Statins

Question 1

High intensity statins

Answer 1

Atorvastatin 20-80mg (43%-55%) Max dose 10mg when given with ciclosporin
Rosuvastatin 10mg-40mg (43%-53%)
Simvastatin 80mg (42%)

Total cholesterol, HDL cholesterol and non-HDL cholesterol concentrations should be checked 3 months after starting treatment with a high intensity statin.

NICE recommends to aim for a reduction in non-HDL cholesterol concentration greater than 40%.
Target non-HDL conc. of below 2.5mmol/L

Question 2

Simvastatin

Dose adjustments

Answer 2

Max. 10mg OD with concurrent use of bezafibrate or ciprofibrate.
Max. 20mg OD with concurrent use of amiodarone, amlodipine, ranolazine.
Max. 20mg OD with concurrent use of CYP3A4 inhibitors: verapamil and diltiazem
Max. 40mg OD with concurrent use of lomitapide or ticagrelor
Max.20mg OD with concurrent use of elbasvir with grazoprevir.

Question 3

Statins

Mechanism of action

Answer 3

Inhibits HMG-CoA reductase an enzyme involved in making cholesterol. Decrease cholesterol production in the liver and increase clearance of LDL cholesterol from blood to reduce blood LDL levels. Indirectly reduce TG and increase HDL. Through this they slow progression of atherosclerosis and may even reverse it.

Traditionally taken in the evening as there is some evidence that they have a greater effect when dietary intake is at its lowest.

Question 4

Statins

Adverse effects

Answer 4

Generally safe and well tolerated. 
Headache and GI disturbances
Rare= Muscle pain, myopathy, rhabdomyolysis.=DISCONTINUE and REPORT
Rise in liver enzymes (e.g. ALT)
Hyperglycaemia

Question 5

Statins

Contraindications

Answer 5

Caution in patients with high alcohol intake
Pregnancy- discontinue 3 months before attempting to conceive
Caution in those with a history of liver disease
Avoid in active liver disease.

Question 6

Statin

Monitoring

Answer 6

• non-HDL cholesterol after 3 months
• measure baseline creatinine kinase before initiation. 5 times above UL twice- do not initiate
• liver function- measure serum transaminases (e.g. ALT)3 times above UL
• fasting blood-glucose concentration or HbA1C checked before initiation

Question 7

ACE inhibitors

Mechanism of action

Answer 7

Blocks ACE to prevent the conversion of angiotensin 1 to angiotensin 2. Angiotensin 2 is a potent vasoconstrictor and stimulates aldosterone secretion. Blocking this conversion reduces afterload because vasodilation the blood vessels reduces blood pressure. Preload (venous return) is also reduced because aldosterone is not secreted to aid sodium and water retention.

Question 8

ACE inhibitors

Adverse effect

Answer 8

Persistent dry cough
First-dose hypotension. Take at night. Increased risk if taken with diuretic
Hyperkalaemia
Angioedema

Question 9

ACE inhibitors

Contraindications

Answer 9

Renal artery stenosis
Acute kidney injury
Pregnancy or thinking about conception
Breastfeeding

Question 10

ACE inhibitors

Interactions

Answer 10

NSAIDs- can precipitate renal failure

Potassium-elevating drugs- potassium supplement, potassium-sparing diuretics

Question 11

ACE inhibitors

Monitoring

Answer 11

Blood pressure
Renal function
Potassium levels
Relief of symtptoms