W2 Clinical management of Hyperlipidemia Flashcards
Why is Lipid modification important?
What is CVD caused by?
What is atherosclerosis?
- The risk of CVD can be reduced by modification of the blood lipid profile.
- CVD is caused by blood clots (thrombosis), or atherosclerosis.
- Atherosclerosis is a condition where there is a build-up of fatty deposits (plaques) inside an artery which cause the artery to harden and narrow, restricting blood flow.
What are the CVD conditions caused by atherosclerosis? (4)
-Coronary heart disease (including angina and myocardial infarction)
-Stroke.
-Transient ischaemic attack (TIA)
-Peripheral arterial disease
Preventing Cardiovascular Events
What is primary and secondary prevention?
Primary prevention strategies identify and alter modifiable risks to reduce incidence in disease-free individuals or in the
population. (before disease)
Secondary prevention strategies target individuals with established disease, who have usually had an ‘event’, to reduce morbidity and mortality. (after disease)
What are the normal values for cholesterol?
TC?
TC: HDL ratio?
HDL?
Non-HDL?
Total cholesterol= 5mmol/L or below
Total cholesterol to HDL cholesterol ratio= Below 6
HDL (good cholesterol)= 1mmol/L or above for men or 1.2 mol/L or above for women
Non-HDL (bad cholesterol) = 4mmol/L or below
Identifying people for full formal risk assessment:
(hyperlipidemia- for info)
- For the primary prevention of cardiovascular disease (CVD) in primary care, use a systematic strategy to identify people who are likely to be at high risk of CVD.
- Prioritise people based on an estimate of their CVD risk before doing a full formal risk
assessment. Estimate their CVD risk using CVD risk factors already recorded in primary care electronic medical records. - Review estimates of CVD risk on an ongoing basis for people over 40.
- Prioritise people for a full formal risk assessment if their estimated 10‑year risk of CVD is 10% or more.
- Discuss the process of risk assessment with the person identified as being at risk, including the option of declining any formal risk assessment.
- Do not use opportunistic assessment as the main strategy in primary care to identify CVD risk in unselected people.
Formal risk assessment:
Who should QRISK be done on?
- QRISK 3 for people aged between 25-84 without established CVD – including those with type 2 diabetes
- Do not use a risk assessment tool for people at high risk of CVD, e.g. type 1 diabetes, eGFR < 60ml/min/1.73m2 or familial hypercholesterolaemia, 85 years and over
- Risk assessment tools can underestimate risk in some people, such as: people with HIV, people already treated for CVD, people who have recently stopped smoking, people on
immunosuppressants, people with severe mental illness.
After full risk assessment of hypertension, what then?
- Offer people information about their absolute risk of CVD and about the absolute benefits and harms of an intervention over a 10‑year period. This information should be in a form that:
-presents individualised risk and benefit scenarios
-presents the absolute risk of events numerically
-uses appropriate diagrams and text.
-If risk exceeds 10% offer pharmacological treatment
Also, if a patient has a cardiovascular risk under 10% or under 40 with CVD risk factors offer QRISK3-lifetime assessment
Non-pharmacological treatment for hyperlipidemia:
- Smoking cessation advice/referral/Tx
- Healthy diet
-total fat intake <30%, saturated fat <7%
-reduce sugar intake, particularly refined sugars
-5 portions fruit and veg daily
-2 portions fish (inc. one oily) weekly
-low salt
-maximum alcohol intake 14 units/wk with alcohol-free days - Weight loss
- BMI 18.5-25
- Exercise
-At least 150 minutes/wk of moderate-intensity activity
Modifiable (4) and Non-modifiable (7) risk factors for CVD:
- smoking
- cholesterol
- blood pressure
- BMI
Non
* age
* sex
* FHx
* migraine
* RA
* SLE
* severe mental illness
Pharmacological treatment:
When should the decision be made to start?
What are the aims of treatment?
- The decision to start statin treatment should be made after an informed discussion with the person about the risks and benefits of treatment, taking into account factors such as co-morbidities, potential benefits from lifestyle intervention, and the person’s preference.
