Statins

Question 1

MoA

Answer 1

Lowers LDL cholesterol synthesis by the liver.
Inhibits HMG-CoA reductase (indirectly reduces triglycerides and increases HDL cholesterol)

Question 2

When should statins be taken?

Answer 2

At night EXCEPT atorvastatin.
Cholesterol synthesis is greater at night, therefore it will be more effective.

Question 3

Prevention of CVD

Answer 3

High intensity statin.
Atorvastatin:
- Primary prevention = 20 mg
- Secondary prevention = 80 mg
Rosuvastatin 10 mg
Simvastatin 80 mg

Question 4

Hyperlipidaemia - primary hypercholesterolaemia

Answer 4

High-intensity statin
If statin not tolerated or contra-indicated give ezetimibe.

Question 5

Hyperlipidaemia - familial hypercholesterolaemia

Answer 5

High-intensity statin
If statin not tolerated or contra-indicated give ezetimibe.

Question 6

Hyperlipidaemia - moderate hypertriglyceridaemia

Answer 6

If statin not tolerated or contra-indicated give fibrate

Question 7

Severe hyperlipidaemia

Answer 7

Add on ezetimibe

Question 8

Resistant hyperlipidaemia

Answer 8

Triglycerides still high after LDL reduced
- Add fibrate or nicotinic acid (also lowers LDL)

Question 9

Before starting statins

Answer 9

Address any secondary causes of dyslipidaemia:
- Hypothyroidism (underlying cause of reversible hyperlipidaemia - treating this can remove the need for statins)
- Uncontrolled diabetes
- Nephrotic syndrome (albuminuria)
- Liver disease e.g. alcoholic cirrhosis

Question 10

Statins - side effects

Answer 10

Common:
- Headaches
- GI disturbances

Severe:
- Myopathy
- Rhabdomyolysis
- Myositis
- Patients should report tender, weak and painful muscles

Question 11

Statins - Muscle toxicity (general)

Answer 11

Increased risk in:
- personal/family history of muscle disorder.
- high alcohol intake
- renal impairment
- hypothyroidism (treat before initiating statin)

Question 12

Statin + Fibrate

Answer 12

Increased risk of muscle related SE
Should only be used under specialist supervision.

Question 13

Statin + gemfibrozil

Answer 13

DO NOT use together
Significantly increased risk of rhabdomyolysis

Question 14

Statin + Fusidic acid

Answer 14

Avoid use together
Temporarily stop statin
Restart 7 days after last dose

Question 15

Drug interactions - increase plasma concentration of statin

Answer 15

Metabolism of statins is impaired by CYP inhibitors.
Amiodarone
Grapefruit juice
CCBs e.g. diltiazem
Amlodipine
Macrolide antibiotics
Imidazoles
Triazole antifungals
Ciclosporin

Question 16

Statins - ILD

Answer 16

Interstitial lung disease
Patients should report:
- SOB
- Cough
- Weight loss

Question 17

Statins + diabetes

Answer 17

Use with caution in those with/at risk of diabetes
Statins can raise HbA1c/blood glucose levels.
Check HbA1c before starting treatment and repeat after 3 months.

Question 18

Monitoring

Answer 18

• Baseline lipid profile
• Renal function
• Thyroid function
• HbA1c (with/at risk of diabetes)

Question 19

Statins - monitoring parameters

Answer 19

Severe muscle symptoms = discontinue

Creatinine kinase 5X baseline = discontinue, if level returns to normal and muscle symptoms resolve reintroduce at a low dose and monitor.

LFT 3x baseline = discontinue

Question 20

Pregnancy

Answer 20

Teratogenic
Effective contraception whilst on statin and 1 month after stopping.
Stop 3 months before conceiving and restart after breastfeeding finished.

Question 21

Simvastatin dosing - dose adjustments due to interactions

Answer 21

Fibrates = max 10 mg
Amiodarone, amlodipine, diltiazem, verapamil = max 20 mg

Question 22

Atorvastatin dosing - dose adjustments due to interactions

Answer 22

Ciclosporin = max 10 mg

Question 23

Rosuvastatin dosing - dose adjustments due to interactions

Answer 23

Clopidogrel = initally 5 mg, max 20 mg

Question 24

Statins in hepatic impairment

Answer 24

Use with caution

Question 25

Statins in renal impairment

Answer 25

All statins EXCEPT rosuvastatin are eliminated by the kidneys.
Renal impairment = dose reduction