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pre reg afsha CV > lipid modification > Flashcards

lipid modification Flashcards

1
Q

What are the high intensity statins, and their doses?

A
  • Atorvastatin 20mg, 40mg, 80mg
  • Rosuvastatin 10mg, 20mg, 40mg
  • Simvastatin 80mg
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2
Q

MHRA advice - simvastatin

A
  • increased risk myopathy with high dose simvastatin (80mg)
  • consider only in pt with severe hypercholesterolaemia and high risk of CV complications who have not achieved their treatment goal s on lower doses
  • benefit vs risk only!
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3
Q

What to do if pt still has high triglyceride levels even after LDL-C has reduced adequately with statins

A
  • Add e.g. fenofibrate
  • Fibrates more effective in reducing triglyceride concentration
  • Max. dose 200 mg daily with concurrent use of a statin!
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4
Q

What to offer pt with familial hypercholesteorlaemia and why

A
  • High risk of premature CHD
  • Offer lifelong lipid modifying therapy to all pt
  • And advice on lifestyle changes to all pt
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5
Q

what is the primary target for reducing CV risk with lipid modifying treatment

A

Non-HDL cholesterol (replaced LDL cholesterol)

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6
Q

what are the healthy levels of all cholesterol

A
  • Total cholesterol <5mmol/L
    ○ TOO HIGH = 5-6.4 mmol/L
    ○ VERY HIGH = 6.5-7.8 mmol/L
    ○ EXTREMELY HIGH = >7.8mmol/L
  • Non-HDL <4mmol/L
  • HDL >1mmol/L
    ○ HDL is the good cholesterol which absorbs cholesterol in the blood and carries it back to liver
    ○ High levels of HDL can lower risk for heart disease and stroke
  • LDL <3mmol/L
    ○ Bad cholesterol
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7
Q

healthy levels of triglyceride, fasting and non-fasting

A
  • Fasting triglyceride <1.7mmol/L
  • Non-fasting triglyceride
    <2.3mmol/L
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8
Q

primary prevention of CVD with high intensity statin treatment should be offered to people

A
  • 25-84yrs (incl T2D) if estimated 10 year risk of developing CVD using QRISK3 is 10% or more, and lifestyle modification is ineffective/inappropriate
  • T1D (w/o need for formal risk assessment) who are >40, diabetes >10years, established nephropathy, other CVD RF
  • CKD (w/o need for formal risk assessment)
  • familial hypercholesterolaemia
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9
Q

consider offing lipid modification therapy for primary prevention of CVD to

A
  • all people with T1D (w/o need for formal risk assessment)
  • 85 or over, esp smokers/hypertension, taking into account risk vs benefit. pt pref, lifestyle modification, comorbid, polypharmacy, frailty, life expectancy (w/o need formal risk assessment)
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10
Q

before offering lipid modification treatment for primary prevention, what interventions and tests hold be implemented? (LIPID PROFILE)

A
  • clinical findings, lipid profile and FHx to judge likelihood of familial lipid disorder
  • exclude possible secondary causes (e.g. excess alcohol, uncontrolled DM, hypothyroid, liver disease, nephrotic syndrome)
  • discuss benefit of lifestyle modifications and optimise management of other modifiable CVD RF
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11
Q

Before giving lipid modification therapy, perform baseline blood tests (if not already done as part of the CV risk assessment) and a clinical assessment. Include all of the following:

A
  • take at least one lipid sample to measure full lipid profile
  • lipid measurement: total cholesterol, HDL-C, non-HDL-C, triglycerides
  • fasting sample not needed
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12
Q

What to do if a pt has total cholesterol >7.5 mmol/L and FHx premature CHD

A
  • consider possibility of familial hypercholesterolaemia
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13
Q

What do to if a pt has total cholesterol >9.0 mmol/L or non-HDL cholesterol >7.5 mmol/L

A
  • arrange for specialist assessment, even in absence of 1st degree FHx premature CHD
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14
Q

What to do if a pt has triglyceride >20 mmol/L that is not the result of excess alcohol or poor glycaemia control

