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Pre Reg Pharmacy > Chapter 2 - Dyslipidaemia > Flashcards

Chapter 2 - Dyslipidaemia Flashcards

1
Q

What are the causes of hypercholestsrolaemia and hypertriglyceridaemia?

A

Inherited (familial hypercholestsrolaemia)
Alcohol
Fatty food
Poor glycaemic control
Smoking
Obesity
Medication - corticosteroids, immunosuppressants, antipsychotics

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2
Q

What are the aims in hypercholestsrolaemia?

A

Total cholesterol <5mmol/L
LDL <3mmol/L
HDL >1mmol/L
Triglycerides <2.3mmol/L

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3
Q

Give examples of high intensity statins

A

Atorvastatin 20, 40, 80
Rosuvastatin 10, 20, 40
Simvastatin 80

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4
Q

How much do high intensity statins reduce LDL cholesterol by?

A

> 40%

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5
Q

Give some examples of medium intensity statins

A

Atorvastatin 10
Rosuvastatin 5
Simvastatin 20, 40
Fluvastatin 80

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6
Q

How much do medium intensity statins reduce LDL cholesterol by?

A

30-40%

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7
Q

Give examples of low intensity statins

A

Simvastatin 10
Fluvastatin 20, 40
Pravastatin 10, 20, 40

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8
Q

How much do low intensity statins reduce LDL cholesterol by?

A

<30%

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9
Q

What is familial hypercholestsrolaemia and when should this be suspected?

A

This is inherited hypercholestsrolaemia

If should be suspected history
Total cholesterol is >7.5mmol/L
There is a personal or family histrionic of CHD

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10
Q

What is the lifestyle advice associated with familial hypercholestsrolaemia?

A

Stop smoking
Lose weight
Reduce alcohol consumption

This should be given to every patient affected

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11
Q

What is the first line treatment for familial hypercholestsrolaemia?

A

High intensity statin e.g. atorvastatin 20mg

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12
Q

What drugs can be considered if a statin is contraindicated, not tolerated or not effective as monotherapy?

A

Ezetimibe
Fibrates (when TG >10mmol/L)
Lipid modifying drugs

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13
Q

In hypercholestsrolaemia, who should primary prevention be given to?

A

Anyone with familial hypercholestsrolaemia

Anyone with type 1 diabetes

Anyone with CKD

Anyone with a 10 year CVD risk of >10% (QRISK score)

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14
Q

What is first line for primary hypercholestsrolaemia?

A

Atorvastatin 20mg

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15
Q

When is secondary prevention given in hypercholestsrolaemia?

A

In patients with established CVD e.g. MI, angina, stroke, TIA

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16
Q

What is the first line drug treatment for secondary hypercholestsrolaemia?

A

Atorvastatin 80mg

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17
Q

What type of cholesterol are statins best at reducing?

A

LDL-C

They are not as effective at reducing triglycerides

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18
Q

What type of cholesterol are fibrates good at reducing?

A

Triglycerides

They are usually given when TG levels are high (>10mmol/L) even after LDL-C had been reduced

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19
Q

What monitoring needs to be done before lipid modifying therapy is started?

A

TC
HDL-C
Non HDL-C
TG

Creatinine kinase (in patients with an increased risk of myopathy or unexpected muscle pain)
Renal function 
LFTs (then measure at 3 and 12 months)
Thyroid function 
HbA1c
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20
Q

What is rhabdomyolysis?

A

This is a serious syndrome caused by direct muscle injury

The muscle fibres die and release their contents into the bloodstream

This can lead to serious complications e.g. renal failure

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21
Q

What are the symptoms of rhabdomyolysis?

A

Muscle pain
Muscle weakness of trouble moving
Dare red or brown urine, or decreased urination

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22
Q

What is the mechanism of action of statins

A

They competitively inhibit HMG-CoA reductase

Which controls the synthesis of cholesterol in the liver

23
Q

What are the cautions associated with statins?

A

Elderly
Liver disease
Increased risk of myopathy

24
Q

What increases the risk of myopathy associated with statins?

A 
High dose
High alcohol consumption 
Hypothyroidism 
Renal impairment 
Personal or family history or muscle disorders
25
Q

What are the side effects of statins?

A

Common - myalgia, thrombocytopenia

Uncommon - hepatic disorders

Rare - myopathy, rhabdomyolysis, interstitial lung disease

26
Q

Can statins be given in pregnancy?

A

No

Discontinue statins 3 months before attempting to conceive

The patient should be on adequate contraception during treatment and for 1 month afterwards

27
Q

What patient counselling should be given for statins?

