Cholesterol

Question 1

What is Hyperlipidaemia?

Answer 1

high cholesterol, high triglycerides, or both

Question 2

What are the different causes of Hyperlipidaemia?

Answer 2

• Liver or kidney disease
• Family history
• Diabetes
• Hypothyroidism
• Lifestyle factors e.g. obesity, smoking
• Medicines e.g. antipsychotics, immunosuppressant, antiretrovirals, corticosteroids

Question 3

What is considered a high risk patient?

Answer 3

• Type 1 diabetes and aged 40+
• Type 2 diabetes if CVD risk is >10%
• Chronic kidney disease
• Familial hypercholesterolaemia
• 85 years of age and over
• 10-year CVD risk >10%

Question 4

What should high risk patients be given?

Answer 4

They should be given a statin regardless of cholesterol

Question 5

How is CVD risk assessed?

Answer 5

Assessed with QRISK, QRISK2, QRISK3, JBS3, or ASSIGN [Scotland].

Question 6

What do QRISK, JBS3 and ASSIGN assess?

Answer 6

The risk of someone’s chances of having a heart attack of stroke in the next 10 years

Question 7

At what % risk must be a statin be given?

Answer 7

If 10-year risk is greater than 10% = give a statin for primary prevention.

Question 8

What is the recommended statin for primary prevention?

Answer 8

Atorvastatin 20mg

Question 9

What is the recommended statin for secondary prevention?

Answer 9

Atorvastatin 80mg

Question 10

What are the lipid ranges?

Answer 10

High Density Lipids (HDL Cholesterol) - >1mmol/L

Triglycerides - <1.8mmol/L

Low Density Lipids (LDL Cholesterol) for high-
risk patients - <2mmol/L

Low Density Lipids (LDL Cholesterol) - <3mmol/L

Total Cholesterol for high-risk patients - <4mmol/L

Total Cholesterol for healthy adults - <5mmol/L

Question 11

How is Hyperlipidaemia diagnosed?

Answer 11

When total cholesterol is 6mmol/L or higher

Question 12

What do statins do?

Answer 12

Reduce the risk of CVD by reducing cholesterol levels. They are the drug of choice for primary and secondary prevention of CVD

Question 13

What is the % of reduction for each station and dose?

Answer 13

Atorvastatin:
20mg - 43%
40mg - 49%
80mg - 55%

Rosuvastatin:
10mg - 43%
20mg - 48%
40mg - 53%

Simvastatin:
80mg - 42%

Question 14

What is the mechanism of action for statins?

Answer 14

They competitively inhibit 3-hydroxy-3-methylglutaryl coenzyme A
(HMG CoA) reductase, an enzyme involved in cholesterol synthesis, in the liver.

Question 15

What must be monitored before starting a statin?

Answer 15

• Lipid profile
• Liver enzymes 3 months + 12 months
• Creatine kinase
• HbA1c or fasting blood glucose 3 months
• Thyroid function
• Renal function

Question 16

What must be monitored after starting a statin?

Answer 16

Liver enzymes - 3 month & 12 months

HbA1c or fasting blood glucose - 3 months

Question 17

What drug can be used if statins aren’t tolerated or effective?

Answer 17

Ezetimibe

Question 18

What should be done if patients can’t take a statin or ezetimibe?

Answer 18

They should be referred to a specialist for a
bile acid sequestrant, a fibrate, or nicotinic acid.

Question 19

What drugs can be given if statins and ezetimibe cannot be tolerated?

Answer 19

Bile acid sequestrant, a fibrate, or nicotinic acid.

Question 20

What should be done if triglyceride levels are high?

Answer 20

Add a fibrate

Question 21

What can Nicotinic acid be used for?

Answer 21

To lower triglycerides and LDL concentration.

Question 22

What is the main side effect of statins?

Answer 22

Muscle toxicity - causes Rhabdomyolysis (the destruction of muscle cells)

So must tell patients to report any muscle pain

Question 23

What advice should patients taking statins be given?

Answer 23

Report any muscle pain.

Question 24

What warnings are given with statins?

Answer 24

Simvastatin 80mg can cause rhabdomyolysis

Question 25

Can statins be given during pregnancy?

Answer 25

NO! Because they are teratogenic.
All statins must be avoided in pregnancy

Therefore adequate contraception is required during treatment and 1 month after treatment

Question 26

How long must statins be discontinued for, before attempting to conceive?

Answer 26

3 months

Question 27

When should statins be taken? Is there an exception?

Answer 27

Statins must be taken at night.

BUT atorvastatin and rosuvastatin can be taken at any time of the day, due to their long duration of action

Question 28

What are the common dose adjustments for statins?

Answer 28

Amlodipine, Amiodarone, or CCB + Simvastatin = Max dose of Simvastatin 20mg

Ciclosporin + Atorvastatin = Max dose of Atorvastatin 10mg

Clopidogrel + Rosuvastatin = Max dose of Rosuvastatin 20mg

Fibrate + Simvastatin = Max dose of Simvastatin 10mg

Question 29

Which drugs increase the risk of rhabdomyolysis when taken with statins?

Answer 29

Amiodarone, Amlodipine, Colchicine, Nicotinic Acid and Fibrates

Question 30

Which drugs increase the exposure of simvastatin?

Answer 30

Clarithromycin, Erythromycin, Ketoconazole, Miconazole and Grapefruit Juice

Question 31

Which drug increases the risk of hepatotoxicity?

Answer 31

Carbamazepine

Question 32

Which drugs cannot be taken with drugs? (There are 6)

Answer 32

Amiodarone, Amlodipine, Colchicine, Nicotinic Acid, Carbamazepine and Fibrates

Question 33

Which drugs cannot be taken with just simvastatin?

Answer 33

Clarithromycin, Erythromycin, Ketoconazole, Miconazole and Grapefruit Juice