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bnf 2021 > 2. Hyperlipidaemia > Flashcards

2. Hyperlipidaemia Flashcards

1
Q

What is

Hyperlipidaemia

A

Hyperlipidaemia is the presence of elevated plasma concentrations of lipids including cholesterol, triglycerides and lipoproteins. It is an important modifiable risk factor for cardiovascular disease (CVD).

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2
Q

Hyperlipidaemia

Can be the cause of: (4)

A

Artherosclerosis

Coronary heart disease like:
Angina
MI

stroke

Peripheral arterial disease

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3
Q

Hyperlipidaemia

CVD prevention

Primary prevention: (6) cases

Give meds?

A

Yes give statins!

Diabetic type 1
Diabetic type 2 CVD risk >10%

Risk calculator QRISK2 results in >10% CVD

Chronic kidney disease or albuminuria

Familial hypercholesterolaemia

Age 85+

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4
Q

Hyperlipidaemia

Secondary prevention

A

Stabilised CVD

Angina
MI
Stroke 
TIA transient ischamic attack (mini stroke) 
Peripheral arterial disease PAD

Note: REGARDLESS OF THEIR SERUM CHOLESTEROL

Stat 80mg atorvastatin

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5
Q

What is

Peripheral arterial disease (PAD)

A

Peripheral arterial disease (PAD) is a common condition where a build-up of fatty deposits in the arteries restricts blood supply to leg muscles.

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6
Q

What is the QRISK2 calculator

A

A risk calculator recommended by NICE

It gives a score of how high a persons risk of developing CVD over the next 10 years

The score determine to give statins or not

Age group 84 and less

Scores of >10 %
Require intervention and lifestyle advice

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7
Q

QRISK2
Not suitable for
:

(5)

As it under estimates the real risk

A 
1 Type 1 diabetic 
2 Established CVD
3 Over 85
4 CKD (eGFR <60ml/min/1.73m2)
5 Familial hypercholesterolaemia
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8
Q

Cholesterol targets

Hyperlipidaemia diagnosis :

A

6 mmol/L and above

In total cholesterol

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9
Q

Hyperlipidaemia

Total cholesterol target in

HEALTHY ADULT

A

5 mmol/L or less

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10
Q

Hyperlipidaemia

Total cholesterol target in
High risk adults

A

4mmol/L or less

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11
Q

Hyperlipidaemia

LDL= low density lipoprotein
Bad ❌

LDL target in healthy adults

A

3mmol/L or less

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12
Q

Hyperlipidaemia

LDL= low density lipoprotein
Bad ❌

LDL target in high risk adults

A

3mmol/L or less

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13
Q

Hyperlipidaemia

HDL: high density lipoprotein
Good

HDL target in all adults

A

1mmol/L or more

The higher this number the better

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14
Q

Hyperlipidaemia

Triglycerides target in all adults

A

1.7mmol/L or less (less is better)

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15
Q

Drugs that cause hyperlipidaemia

10

A 
Antipsychotics 
Immunosuppressants
Corticosteroids 
Antiretrovirals (HIV drugs) 
Diuretics 
retinoids
oral oestrogen
beta-blockers
antidepressants
anticonvulsants
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16
Q

Conditions causing hyperlipidaemia

A 
high-fat diets, 
a sedentary lifestyle, 
obesity 
Diabetes. 
Hypothyroidism 
Liver disease 
Kidney disease

There are also genetic causes. Familial hypercholesterolemia, one form of hyperlipidemia, is the most common dominantly inherited genetic disorder in humans worldwide.

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17
Q

Hyperlipidaemia

Tx is to prevent CVD

Before starting a stating which underlying conditions must be treated first (3)

A

Liver disease

Hypothyroidism-hyperthyroidism

Nephrotic syndrome (albuminuria)

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18
Q

When are statins best taken

Any exemptions?

A

At night!