A

Seek advice if you develop muscle pain, weakness, tenderness or dark urine/less urine (rhabdomyolysis)

Seek advice if you develop difficulty breathing, a cough or weight loss (interstitial lung disease)

Statins have many interactions with food and medications e.g. grapefruit juice

28
Q

What time should to take statins and why?

A

Simvastatin, pravastatin, fluvastatin
Night - cholesterol synthesis is highest when dietary intake is lowest

Atorvastatin, rosuvastatin
Any time - it has a longer half life

29
Q

When should the dose of rosuvastatin be reduced?

A

Risk factors for myopathy or rhabdomyolysis

Concurrent use of fibrates, clopidogrel and some antifungals

Patients aged over 70

Patients of an Asian origin

30
Q

What are the main drug interactions of statins?

A

Amiodarone, verapamil, diltiazem, amlodipine- increased risk of myopathy

Clarithromycin, erythromycin, ciclosporin - temporarily stop the statin during antibiotic treatment

Grapefruit juice - take 12h apart
At johns wort

Fibrates, ezetimibe

31
Q

Can simvastatin be sold OTC?

A

Yes, for primary prevention

Max pack side 28
Max dose 10mg daily

32
Q

What is the mechanism of action of ezetimibe?

A

They reduce the intestinal absorption of cholesterol

They have a greater effect on LDL-C than they do on TGs

33
Q

What are the main side effects of ezetimibe?

A

Myopathy

Pancreatitis

34
Q

Are fibrates better at reducing LDL cholesterol or triglycerides?

A

Triglycerides

They are used when TG levels remain high >10mmol/L

35
Q

When are fibrates cautioned?

A

Myopathy
Increased risk of myopathy e.g. renal impairment
Hypothyroidism - correct thyroid levels before initiating

36
Q

What additional monitoring should be carried out when fibrates and statins are used?

A

Hepatic function

Creatinine kinase

37
Q

Can lomitapide be given in pregnancy?

A

No - it is teratogenic

38
Q

Give some examples of bile acid suppressants

A

Colestryramine
Colestipol
Colesevelam

39
Q

What is the mechanism of action of bile acid sequestrants?

A

Bind to bile acids and prevent their reabsorption

This promotes the conversion of cholesterol into bile acids

40
Q

What is an issue associated with the long term use of bile acid sequesterants?

A

Deficiency of fat soluble vitamins e.g. vitamin A, D, K and folic acid

41
Q

Which groups of lipid regulating drugs are the most effective at reducing LDL-C?

A

Statins

42
Q

What is the main problem associated with bile acid seqesterants in reducing cholesterol?

A

They can efficiently reduce LDL-C, but can aggregate hypertriglyceridaemia

43
Q

What is the advice surrounding bile acid sequestrants if a patient is on other medications?

A

Don’t take them at the same time

Take other drugs 1 hour before or 4 hours after

Bile acid sequestrants can affect the absorption of other medications

44
Q

Why is it important to treat hypothyroidism before starting lipid modifying therapy?

A

Hypothyroidism can exacerbate hyperlipidaemia

Treating hypothyroidism may reduce cholesterol and therefore the need for statins

45
Q

What is the maximum atorvastatin dose when taking ciclosporin?

A

10mg

46
Q

What creatinine kinase is a concern in a patient on a statin?

A

5 times the upper limit

47
Q

What is the maximum dose of atorvastatin if a patient is also taking ciclosporin?

A

10mg

48
Q

Can a statin and gemfibrozil be used together?

A

No - increased risk of myopathy and rhabdomyolysis

49
Q

If a patient is on a statin, what LFT level would you stop the statin?

A

3 times the upper limit

50
Q

In what patient groups would you offer statins without assessing them?

A

Type 1 diabetes
CKD eGFR<60
Familial hypercholestsrolaemia

51
Q

Who do we offer lipid modifying therapy to?

A

QRISK >10% (CV event in the next 10 years)
Type I diabetics
CKD
Familial hypercholestsrolaemia

52
Q

What cardiovascular risk assessment calculators do we use?

A

QRISK2
QRISK3 - considers additional factors e.g. migraines, corticosteroid use
JBS3 - long term assessment

53
Q

What is used for the secondary prevention of CV events

A

Lipid modifying therapy e.g. statin

Aspirin if atherosclerotic disease

54
Q

Why do we tend to avoid high dose simvastatin (80mg)

A

Risk of myopathy and rhabdomyolysis

Pre Reg Pharmacy (36 decks)

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