A

Refer for urgent specialist review

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15
Q

What to do if a pt has triglyceride levels between 10-20mmol/L

A
  • repeat measurement with fasting test, after 5 days but within 2 weeks
  • review for potential secondary causes of hyperlipidaemia
  • seek specialist advice if conc remains above 10mmol/L
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16
Q

What interventions and tests should I implement before starting lipid modification treatment for the primary prevention of cardiovascular disease? (CK)

A
  • Creatinine kinase: ask if persistent generalised unexplained muscle pain
  • if present, measure CK level
  • if raised by less than 5x UL of normal, start statin treatment at lower dose
  • if 5x UL normal, remeasure after 7 days
  • if still 5x UL normal, do not start statin treatment - seek specialist advice
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17
Q

What interventions and tests should I implement before starting lipid modification treatment for the primary prevention of cardiovascular disease? (LFTs)

A
  • alanine aminotransferase or aspartate aminotransferase
  • if abnormal, further investigations to determine cause e.g. NAFLD
  • do not routinely exclude treatment for people who have liver enzymes elevated by less than 3x UL normal
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18
Q

What interventions and tests should I implement before starting lipid modification treatment for the primary prevention of cardiovascular disease? (renal function)

A
  • including eGFR
  • CKD does not preclude the use of lipid lowering drugs as these pt are at increased risk of CVD
  • however specific doses are recommended depending on stage of CKD
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19
Q

What interventions and tests should I implement before starting lipid modification treatment for the primary prevention of cardiovascular disease? (HbA1c)

A
  • to diagnose DM
  • do not stop lipid lowering treatment due to acute elevations in blood glucose
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20
Q

What interventions and tests should I implement before starting lipid modification treatment for the primary prevention of cardiovascular disease? (TFTs)

A
  • TSH in pt with symptoms of under or overactive thyroid
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21
Q

5 factors that also need to be included in a clinical assessment before starting statin therapy

A
  • Alcohol consumption.
  • Blood pressure.
  • Body mass index.
  • Smoking status.
  • Diabetes status
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22
Q

What should you offer as first line lipid modification therapy for primary prevention of CVD

A

high intensity statin (unless contraindicated e.g. pregnancy)
if they are willing to take statins, offer atorv 20mg OD

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23
Q

if statin for primary prevention of CVD is contraindicated, consider offering the following drug to people with primary hypercholesterolaemia

A

ezetimibe

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24
Q

follow up after initiation of lipid modification therapy for primary prevention

A

measure total C, HDL-C and non HDL-C in all pt 203 months after starting or changing lipid lowering therapy

if >40% reduction in non HDL-C not achieved, discuss adherence and timing of dose, encourage diet and lifestyle changes, and consider increasing dose of atorvastatin if it is less than 80mg and people it judged to be at higher risk of CVD

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25
Q

you prescribed atorv 20mg as primary prevention of CVD to a pt. on the 3 month review, non HDL-C had not been reduced by >40%. So you increased dose to atorv 80mg. You are now seeing them 3 months later, but still their non HDL-C has not reduced by >40%. What do you do

A

if reduction in non-HDL-C of >40% still not achieved after appropriate dose titrations of atorv, or bc dose titration is limited by adverse effects

consider ezetimibe + atorv for pt with primary hypercholesterolaemia

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26
Q

pt taking ezetimibe for primary prevention of CVD (bc statins contraindicated) but monotherapy has not controlled LDL-C well enough. what do you do?

A

consider + bempedoic acid

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27
Q

When should I advise lipid modification therapy for secondary prevention of cardiovascular disease?

A
  • Advise adults to start lipid modification therapy if they have established CVD disease
  • e.g. past or current history of myocardial infarction, angina, stroke, transient ischaemic attack, or peripheral arterial disease
28
Q

Which first-line lipid modification therapy is recommended for secondary prevention of CVD?

A
  • ATORVASTATIN 80mg OD
  • Offer high intensity statin treatment unless this is contraindicated (for example in pregnancy).
  • If the person is already taking a different statin for secondary prevention of cardiovascular disease, switch to a high intensity one
  • if they are taking simvastatin 80mg, speak to them about switching to e.g. atorvastatin 80mg, as there is increased myopathy risk
  • ideal: atorv 80mg daily, lower dose if interactions/increased risk adverse events/ pt requests to start with lower dose
  • need to do it alongside lifestyle measures e.g. increased exercise, reduced alcohol, good diet
29
Q

Should you offer statin in combination with bile acid sequestrates, nicotinic acid, omega-3 fatty compounds or a fibre in combination with a statin?

