Statins Flashcards
MoA
Lowers LDL cholesterol synthesis by the liver.
Inhibits HMG-CoA reductase (indirectly reduces triglycerides and increases HDL cholesterol)
When should statins be taken?
At night EXCEPT atorvastatin.
Cholesterol synthesis is greater at night, therefore it will be more effective.
Prevention of CVD
High intensity statin.
Atorvastatin:
- Primary prevention = 20 mg
- Secondary prevention = 80 mg
Rosuvastatin 10 mg
Simvastatin 80 mg
Hyperlipidaemia - primary hypercholesterolaemia
High-intensity statin
If statin not tolerated or contra-indicated give ezetimibe.
Hyperlipidaemia - familial hypercholesterolaemia
High-intensity statin
If statin not tolerated or contra-indicated give ezetimibe.
Hyperlipidaemia - moderate hypertriglyceridaemia
If statin not tolerated or contra-indicated give fibrate
Severe hyperlipidaemia
Add on ezetimibe
Resistant hyperlipidaemia
Triglycerides still high after LDL reduced
- Add fibrate or nicotinic acid (also lowers LDL)
Before starting statins
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
Statins - side effects
Common:
- Headaches
- GI disturbances
Severe:
- Myopathy
- Rhabdomyolysis
- Myositis
- Patients should report tender, weak and painful muscles
Statins - Muscle toxicity (general)
Increased risk in:
- personal/family history of muscle disorder.
- high alcohol intake
- renal impairment
- hypothyroidism (treat before initiating statin)
Statin + Fibrate
Increased risk of muscle related SE
Should only be used under specialist supervision.
Statin + gemfibrozil
DO NOT use together
Significantly increased risk of rhabdomyolysis
Statin + Fusidic acid
Avoid use together
Temporarily stop statin
Restart 7 days after last dose
Drug interactions - increase plasma concentration of statin
Metabolism of statins is impaired by CYP inhibitors.
Amiodarone
Grapefruit juice
CCBs e.g. diltiazem
Amlodipine
Macrolide antibiotics
Imidazoles
Triazole antifungals
Ciclosporin
Statins - ILD
Interstitial lung disease
Patients should report:
- SOB
- Cough
- Weight loss
Statins + diabetes
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.
Monitoring
- Baseline lipid profile
- Renal function
- Thyroid function
- HbA1c (with/at risk of diabetes)
Statins - monitoring parameters
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
Pregnancy
Teratogenic
Effective contraception whilst on statin and 1 month after stopping.
Stop 3 months before conceiving and restart after breastfeeding finished.
Simvastatin dosing - dose adjustments due to interactions
Fibrates = max 10 mg
Amiodarone, amlodipine, diltiazem, verapamil = max 20 mg
Atorvastatin dosing - dose adjustments due to interactions
Ciclosporin = max 10 mg
Rosuvastatin dosing - dose adjustments due to interactions
Clopidogrel = initally 5 mg, max 20 mg
Statins in hepatic impairment
Use with caution
Statins in renal impairment
All statins EXCEPT rosuvastatin are eliminated by the kidneys.
Renal impairment = dose reduction
