Statins Flashcards
What is the mechanism of action of statins?
Inhibit the action of HMG-CoA reductase, the rate limiting enzyme in hepatic cholesterol synthesis
What are 3 key adverse effects of statins?
- Myopathy: myalgia, myositis, rhabdomyolysis and asymptomatic raised creatine kinase
- Liver impairment
- May increase risk of intracerebral haemorrhage in those who’ve previously had a stroke
What are 5 risk factors for myopathy (myalgias, rhabdomyolysis) when taking statins?
- Advanced age
- Female sex
- Low BMI
- Presence of multisystem disease e.g. diabetes mellitus
- More common in lipophilic statins (simvastatins, atorvastatin) than relatively hydrophilic (rosuvastatin, pravastatin, fluvastatin)
What monitoring is recommended when prescribing statins?
- LFTs: baseline, 3 months and 12 months
When should treatment with statins be discontinued based on monitoring blood tests?
If serum transaminase (LFTs essentially) concentrations rise to and persist at 3 times the upper limit of the reference range
What are 3 contraindications to statins?
- Avoid in patients with history of intracerebral haemorrhage - risk of recurrence
- Macrolides (e.g. erythromycin, clarithromycin) - important interaction, stop statins until course completed
- Pregnancy
What are 4 groups of people who should receive a statin?
- All people with established cardiovascular disease: stroke, TIA, ischaemic heart disease, peripheral arterial disease
- Anyone with 10 year cardiovascular risk >10% (QRISK)
- Assess pts with T2DM with QRISK2 to determine whether to start
- T1DM diagnosed > 10 years ago OR aged >40y OR have established nephropathy
When should statins be taken and why?
At night - when the majority of cholesterol synthesis takes place
especially true for simvastatin - shorter half life than others
What statin type and dose is recommended for primary and secondary prevention of cardiovascular disease?
- Atorvastatin 20mg od for primary prevention
- Increase dose if non-HDL has not fallen by >40% up to 80mg
- Atorvastatin 80mg od for secondary prevention
What 2 categories can treatment with statins be divided into?
- Primary prevention of CVD
- Secondary prevention
What are 3 scenarios when statins are used for primary prevention of CVD?
- 10-year cardiovascular risk >10%
- most type 1 diabetics
- CKD if eGFR <60
What are 3 examples of when statins can be used for secondary prevention of CVD?
- Known ischaemic heart disease
- Cerebrovascular disease
- Peripheral arterial disease
At what age should you start to assess for QRISK and therefore treatment with statins?
40 years
What is the maximum age at which to use QRISK2 for CVD risk assessment and why?
84; >85 years are at high risk due to age
What are 3 patient groups in whom the QRISK2 assessment tool should not be used and why?
- type 1 diabetics
- patients with an estimated glomerular filtration rate (eGFR) less than 60ml/min and/or albuminuria
- patients with a history of familial hyperlipidaemia
What are 4 patient groups in whom the QRISK2 assessment may underestimate CVD risk?
- people treated for HIV
- people with serious mental health problems
- people taking medicines that can cause dyslipidaemia such as antipsychotics, corticosteroids or immunosuppressant drugs
- people with autoimmune disorders/ systemic inflammatory disorders such as SLE
What blood test should be checked before starting a statin and why?
NON-fasting full lipid profile, including triglycerides
Looking at total cholesterol : high-density lipoprotein ratio
When should familial hyperlipidaemia be suspected and what should be done?
total cholesterol concentration >7.5mmol/l and there is family history of premature coronary heart disease
total cholesterol >9.0 mmol/l or non-HDL cholesterol of >7.5 mmol/l even in absence of first degree family history of premature coronary heart disease
if this is the case - refer
Should you start a statin straight away if QRISK2 >10%?
Recommend we give patients option of having CVD risk reassessed after period of time before starting a statin
What are 4 groups of type 1 diabetics who should be offered a statin?
- >40 years old
- Have had diabetes for more than 10y
- have established nephropathy
- have other CVD risk factors
How are statins used in chronic kidney disease?
- Atorvastatin 20mg offered; increase dose if greater than 40% reduction in non-HDL cholesterol not achieved and eGFR >30ml/min.
- If eGFR <30ml/min renal specialist should be consulted before increasing dose
What follow-up should be performed when people started on statins?
- at 3 months, repeat full lipid profile
- if non-HDL cholesterol has not fallen by at least 40%, concordance and lifestyle changes should be discussed with patient
- consider increasing to 80mg
What are 10 elements of a cardioprotective diet - a form of lifestyle modification for hyperlipidaemia?
- total fat intake should be <30% of total energy intake
- saturated fats should be <7% of total energy intake
- intake of dietary cholesterol should be <300mg/day
- saturated fats should be replaced by monounsaturated and polyunsaturated fats where possible
- replace saturated and monounsaturated fat intake with olive oil, rapeseed oil or spreads based on these oils
- choose wholegrain varieties of starchy food
- reduce their intake of sugar and food products containing refined sugars including fructose
- eat at least 5 portions of fruit and veg a day
- 2 portions of fish per week, including portion of oily fish
- eat at least 4-5 portions of unsalted nus, seeds and legumes / week
What are the recommendations for physical activity to advise patients with hyperlipidaemia? 2 points
- aim for at least 150 min moderate intensity aerobic activity or 75 minutes of vigorous intensity aerobic activity or mix of moderate and vigorous
- muscle strenghtening activities on 2 or more days a week that work all major muscle groups (legs, hips, back, abdomen, chest, shoulders and arms) in line with national guidance for genearl population
What are 3 elements of the alcohol guidelines?
- No more than 14 units a week for men and women
- Spread evenly over 3 or more days
- Good to have several alcohol free days
Overall what are 4 lifestyle points to advise patients on with hyperlipidaemia?
- Exercise
- Cardioprotective diet
- Alcohol
- Stop smoking