A

No

30
Q

What drug can you consider to treat people with primary hypercholesterolaemia

A

ezetimibe

31
Q

secondary care treatment options for people with primary non familial hypercholesterolaemia or mixed dyslipidaemia

A

aliorocumab
evolocumab

32
Q

How should I manage someone who is already taking a different statin for secondary prevention of cardiovascular disease?

A
  • discuss benefits of changing to high intensity treatment with atorv 80mg (or lower if necessary) or a medium intensity statin (e.g. simv 20 or 40mg)
  • if pt unwilling to change to atorv 80mg, reassure them they will still get benefit from current treatment
  • if pt is stable on high intensity statin simv 80, speak to them about switching to high intensity atorv instead
33
Q

How should I follow up a person after initiating lipid modification therapy for secondary prevention of CVD?

A
  • after 3 months of high intensity strain treatment, measure total cholesterol, HDL-C and non-HDL-C
  • aim of treatment: >40% reduction in baseline non-HDL-C levels
34
Q

What to do if >40% reduction in non-HCL-C is not achieved after 3 months high intensity statin

A
  • discuss adherence and timing of dose
  • optimise adherence to diet and lifestyle measures
  • consider increasing dose if <80mg atorv, if pt is judged to be at higher risk of cVD because of comorbids, risk score, or clinical judgement
35
Q

what to do if > 40% reduction in non-HDL-C is still not achieved after appropriate dose titrations of atorvastatin, or because dose titration is limited by adverse effects

A

Consider ezetimibe co-administered with atorvastatin for people with primary hypercholesterolaemia (consider seeking specialist advice).

36
Q

monitoring - statins

A
  • recheck LFTs within 3 months of starting treatment, and again at 12 months.
  • further monitoring is not necessary unless clinically indicated (for example symptoms or signs of hepatotoxicity develop).
37
Q

how often should you review statin treatment, and what should you discuss

A
  • annually
  • consider performing a non-fasting blood test for non-HDL-C to inform the discussion
  • discuss adherence and lifestyle factors
  • discuss with people who are stable on a low- or medium-intensity statin the likely benefits and potential risks of changing to a high-intensity statin
38
Q

what to do if unexplained muscle symptoms e.g. pain, tenderness, weakness occur

A
  • check CK (do not measure in asymptomatic people)
  • if CK <5x UL normal, reassure that symptoms unlikely to be due to statin and explore other causes
  • stop statin if CK 5x or more UL normal
  • consider stopping treatment if muscular symptoms severe and cause daily discomfort, even if CK levels are not >5x UL normal
39
Q

If other adverse effects are reported when taking high-intensity statin treatment, discuss the following possible strategies with the person:

A
  • stopping statin and trying again when symptoms resolves to check if they are related to statin use
  • reduce dose within same intensity group
  • changing to a statin in a lower intensity group
40
Q

For people taking ezetimibe monotherapy (if statins are contraindicated or not tolerated), consider the following combination if ezetimibe alone does not control low-density lipoprotein cholesterol well enough.

A
  • NUSTENDI: ezetimibe with bempedoic acid
41
Q

When would you offer icosapent ethyl in people already taking a statin

A
  • for people at high risk of CV events and have raised fasting triglycerides (1.7mol/L or above), if they have established CVD< and LDL-C between 1.04-2.60mmol/L
42
Q

When would you offer inclistiran as an option for treating primary hypehoeolsolaemia or mixed dyslpiademia ask an adjunct to diet

A
  • Hx of CV events e.g. ACS (unstable angina, MI), coronary or other arterial revascularisation procedures, CHD, ischaemic stroke, PAD

and

  • LDL-C conc persistently >2.6mmol/L or more desire max tolerated lipid lowering therapy
43
Q

Pt with primary heterozygous familial hypercholesterolaemia who have contraindications to, or are intolerant of statins, can be considered for treatment with

