Anti-hyperlipidaemics - Statins

Question 1

Cholesterol is often judged as being all bad. However, there are a number of benefits of cholesterol. Which of the following is NOT one of these benefits?

1 - part of lipid membranes
2 - component of bile
3 - synthesise coagulation factors
4 - steroid synthesis
5 - vitamin D

Answer 1

3 - synthesise coagulation factors

• we need cholesterol in our skins cells to make vitamin D from sunlight.

Question 2

The liver is able to synthesis cholesterol, or we can consume it in out diets. Once fats and cholesterol have been digested and absorbed they are transported around the body in lipoproteins (contain phospholipids and proteins tags) as they are hydrophobic. As part of the exogenous pathway, what is the 1st lipoprotein they are packaged in?

1 - chylomicrons
2 - LDL
3 - HDL
4 - VLDL

Answer 2

1 - chylomicrons

• largest lipoprotein
• least dense lipoprotein (essentially they are large and not full, so not dense)
• uses the portal vein for this

Question 3

Once lipids and cholesterol have been packaged into chylomicrons, do they enter the circulatory system or lymphatics?

Answer 3

• lymphatics
• they then enter the circulation at the subclavian vein
• they can then travel to the liver and adipose tissue

Question 4

The liver is able to synthesis cholesterol using the mevalonate pathway. What is the rate limiting step in this pathway, that ultimately determines cholesterol synthesis?

1 - fatty acid synthase
2 - 3-hydroxy-3-methyl-glutaryl-coenzyme A (HMG-CoA) reductase
3 - HMG-CoA synthase
4 - acetyl-coA carboxylase

Answer 4

2 - 3-hydroxy-3-methyl-glutaryl-coenzyme A (HMG-CoA) reductase

• this enzyme creates mevalonate, which is the precursor of cholesterol

Question 5

Once cholesterol has been synthesised in the liver, it is once again packed up into lipoproteins and sent off into the circulation to carry TAGs to the rest of the body as part of the endogenous. Which type of lipoprotein is used 1st?

1 - chylomicrons
2 - LDL
3 - HDL
4 - VLDL

Answer 5

4 - VLDL

• low density refers to the concentration of cholesterol
• VLDL = high TAGs and low cholesterol
• LDL = low TAGs and high cholesterol

Question 6

Once VLDL have been distributed around the body and distributed TAGs they become LDLs (distribute cholesterol around the body as part of the endogenous), and ultimately HDLs. What is the benefit of HDLs?

1 - remove excess TAGs from blood
2 - collect excess cholesterol and return it to the liver
3 - remove cholesterol from plaques
4 - distribute cholesterol around the body

Answer 6

2 - collect excess cholesterol and return it to the liver

• part of the reverse pathway

Question 7

What receptor is missing in patients with Familial hypercholesterolemia, meaning they are unable to absorb cholesterol?

1 - VLDL receptors
2 - LDL receptors
3 - lipoprotein lipase receptors
4 - GPCR

Answer 7

2 - LDL receptors

• causes very high cholesterol

Question 8

If these is a lot of LDL, the tissues taking up the cholesterol become saturated. What is a key risk of this in the endothelium of blood vessels?

1 - cause vasodilation
2 - cause damage to endothelium and initiate the coagulation cascade
3 - collect on endothelium and form plaques
4 - all of the above

Answer 8

3 - collect on endothelium and form plaques

• increase risk of strokes, MI and PVD

Question 9

Which of the 2 drugs below is a anti-hyperlipidaemic statins that we need to be aware of?

1 - Simvastatin
2 - Bisoprolol
3 - Ramipril
4 - Atorvastatin

Answer 9

1 - Simvastatin
4 - Atorvastatin

Question 10

Simvastatin and Atorvastatin are anti-hyperlipidaemics statins. What is the mechanism of action of both of these drugs?

1 - inhibit lipid absorption in the GIT
2 - inhibit HMG-CoA reductase
3 - activates lipoprotein lipase
4 - inhibit HMG-CoA synthase

Answer 10

2 - inhibit HMG-CoA reductase

• less cholesterol is available, so hepatocytes take up LDL from blood to make more cholesterol
• reduces LDL
• reduces cholesterol
• reduces TAG
• increased HDL

Question 11

Simvastatin and Atorvastatin are the 2 core anti-hyperlipidaemics that we need to be aware of. Which of the following is NOT an effect of these medications?

1 - reduced cholesterol
2 - reduced LDL
3 - total cholesterol
4 - reduced blood glucose
5 - triglycerides
6 - increased HDL

Answer 11

4 - reduced blood glucose

Question 12

Which of the following is NOT an indication of anti-hyperlipidaemics statins?