- The aim of treatment is to achieve a greater than 40% reduction in non-HDL-C levels.
- Patients should also adhere to non-pharmacological
treatment
What does taking a statin prevent you from developing?
But SE?
It means that you are less likely to get heart disease or have a stroke
Although Statins can cause muscle pain.
What are the baseline blood tests should be performed before starting lipid modification therapy? (5)
- A non-fasting lipid profile.
- Liver function tests (transaminases).
- Renal function, including estimated glomerular filtration rate.
- HbA1c.
- Creatine kinase (if the person has persistent generalized unexplained muscle pain).
- Thyroid-stimulating hormone in people with symptoms of
underactive or overactive thyroid
What is the primary prevention for CVD?
Who should it be OFFERED to?
Who should it be CONSIDERED to?
For primary prevention of CVD, high-intensity statin treatment
atorvastatin 20 mg daily should be offered to people:
- Aged 84 years and younger if their estimated 10-year risk of developing CVD using the QRISK3 assessment tool is 10% or more.
- With type 1 diabetes (without the need for a formal risk assessment) who are aged more than 40 years, have had diabetes for more than 10 years or have established nephropathy, or have other CVD risk factors.
- With **chronic kidney disease or familial hypercholesterolaemia **(without the need for a formal risk assessment).
CONSIDER
* With type 1 diabetes.
* Aged 85 years of age or older, taking into account the benefits and risks of treatment and any comorbidities that make treatment appropriate
What is treatment for the secondary prevention of CVD in patients?
Atorvastatin 80 mg daily should be advised in people with existing CVD (for example past or current history of myocardial infarction, angina, stroke, transient ischaemic attack or peripheral arterial disease)
What is Familial hypercholesterolaemia?
- (FH) is an inherited condition characterized by high cholesterol concentration in the blood.
- It is present from birth and may lead to early development of
atherosclerosis and coronary heart disease. - Most people with FH have inherited a defective gene for the
condition from one parent only (heterozygous FH – affects around 1
in 250 to 1 in 500 of the population). Rarely, an affected person will
inherit a genetic defect from both parents (homozygous FH – affects around 1 in 1,000,000). - Siblings and children of a person with FH have a 50% risk of
inheriting the condition
What are the Clinical signs of hypercholesterolaemia? (3)
Usually completely asymptomatic, but may be some clinical signs – especially in familial hypercholesterolaemia
- Tendon xanthoma = cholesterol deposits in tendons
- Xanthelasmata= Yellosih deposited cholesterol underneath skin around eyelids
- Corneal arcus- lipid deposits as rings on the outer region of the cornea
Familial hyperlipidaemia-
Without treatment:
Heterozygous familial hypercholesterolaemia (FH) leads to a greater than 50% risk of coronary heart disease (CHD) in men by the age of 50 years and at least 30% in women by the age of 60 years.
Homozygous FH is associated with early death from CHD.
* If treatment is started early enough in life, people with FH will have the same life expectancy as the general population.
Aggressive, early treatment necessary as soon as diagnosed in adults.
* In children with homozygous FH - lipid-modifying drug treatment is usually started by the age of 10 years or at the earliest opportunity thereafter.
Hyperlipidaemia: Pharmacological treatment with Statins:
What drug and dose can be prescribed?
Duration? Rationale?
SE? C/I? Cautions? Monitoring?
Counselling?
Notes?
HMG-coA reductase inhibitors
Dose: Atorvastatin 20mg or 80mg (OR simvastatin, rosuvastatin, pravastatin, fluvastatin)
- Titrate up to reduce non-HDL-C by 40%
DURATION: usually lifelong
* Rationale: blocks enzyme involved in cholesterol synthesis
Side effects:
* muscle effects, inc. toxicity
* GI disturbances
* sleep disorders
* nose bleeds
* skin reactions, inc. severity
- C/I: none
- Cautions: those at increased risk of muscle effects, hypothyroidism, haemorrhagic stroke
Monitoring: (3 months after initiation)
* Liver function
* Lipids
- Counselling:
-Advise patients to report promptly unexplained muscle pain, tenderness, or weakness. - Notes:
-Adequate contraception during treatment and a month after stopping
Other medicines for hypercholesterolaemia- when to use ezetimibe?