Except atorvastatin

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19
Q

High intensity statins

What does that mean and which ones are they? 3

A

They are statins that proxy a greater LDL reduction than

SIMVASTATIN 40mg

Atorvastatin
Primary prevention: 20mg OD
Secondary prevention: 80mg OD

Rosuvastatin 10mg +

⚠️Simvastatin 80 only give if absolutely necessary

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20
Q

High intensity statin

Statin CI what to do?

A
  1. Reduce dose of high intensity statin
  2. Switch to lower intensity statin
  3. If pt intolerant of all 3 statins -> specialist
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21
Q

Hyperlipidaemia

Hypercholesterolaemia
Tx

A
  1. Statins
  2. High intensity statins
    3 statins CI ezitime

Primary
Familial cholesterolaemia

In SEVERE hyperlipidaemia ADD ezitime to statin

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22
Q

Hyperlipidaemia

Hyper triglyceridaemia

Tx

Moderate

Severe

A
  1. Statin
  2. high intensity statin
    3 statin CI give FIBRATE

Or if triglycerides still high abs LDL reduced

Add (to the statin) FIBRATE ( except: gemfibrozil)

Or
add (to statin) nicotinic acid

23
Q

Statins

Pts MUST REPORT:

A 
Symptoms 
Muscle pain, decreased urination 
Brown urine 
Pain in lower back thighs and shoulders 
Tiredness
SOB

Myopathy

Myositis

⚠️Rhabdomyolysis
is a serious syndrome due to a direct or indirect muscle injury. It results from the death of muscle fibers and release of their contents into the bloodstream. This can lead to serious complications such as renal (kidney) failure. This means the kidneys cannot remove waste and concentrated urine

24
Q

Statins

Increased risk of muscle toxicity in

(Conditions 4)