1 - primary prevention of adverse cardiovascular (CV) event
2 - dyslipidaemia
3 - hypertension
4 - secondary prevention of adverse cardiovascular (CV) event

Answer 12

3 - hypertension

• secondary CV relates to those with IHD, PVD or previous strokes

Question 13

Anti-hyperlipidaemics statins, atorvastain and simvastatin are indicated in the primary prevention of adverse cardiovascular (CV) event. This relates to individuals >40 y/o who have not had a CV event, but are at risk of having one (stroke, MI etc..). Using a validated scoring tool such as the Q-risk, what is the 10 year cut off risk to begin using statins?

1 - >1%
2 - >10%
3 - >20%
4 - >40%

Answer 13

2 - >10%

Question 14

There are 3 common adverse events of statin use. Which of the following is NOT a common adverse event?

1 - headache
2 - rhabdomyolysis
3 - GI upset
4 - muscle aches

Answer 14

2 - rhabdomyolysis

• can occur but this is rare

Question 15

Although rare, which 2 of the following can statins cause in the liver?

1 - NAFLD
2 - fibrosis
3 - drug induced hepatitis
4 - increased liver enzymes

Answer 15

3 - drug induced hepatitis
4 - increased liver enzymes

Question 16

Which 2 of the following should the prescription of statins be used with caution?

1 - hepatic impairment
2 - GU ischaemia
3 - splenomegaly
4 - renal impairment

Answer 16

1 - hepatic impairment
- statins metabolised by cytochrome P450 (CYP)
- CYP, mostly in liver

4 - renal impairment
- statins eliminated by kidneys.
- can be used but dosage should be reduced

Question 17

Which 2 of the following are statins contraindicated in?

1 - renal impairment
2 - hepatic impairment
3 - pregnant women
4 - women breastfeeding

Answer 17

3 - pregnant women
- cholesterol is essential in foetal development

4 - women breastfeeding
- may pass into breast milk

Question 18

Stains, atorvastatin and simvastain are both metabolised by cytochrome P450 (CYP). What effect would a CYP inhibitors have on statins?

Answer 18

• statins will not be metabolised, so they can accumulate
• increases risk of adverse events

Question 19

Knowing which drugs/ drug classes interact with cytochrome P450 (CYP) in the liver is important, as statins are metabolised by CYP. Which of the following is NOT a CYP minhibitor?

1 - amiodarone
2 - benzodiazepines
3 - diltiazem
4 - macrolids
5 - protease inhibitors
6 - grapefruit juice

Answer 19

2 - benzodiazepines

• amiodarone and diltiazem= Ca2+ channel blocker
• macrolids = antibiotics
• protease inhibitors

Question 20

What dose of atorvastain would be prescribed in a patient with CVD as a primary preventative?

1 - 1mg daily
2 - 5mg daily
3 - 10mg daily
4 - 40mg daily

Answer 20

3 - 10mg daily

Question 21

What dose of simvastatin would be prescribed in a patient with CVD as a primary preventative?

1 - 1mg daily
2 - 5mg daily
3 - 10mg daily
4 - 40mg daily

Answer 21

4 - 40mg daily

• baseline lipid profile
• 3 month lipid profile

Question 22

What dose of simvastatin would be prescribed in a patient as a primary preventative?

1 - 1mg daily
2 - 5mg daily
3 - 40mg daily
4 - 80mg daily

Answer 22

4 - 80mg daily

• monitor liver enzymes at 3 and 12 months

Question 23

Statins are generally encouraged to be taken in the evenings, why is this?

1 - hypotension
2 - drowsiness
3 - cholesterol synthesis is highest in mornings
4 - all of the above

Answer 23

3 - cholesterol synthesis is highest in mornings

Question 24

Once statins are started, how long will the patient normally take them for primary and secondary prevention?

1 - 6 months
2 - 1 years
3 - 6 years
4 - indefinitely

Answer 24

4 - indefinitely

Question 25

When patients are prescribed statins as part of primary prevention, what is the aim to reduce LDL by within 3 months?

1 - 4%
2 - 14%
3 - 40%
4 - 80%

Answer 25

3 - 40%

Question 26

Prior to starting statins, what conditions should be rules out?

1 - hypertension
2 - hypothyroidism
3 - CHF
4 - CKD

Answer 26

2 - hypothyroidism

• reversible cause of hyperlipidaemia and increases the risk of myositis

Question 27

In patients <80 y/o with hypertension, what are the NICE guidelines for BP?

1 - 130/85
2 - 140/90
3 - 150/90
4 - 160/90

Answer 27

2 - 140/90
- 130/85 in diabetes
- 150/90 in >80 y/o