(Selective cholesterol absorption inhibitors)
If a greater than 40% reduction in non-HDL-C is still not achieved after appropriate dose titrations of atorvastatin, or because dose titration is limited by adverse effects:
* Consider ezetimibe, co-administered with atorvastatin for people with primary hypercholesterolaemia
Ezetimibe
What is the dose?
Duration? Rationale?
SE? C/I?
Monitoring? Counselling?
Notes?
Ezetimibe 10mg daily
* DURATION: usually lifelong
* Rationale: inhibits the intestinal absorption of cholesterol
Side effects:
* GI disturbances
* asthenia
* muscle pain - uncommon
C/I: none
- Cautions: none
Monitoring: - None – useful to look at lipids to ensure having good effect
Counselling:
* Ok in pregnancy if benefits outweigh risk
Notes
* If used alone, it has a modest effect on lowering LDL cholesterol, with little effect on other lipoproteins
Other medicines for hypercholesterolaemia- when to use bempedoic acid:
For people taking ezetimibe monotherapy (if statins are contraindicated or not tolerated), consider ezetimibe with bempedoic acid if ezetimibe alone does not control low-density lipoprotein cholesterol well enough
Only if the company provides bempedoic acid and bempedoic acid with ezetimibe according to the commercial arrangement
Hyperlipidaemia: Pharmacological treatment:
Adenosine triphosphate citrate lyase (ACL) inhibitor (bempedoic acid)
Dose? Duration?
Rationale?
SE? Counselling?
DOSE:
* Bempedoic acid 180mg daily (+/ezetimibe 10mg)
* DURATION: usually lifelong
* Rationale: inhibits cholesterol synthesis in the liver, thereby lowering LDL-cholesterol
Side effects:
* anaemia
* gout
* hyperuricaemia
* GI disturbances
* C/I: none
* Cautions: none
Monitoring: (three months after initiation)
* None – useful to look at lipids to ensure they have a good effect
Counselling:
* Avoid in pregnancy and breast feeding
Notes
* Should only be started if company provides it at a discount
What are the less common medicines for hyperlipidaemia? (3)
- Fibrates (e.g. bezafibrate)
* NICE says - Do not routinely offer fibrates to prevent CVD to any of the following: primary prevention, secondary prevention, people with CKD, people with type 1 diabetes or people with type 2 diabetes.
* Sometimes used in FH - Resins/bile acid sequestrants (e.g. colestyramine)
- Inclisiran can be used for a subpopulation of patients in
Wales:
* patients with high risk due to previous CV events and LDL-C ≥4.0 mmol/L, OR
* patients with recurrent/polyvascular disease and LDL-C ≥3.5 mmol/L, OR
* patients with heterozygous familial hypercholesterolaemia (HeFH)
and LDL-C ≥3.5 mmol/L, for secondary prevention of CV events, OR
* patients with HeFH and LDL-C ≥5.0 mmol/L, for primary prevention
of CV events.
Specialist care:
4. Alirocumab
5. Evolocumab
6. Volznesorsen
Hyperlipidaemia: Pharmacological treatment
PCSK9-targeting short interfering RNA (siRNA) (inclisiran)
Dose? Duration?
Rationale?
SE? C/I?
Counselling
Notes?
- DOSE:
- Inclisiran 284 mg for 1 dose, followed by 284 mg after 3 months for 1 dose, then 284 mg every 6 months
- DURATION: ?lifelong
- Rationale: limits production of PCSK9, increasing uptake of LDL-cholesterol and thereby lowering levels in blood
Side effects:
* injection site reactions
C/I: pregnancy, breast feeding, severe renal disease, sever hepatic disease
- Cautions: none known
- Monitoring:
None – useful to look at lipids to ensure having good effect
Counselling: - Injection technique
Notes
* Should not be used outside pt population noted
* If a dose is more than 3 months late, treatment should be re-initiated.
* New medication - uncertain
