Hyperlipidemia

Question 1

Hyperlipidemia Risks

Answer 1

Cardiovasc diseases: coronary heart disease (angina, MI), cereberovasc disease (stroke/TIA), peripheral arterial disease

Question 2

Primary prevention

Answer 2

T1DM
T2DM if CVD risk >10% (QRISK2)
CKD/albuminuria
Familial hypercholesterolemia
85+ (reduces risk of non-fatal MI)

Question 3

Secondary prevention

Answer 3

Established CVD : coronary heart disease (angina, MI), cereberovasc disease (stroke/TIA), peripheral arterial disease

Question 4

QRISK2 criteria

Answer 4

assesses CV risk in 84 and under ( >10% risk in 10 yrs= primary prevention)
Unsuitable if high cardiovascular risk ( eg DM, established CVD, CKD, 85+, familial hypercholesterolemia

Question 5

Lipid `targets

Answer 5

(hyperlipidemia diagnosis at >6mmol/L)
<=5mmol/L total in healthy adults, <=4 in high risk adults
<= 3mmol/L LDL in healthy adults, <=2 in high risk adults
>1 HDL in all adults (higher=better), <1.7 TG in all adults

Question 6

Hyperlipdemia causes

Answer 6

Drugs: antipsychotics, corticosteroids, immunosuppressants, antiretrovirals
Conditions: hypothyroidism, liver/kidney disease, DM, familial hyper., lifestyle factors (smoking, alcohol, diet)

Question 7

Statin MOA

Answer 7

Lowers LDL cholesterol synthesis by inhibiting HMG-CoA reductase (indirectly reduces TGs and increases HDL) Taken at night as cholesterol produced more at night

Question 8

Statin High intensity

Answer 8

Atorvastatin (1st choice): PP 20mg, SP 80mg. Rosuvatstain: 10mg
Simvastatin: 80mg (MHRA warning-high risk of rhabdo)

Question 9

Hyperlipidemia treatment

Answer 9

Statin first choice
Primary and familial hyperchol. high intensity statin -> ezetimibe if statin CI/not tolerated
Moderate triglycerydemia, high intensity statin -> fibre if statin CI/not tolerated

Question 10

Before statin initiation

Answer 10

address secondary causes (hypothyroidism, uncontrolled DM, nephrotic syndrome(albuminuria), liver diseases such as alcoholic cirrhosis)

Question 11

Statin ADRs

Answer 11

Myopathy, myositis (muscle inflammation), rhabdo - counsel re muscle pain/weakness
High risk of muscle toxicity in familial, excess EtOH, renal impairment, hypothyroidism
^ myopathy risk with ezetimibe, fibrates (esp. Gemfibrozil), fuscidic acid (restart statin 7 days after finished course)
Interstitial lung disease - counsel to report SOB, cough, weight loss
Diabetes - statins can inc HbA1c and glucose levels

Question 12

Statin monitoring

Answer 12

Baseline lipid profile, renal, thyroid function, HbA1c. Discontinue if transaminases 3x normal, CK 5x normal, muscle symptoms

Question 13

Statin interactions

Answer 13

Increased exposure = increased risks
amiodarone, CCBs, antifingals, grapefruit juice (increase exposure)
Macrolides - stop statin whilst on macrolide - rhabdo risk
ezetimibe, fibrates (esp. Gemfibrozil), fuscidic acid (stop 7/7 post course) - increase myopathy risk

Question 14

Statin dose adjustments

Answer 14

Simva: 10mg max w/ fibre
Simva: 20mg max w/ amiodarone, amlodipine, Diltiazem and verapamil,
Atorva: 10mg max with ciclosporin
Rosuva: 5mg initially, max 20mg with clopidogrel

Question 15

Statins and pregnancy

Answer 15

Teratogenic. use effective contraception during therapy. stop 3/12 before conception, only restart when breastfeeding stopped

Question 16

Ezetimibe MOA

Answer 16

Reduces blood cholesterol by inhibiting absorption of cholesterol by small intestine

Question 17

Fibrate MOA

Answer 17

Lower blood TG levels by reducing the liver’s production of VLDL (triglyceride carrying substance in blood) and speeding up removal of TG from blood.

Question 18

Fibrate examples and indication

Answer 18

Bezafibrate, fenofibrate, ciprofibrate, Gemfibrozil

Hypertriglyceridemia >10mmol/L or statins not tolerated/CI

Question 19

Bile acid sequestrants MOA

Answer 19

bind/sequester bile, meaning liver produces more bile acids using excess cholesterol (reduces LDL)

Question 20

Bile acid sequestrant examples and interactions

Answer 20

colesevelam, colestyramine, colestipol

Impair absorption of fat soluble vitamins (ADEK) & other drugs, give other drugs 1 hr before/4h after.