0 mmol/L

Question 3

Total cholesterol

Answer 3

5 or below

Question 4

HDL (good cholesterol)

Answer 4

1 or above

Question 5

LDL (bad cholesterol)

Answer 5

3 or below

Question 6

Non-HDL

Answer 6

4 or below

Question 7

Triglycerides

Answer 7

2.3 or below

Question 8

Hyperlipidaemia

Answer 8

High blood levels of cholesterol, triglycerides or both

Question 9

Before giving statins, what causes of high cholesterol should be addressed?

Answer 9

SECONDARY CAUSE
- Uncontrolled diabetes
- hepatic disease
- nephrotic syndrome
- Excessive alcohol consumption
- Hypothyroidism (by correcting hypothyroidism, you may return to normal lipids)

Question 10

What can indicate the possibility of familial hypercholesterolaemia

Answer 10

• Total cholesterol concentration of more than: 7.5mmol/Litre
  AND
• Family history of premature coronary heart disease

Question 11

When would specialist intervention be
required based on lipid profile readings?

Answer 11

1. Total cholesterol > 9 mmol/L
2. Non-HDL > 7.5 mmol/l
3. Triglyceride > 20mmol/L (which is not a result of excess alcohol or poor glycaemic control)

Question 12

Before starting statin treatment, what baseline blood tests and clinical assessments need to be done?

Answer 12

• BP
• Total cholesterol, non-HDL, HDL and triglycerides
• HbA1c
• Renal function and eGFR
• Transaminase level (alanine aminotransferase or aspartate aminotransferase)

Question 13

Which statin does
NICE recommend?

Answer 13

For primary prevention:
- Atorvastatin should be offered to those with a 10-year cardiovascular risk of 10% or more and patients aged 85 years old or older
- atorvastatin 20mg

For secondary prevention:
- Atorvastatin 80mg

Question 14

Which statin and strength do you use for secondary prevention of CVD?

Answer 14

Atorvastatin 80mg
Use a lower dose if:
- Potential drug interactions
- High risk of adverse effects
- Patient preference

Question 15

Statins and diabetes

Answer 15

A statin is recommended in all adult with type 1 diabetes, particularly those:
- 40+
- Diabetes for more than 10 years
- Established nephropathy or other risk factors for cardiovascular disease

Question 16

What needs to be checked after statin treatment to check if treatment is working?
i.e target reduction

Answer 16

• Total cholesterol, HDL-cholesterol and non-HDL cholesterol concentrations
  should be checked 3 months after starting treatment with high-intensity statin
• NICE recommends aiming in a reduction of non-HDL cholesterol concentration by 40% or more

Question 17

Which lipid-modifying drugs are not
recommended for routine use in primary and secondary prevention of CVD according to NICE?

Answer 17

• Fibrates (e.g. Bezafibrate or
  Fenofibrate
• Nicotinic acid
• Bile acid suppressants
• Omega-3 fatty acid compounds

Question 18

Can ezetimibe be used for the prevention of CVD?

Answer 18

• primary (heterozygous-familial or non-familial) hypercholesterolaemia
• statin is contraindicated or not tolerated
• can be used in combination