STATINS Flashcards

1
Q

MOA

A
  • They competitively inhibit 3-hydroxy-3-methylglutaryl coenzyme A (HMG CoA)
    reductase
  • This enzyme is involved in cholesterol synthesis
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2
Q

When should statins be taken? i.e. what part of the day

A
  • Atorvastatin can be taken anytime during the day
  • Simvastatin, pravastatin, and fluvastatin should be taken in the evening
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3
Q

Cautions

A
  • Elderly
  • High alcohol intake
  • History of liver disease
  • Hypothyroidism (because of higher risk of muscle toxicity)
  • Those with increased risk of muscle toxicity (e.g Rhabdomyolosis) due to FHx
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4
Q

Which patients are at high risk of muscle toxicity (rhabdomyolysis)
which requires caution when using a statin?

A
  • Personal or family history of muscular disorders
  • previous history of muscular toxicity
  • high alcohol intake
  • renal impairment
  • hypothyroidism
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5
Q

Side effects - common

A
  • Headache
  • Gl disturbances
  • Myalgia (just muscle pain/ ache)
  • Hyperglycaemia
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6
Q

Side effects - rare

A
  • Muscle effects (Myopathy, myositis, rhabdomyolysis)
  • Interstitial lung disease: dyspnoea, cough, weight loss

RED FLAG

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7
Q

Pregnancy

A

AVOID
- congenital abnormalities
- decreased synthesis of cholesterol affects foetal development

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8
Q

Statins and conception

A
  • Statins needs to be discontinued 3 months before attempting to conceive
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9
Q

Statins and women of childbearing potential?

A
  • Contraception required during treatment and 1 month after stopping statins (not necessarily the pill but at least condom)
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10
Q

Breastfeeding

A

NO

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11
Q

Hepatic impairment

A
  • Caution in Hx of liver disease
  • Avoid in active liver disease
  • Avoid when there are unexplained persistent elevations in serum transaminases
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12
Q

Why should statins be used with caution in history of liver disease

A

Statins can cause hepatoxicity

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13
Q

What are the monitoring requirements for statins?

A
  1. One full lipid profile (non-fasting)
  2. Thyroid stimulating hormone (TSH)
  3. Renal function
  4. Liver function tests (LFTs)
  5. Creatinine kinase
  6. HbA1c (for patient at high risk of diabetes)
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14
Q

Monitoring - full lipid profile

A
  • Total cholesterol, HDL-cholesterol, non-HDL and triglycerides
  • Before treatment
  • 3 months after in prevention of CVD to assess reduction
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15
Q

Monitoring - Renal function

A
  • renally excreted requiring dose adjustment or avoidance
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16
Q

Thyroid stimulating hormone (TSH)

A

Before treatment
- Hypothyroidism is a reversible cause of hyperlipidaemia
- By correcting hyperthyroidism, you can get normal cholesterol
- increases the risk of muscle toxicity with statins

17
Q

How do you interpret the LFT result for statins?

A
  • Before treatment, then within 3 months then 12 months after starting
  • Measure before if signs of hepatoxicity
  • STOP if more than 3 x UP
18
Q

Monitoring - creatinine kinase

A
  • Before initiation if patient had persistent, unexplained muscle pain (not necessarily due to lipid-regulating drug)
  • If patient complains of muscle pain whilst on statin
  • If more than 5 x UL = repeat after 7 days, if still 5 x UL then don’t start statin
19
Q

If the patient reports muscle symptoms
AND
Creatinine kinase is elevated

A

STOP

20
Q

Monitoring - HbA1c

A
  • patients at high risk of diabetes should have HbAc checked before starting statin treatment and then repeated after 3 months
  • Statins can cause hyperglycaemia
21
Q

What symptoms should patients be referred to with regards to muscle effects?

A
  • Unexplained muscle pain
  • Tenderness
  • Weakness
22
Q

Drug interactions

A
  • Amiodarone
  • Diltiazem
  • Itraconazole
  • macrolides (e.g. clarithromycin)
  • protease inhibitors
  • Amlodipine (With Simvistatin)
    This is because statins are metabolised by CYP enzymes
23
Q

Interactions - CYP450 Enzyme Inducers

A

Reduces the concentration of statin

24
Q

Interactions - CYP450 Enzyme Inhibitors

A

Increases the concentration of statin → increased risk of rhabdomyolysis
* Patients prescribed macrolides should stop taking their statin during treatment
* Avoid drinking grapefruit juice

25
Q

Interactions Fusidic Acid (oral)

A

Stop statin during treatment → restart 7 days after last dose

26
Q

Amlodipine + Simvastatin = 20mg

A

important interaction
statin may not exceed 20mg
amlodipine increases levels of simvastatin
increased risk of rhabdomyolysis

27
Q

statin + ezetimibe

A

increased risk of rhabdomyolysis

28
Q

Statins + alcohol

A
  • Advise to keep alcohol to a minimum
  • As both increase the risk hepatoxicity
29
Q

Simvastatin and concomitant use of drugs

A
  • Max 10mg it also taking bezafibrate or
    Ciprofibrate
  • Max 20mg daily
    Amiodarone, Amlodipine, Ranolazine
  • Max 20mg with verapamil and diltiazem
  • Max 40mg with Ticagrelor
30
Q

Which statin has a lower initial dose and max dose in patients of Asian origin?

A

Rosuvastatin
- lower initial dose (5mg) than normal (5-10mg)
- Max 20mg (rather than
40mg)