A

ezetimibe as monotherapy

44
Q

Treatment with fibrate or bile acid sequestrant (e.g. cholestyramine or colestipol HCl) can be considered under specialist advice in pt who…

A

statin or ezetimibe are inappropriate/not tolerated

45
Q

Combination of a statin + fibrate

A

carries an increased risk of muscle-related SE (including rhabdomyolysis) and should be used under specialist supervision

46
Q

concomitant use of gemfibrozil + statin

A

increases risk of rhabdomyolysis considerably - DO NOT USE THIS COMBINATION

47
Q

Name some filtrates

A
  • gemfibrozil
  • fenofibrate
  • bezofibrate
  • ciprofibrate
48
Q

name the medium intensity statins and doses

A
49
Q

name the low intensity statins and their doses

A
50
Q

which statins need to be taken at bed time and why

A

Simvastatin, pravastatin & fluvastatin
Because these have shorter half lives
Cholesterol is synthesised at night

51
Q

MOA statins

A

Statins competitively inhibit 3-hydroxy-3-methylglutaryl coenzyme A (HMG CoA) reductase, an enzyme involved in cholesterol synthesis, especially in the liver.

52
Q

MHRA advice - all statins, myasthenia graves

A
  • small no. of new onset, or exacerbations of myasthenia graves or ocular myasthenia
  • most cases, pt recover after stopping statin treatment
  • symptom onset ranged from a few days to 3 months after starting statin treatment
  • refer pt who present with suspected new onset mg symptoms after starting statin to neurologist
  • pt should inform HCP of Hx MG or OM as it may exacerbate symptoms
  • pt to continue taking statin unless advised to stop
  • pt to inform Dr of symptoms e.g. weakness arms legs that worsens after activity, double vision, drooping eyelids, difficulty swallowing, SOB
  • seek immediate medical attention if severe breathing or swallowing problems
53
Q

cautions for all statins

A
  • RF for muscle toxicity incl myopathy or rhabdomyolysis e.g. elderly, P/FHx muscle disorders, Hx liver disease, high alcohol intake
  • hypothyroidism should be managed adequately before starting treatment with statin
54
Q

Common SE all statins

A
  • arthralgia
  • asthenia
  • constipation
  • diarrhoea
  • dizzy
  • flatulence
  • GI discomfort
  • headache
  • muscle complaints
  • nausea
  • sleep disorders
  • thrombocytopenia
55
Q

statins & diabetes

A

Statins should not be discontinued if there is an increase in the blood-glucose concentration as the benefits continue to outweigh the risks.

56
Q

statins & interstitial lung disease

A

If patients develop symptoms such as dyspnoea, cough, and weight loss, they should seek medical attention.

57
Q

conception and contraception with statins

A

adequate contraception is required during treatment and for 1 month afterwards.

58
Q

use in pregnancy - statins

A

Statins should be avoided in pregnancy (discontinue 3 months before attempting to conceive) as congenital anomalies have been reported and the decreased synthesis of cholesterol possibly affects fetal development.

59
Q

use in BF - statins

A

avoid

60
Q

use in HI, all statins

A

In general, manufacturers advise caution (risk of increased exposure); avoid in active disease or unexplained persistent elevations in serum transaminases.

61
Q

monitoring requirements for all statins BEFORE treatment

A
  • one full lipid profile (non-fasting): TC, HDL, non-HL, triclyceride
  • TSH
  • renal function
  • LFTs
  • CK in pt with persistent, generalised unexplained muscle pain
  • FBGC or HbA1c in pt at high risk DM
62
Q

ongoing monitoring requirements for all statins

A
  • FBGC or HbA1c in pt at high risk DM after 3 months of starting
  • Liver function within 3 months, and at 12 months of treatment
63
Q

what is the % reduction in LDL-C for atorv 80mg

A

55%

64
Q

what is the % reduction in LDL-C for atorv 20

A

43%

65
Q

what is the % reduction in LDL-C for simvastatin 80mg

A

42%

66
Q

what is the % reduction in LDL-C for rosuv 40mg

A

53%

pre reg afsha CV (38 decks)

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