Management of Hyperlipidaemia

Question 1

What is hyperlipidaemia?

Answer 1

Raised levels of one or more of total cholesterol, LDL cholesterol, or triglycerides.

Question 2

What is the difference between primary and secondary prevention of CVD?

Answer 2

Primary - Preventative measures in people without diagnosed CVD
Secondary - Preventative measurements in patients with a diagnosis of CVD e.g. Stroke, heart attack

Question 3

What is dyslipidaemia?

Answer 3

Hyperlipidaemia and low levels of HDL cholesterol

Question 4

What are the lifestyle modifications of primary and secondary prevention of CVD?

Answer 4

• Cardioprotective diet
• Physical activity (150 mins moderate intensity/75 mins vigorous intensity or mix)
• Weight management
• Alcohol consumption (<14 units/week)
• Smoking cessation
• Plant stanols and sterols

Question 5

What is the preferred statin to be prescribed for hyperlipidaemia.

Answer 5

Atorvastatin

Question 6

How do statins lower LDL levels?

Answer 6

Competitively inhibit HMG CoA reductase, slowing down cholesterol production in liver and increase the livers ability to remove the LDL-C already in blood

Question 7

What is the statin dose for the primary and secondary prevention of CVD?

Answer 7

Primary (after risk assessment) - Atorvastatin 20mg daily
Secondary - Atorvastatin 80mg daily - lower if interactions, high risk of S/Es, preference

Question 8

What is the statin dose for the primary prevention of CVD in type 1 and 2 diabetes?

Answer 8

Type 1 - Consider for all adults, offer if: >40 yrs, Diabetes >10 yrs, nephropathy, other CVD risk factors = Atorvastatin 20mg daily
Type 2 - QRISK2, if >10% = Atorvastatin 20mg daily

Question 9

What is the statin dose for the primary and secondary prevention of CVD in CKD and under what circumstances would you increase the dose?

Answer 9

Primary and secondary - Atorvastatin 20mg daily
Increase if:
- >40% reduction in non-HDL not achieved + eGFR >30 (max 80mg)
- eGFR <30 ( consult renal specialist)

Question 10

What foods and supplements interact with statins?

Answer 10

Grapefruit juice (Atorvastatin/Simvastatin), St. John’s wart

Question 11

What would you measure before starting a statin if a patient is having any generalised unexplained muscle pain?

Answer 11

Creatinine Kinase (CK)
If > 5x upper limit of normal - re measure after a week - still elevated - don’t start statin
If < 5x upper limit of normal - start statin treatment at a lower dose

Question 12

What advise would you give someone starting statin treatment?

Answer 12

Advise to report any unexplained muscle symptoms (muscle pain, tenderness, weakness)

Question 13

What monitoring requirements are required with statin therapy?

Answer 13

Liver transaminase enzymes:
Baseline before starting, within 3 months of starting, at 12 months, not again unless indicated.

Question 14

When are statins contraindicated?

Answer 14

Pregnancy (advise women of childbearing age)

Question 15

What drugs interactions occur with statins?

Answer 15

Drugs that inhibit/induce metabolism via cytochrome P450 enzymes

Question 16

What is the aim of statin treatment?

Answer 16

To achieve a greater than 40% reduction in non-HDL cholesterol

Question 17

When is Ezetimibe used as monotherapy over statins?

Answer 17

When statins are contraindicated or patient is intolerant

Question 18

When is Ezetimibe used in dual therapy with statins?

Answer 18

Total + non-HDL conc not appropriately controlled after statin dose titration and dose titration intolerance

Question 19

What is Ezetimibe, what is the usual dose, important side effect, caution and contraindication?

Answer 19

Cholesterol absorption inhibitor, 10mg OD, myalgia (like statins), pregnancy and the C/I is breast-feeding

Question 20

What patient group is genetically sensitive to Rosuvastatin?

Answer 20

Asian origin (predisposed to rhabdomyolysis)