statins Flashcards
simvastatin max dose with bezafibrate or ciprofibrate
10mg
simvastatin max dose with amiodarone, amlodipine, ranolazine, verapamil, diltiazem
20mg
simvastatin max dose with ticagrelor
40mg
max dose of simvastatin with bempedoic acid or bempedoic acid with ezetimibe
20mg
max dose simvastatin in pt with severe hypercholesterolaemia and at high risk of CV complications
20mg
MHRA advice for all statins - very infrequent reports of this condition …
myasthenia gravis
(v small reports of new onset, or exacerbation of pre existing, or ocular myasthenia)
MHRA advice about all statins - myasthenia gravis
- v small reports of new onset, or exacerbation of pre existing, myasthenia gravis or ocular myasthenia
- most cases: pt recovered after stopping
- minority: continue to experience symptoms
- refer to neurologist if suspected
- symptoms: droopy eyelids, double vision, difficulty facial expressions, problems chewing, difficulty swallowing, slurred speech, weak limbs and neck, SOB
MHRA has released advice about the very small risk of myasthenia gravis with all statins. Tell patients to inform their factor if they experience the following symptoms:
weakness in the arms or legs that worsens after activity, double vision, drooping of the eyelids, difficulty swallowing, or shortness of breath;
seek immediate medical attention if they develop severe breathing or swallowing problems.
true or false - caution with hypothyroidism
true
manage adequately before starting treatment with statin
simv max dose 10mg with beza/ciprafibrate. why?
increases the risk of rhabdomyolysis
clarithromycin, erythromcyin interaction with simvastatin
C predicted to increase exposure to S.
Avoid
Patient is on simvastatin 20mg ON and amlodipine 10mg OD. They have just had an episode of acute gout. Is there anything that should be considered when treating it?
Colchicine has been reported to cause rhabdomyolysis when given with Simvastatin. Manufacturer advises caution or monitor.
all statins are ….toxic
hepato
Avoid this fruit with SOME statins; increased exposure to statins.
Name which statins are unaffected (2)
Grapefruit
rosuvastatin and pravastatin
Itraconazole, fluconazole, isavuconazole, ketoconazole etc interaction with simvastatin (2)
hepatotoxicity
more severe: increases exposure to simvastatin, monitor and adjust dose
A patient comes in with oral thrush. They would like to purchase daktarin oral gel. They take amlodipine 5mg OD, simvastatin 20mg OD. is this safe to sell?
Miconazole (including the oral gel) is predicted to increase the exposure to Simvastatin. Manufacturer advises avoid.
Pt with diabetes taking a statin. They have increased BGC. Should you stop statin?
Statins should not be discontinued if there is an increase in the blood-glucose concentration as the benefits continue to outweigh the risks.
Conception and contraception for all statins
Adequate contraception is required during treatment and for 1 month afterwards.
Use of statins in pregnancy and when attempting to conceive
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.
monitoring for all statins in pt at high risk of DM
fasting blood-glucose concentration or HbA1C checked before starting statin treatment, and then repeated after 3 months.
True or false - need to measure CK in all pt before statin started
false
only in pt who have had persistent, generalised unexplained muscle pain
if baseline conc if >5x ULN, repeat measurement after 5 days
if repeat conc remains >5x ULN, do not start statin
if conc still raised but <5x ULN, start statin at lower dose
results of CK when you measure in pt who have had persistent, generalised, unexplained muscle pain (whether associated or not with previous lipid-regulating drugs) - how to interpret
if baseline conc if >5x ULN, repeat measurement after 5 days
if repeat conc remains >5x ULN, do not start statin
if conc still raised but <5x ULN, start statin at lower dose
some patients may present with extremely elevated baseline creatine kinase concentration, for example because of a physical occupation or rigorous exercise. How should you commence therapy in these pt
specialist advice should be sought regarding consideration of statin therapy in these patients.
LFTs monitoring for statins
before treatment
repeat within 3 months and at 12 months of starting treatment
unless indicated at other times by signs or symptoms suggestive of hepatoxicity
interpreting LFTs
Serum transaminases that are raised, but < 3x the UL of reference range, should not be routinely excluded from statin therapy.
Serum transaminases >3x the UL reference range should discontinue statin therapy.
before starting statins, the following need to be assessed
- at least one full non fasting lipid profile (total cholesterol, HDL, non HDL, triglyceride)
- TSH
- Renal
- LFTs
- CK (only in pt with persistent, generalised, unexplained muscle pain (whether associated or not with previous lipid-regulating drugs
- fasting BGC or HBA1C if high risk of DM
which one is good cholesterol and which one is bad
HDL = good
LDL = bad
MHRA: simvastatin high dose 80mg
risk of myopathy
80 mg dose should be considered only in patients with severe hypercholesterolaemia and high risk of cardiovascular complications who have not achieved their treatment goals on lower doses, when the benefits are expected to outweigh the potential risks.
healthy levels of total cholesterol, HDL-C and non HDL-C
total: below 5
HDL (good): above 1 for men, above 1.2 for women
non HDL (bad): below 4
which statins need to be taken at night, which ones it doesnt matter
night: simvastatin, pravastatin, fluvastatin
doesnt matter: atorv, rosuv
What are the following intensities of statins, as percentages
high
medium
low
high intensity = >40% reduction in LDL-C
medium intensity = 31-40% reduction in LDL-C
low intensity = 20-30% reduction in LDL-C
MOA of statins
competitively inhibit HMG CoA reductase
this enzyme is involved in cholesterol synthesis esp in the liver
muscle toxicity can occur with all statins, however the likelihood increases with higher doses and in certain pt. statins should be used in caution in pt at increased risk of muscle toxicity e.g.
- elderly
- PHx or FHx muscular disorders
- Hx muscular toxicity or unexplained persistent muscle pain
- Hx liver disease
- high alcohol intake
- known genetic polymorphisms
common SE for all statins include
Arthralgia; asthenia; constipation; diarrhoea; dizziness; flatulence; gastrointestinal discomfort; headache; muscle complaints; nausea; sleep disorders; thrombocytopenia
true or false - statins can commonly cause thrombocytopenia
true
a side effect o statins is interstitial lung disease. seek medical attention if the following symptoms occur
dyspnoea, cough, and weight loss
Cs and atorv interaction
Ciclosporin markedly to very markedly increases the exposure to Atorvastatin. Manufacturer advises avoid or adjust Atorvastatin dose.
Manufacturer advises if concurrent use of ciclosporin is unavoidable, max. dose cannot exceed 10 mg daily.
What is the max dose of atorv if concurrent use of Cs is unavoidable
10mg
true or false - start with lower does of rosuvastatin in asian patients as they have increased likelihood of SE
true
max dose of rosuvastatin with leflunomide
10mg
rosuvastatin initial and max dose with fibrates
initially 5mg daily
max dose for gemfibrozil is 20mg daily
max dose for beza, cipro and fenofibrate : 40mg dose is CI