A

Personal/ family history of muscle disorders

Increase alcohol intake

Renal impairment

Hypothyroidism

25
Statins : Caution Concomitant use of statin + (3)
Avoid statin with 1. Ezetimibe 2. fibrates especially (gemfibrozil) 3. Systemic fusidic acid ( restart statin 7 days AFTER last dose of fusidic acid; risk of RHABDOMYOLYSIS) (avoid unless specialist prescribed)
26
Statins SE
SOB COUGH WEIGHLOSS Asthenia (abnormal physical weakness or lack of energy) constipation; diarrhoea; dizziness; flatulence; gastrointestinal discomfort; headache; myalgia; nausea; sleep disorders; thrombocytopenia
27
Statin Caution BNF
Elderly; high alcohol intake; history of liver disease; hypothyroidism; known genetic polymorphisms—consult product literature; patients at increased risk of muscle toxicity, including myopathy or rhabdomyolysis (e.g. those with a personal or family history of muscular disorders, previous history of muscular toxicity and a high alcohol intake)
28
Statins monitoring BNF
Hypothyroidism Hypothyroidism should be managed adequately before starting treatment with a statin. Before starting treatment with statins, at least one full lipid profile (non-fasting) should be measured, including total cholesterol, HDL-cholesterol, non-HDL-cholesterol (calculated as total cholesterol minus HDL-cholesterol), and triglyceride concentrations, thyroid-stimulating hormone, and renal function should also be assessed. Liver function There is little information available on a rational approach to liver-function monitoring; however, NICE suggests that liver enzymes should be measured before treatment, and repeated within 3 months and at 12 months of starting treatment, unless indicated at other times by signs or symptoms suggestive of hepatotoxicity (NICE clinical guideline 181 (July 2014). Lipid Modification—Cardiovascular risk assessment and the modification of blood lipids for the primary and secondary prevention of cardiovascular disease). Those with serum transaminases that are raised, but less than 3 times the upper limit of the reference range, should not be routinely excluded from statin therapy. Those with serum transaminases of more than 3 times the upper limit of the reference range should discontinue statin therapy. Creatine kinase Before initiation of statin treatment, creatine kinase concentration should be measured in patients who have had persistent, generalised, unexplained muscle pain (whether associated or not with previous lipid-regulating drugs); if the concentration is more than 5 times the upper limit of normal, a repeat measurement should be taken after 7 days. If the repeat concentration remains above 5 times the upper limit, statin treatment should not be started; if concentrations are still raised but less than 5 times the upper limit, the statin should be started at a lower dose. Diabetes Patients at high risk of diabetes mellitus should have fasting blood-glucose concentration or HbA1C checked before starting statin treatment, and then repeated after 3 months
29
Statins Monitoring 6
1 baseline lipid profile 2 renal function 3 thyroid function 4 HbA1c if at high risk developing diabetes 5 creatine kinase if 5x the normal STOP! 6 liver function if 3x the normal STOP! “Liver transaminases
30
List Fibrates
Fenofibrate Bezafibrate Ciprofibrate Fenofibric acids Gemfibrozil AVOID WITH STATINS!!!
31
Fibrates SE
Abdominal pain; diarrhoea; flatulence; nausea; vomiting
32
Fibrates Cautions
Gall bladder disease; pancreatitis (unless due to severe hypertriglyceridaemia); photosensitivity to fibrates; photosensitivity to ketoprofen
33
Statins metabolism REDUCED by enzyme inhibitors such as: 10
Rate limiting CCB verapamil and diltiazem Amiodarone Amlodipine Ciclosporin Grapefruit juice Itraconazole Clarithromycin Setraline Sildenafil
34
Dose adjustments Simvastatin with FIBRATE Amiodarone, amlodipine, CCB
MAX 10mg simvastatin MAX 20mg simvastatin
35
Dose adjustment Atorvastatin And Ciclosporin
Max 10mg if atorvastatin
36
Dose adjustment Rosuvastatin And Clopidogrel
Initially 5mg - MAX 20 of rosuvastatin
37
Alternative to Statins what can be given? hyper triglyceridaemia
FIBRATE
38
What to give if statins CI In pts Hyperlipidaemia
Ezetimibe
39
Statins and pregnancy
Contraception Stop statins 3 months before trying to conceive Contraception during treatment Contraception 1 month after treatment Restart AFTER Breastfeeding
40
Tx for Hypercholesterolaemia Bike acids What are they?
Bile acid sequestrants act by binding bile acids, preventing their reabsorption; this promotes hepatic conversion of cholesterol into bile acids; the resultant increased LDL-receptor activity of liver cells increases the clearance of LDL-cholesterol from the plasma
41
Bike acids Initiated by specialist List When & how to take
``` cholestyramine. colesevelam. (4hrs before n 4 after) Colestipol Colestid. LoCholest. Prevalite. Questran. Questran Light. ``` “1 hr before food or 4 hrs after” Impair absorption of Fat soluble vits ADEK
42
Bile acids sequestrates SE
Constipation; gastrointestinal discomfort; headache; nausea; vomiting
43
Hyperlipidaemia Omega 3 fatty acids
No evidence for use
44
Name 3 long 1/2t statins Can be taken at anytime of the day
Atorvastatin Rosuvastatin Pitavastatin
45
Name 3 statins that have a short half life have to be taken at NIGHT only
Simvastatin Lovastatin Fluvastatin
46
Lipophilic statins Increased risk of developing myalgias
atorvastatin, simvastatin, fluvastatin,
47
Hydrophobic Statins Less risk of developing myalgias
rosuvastatin pravastatin Fluvastatin
48
Statins and impaired renal function Best statin to give
Atorvastatin Or Fluvastatin
49
Statins and impaired renal function Statin to AVOID:
Rosuvastatin
50
Statins and CYP3A4 Drug interaction AVOID those 2 statins
Simvastatin And Atorvastatin
51
Statins and CYP3A4 Drug interaction To give:
Pravastatin Or Rosuvastatin
52
Statins List
``` atorvastatin fluvastatin pravastatin rosuvastatin simvastatin ```
53
TLD THIAZIDES LIKE DIURETICS In renal impairment
Not effective ❌ Therefore give LOOP DIURETICS Furosemide Bumetanide

bnf 2021 (20 decks)

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