Dyslipidaemia

Question 1

What is the line treatment for hypercholesterolaemia and moderate hypertriglyceridaemia?

Answer 1

statins

for severe HC and HT: statins + ezetimibe

Question 2

What is the line treatment for familial hypercholesterolaemia?

Answer 2

high intensity statin ( >40% LDL-C reduction)

if it is primary heterozygous familial hypercholesterolaemia
- statins or ezetimibe monotherapy if CI or combination
- fibrate or a bile acid sequestrant (such as colestyramine or colestipol hydrochloride) if the above are CI

if it is primary homoozygous familial hypercholesterolaemia
- specialist advice

Question 3

What combination of statin and fibre should be avoided and why?

Answer 3

statin + gemfibrozil (esp simvastatin)
- increased rhabdomyolysis risk

Question 4

When are fibrates used?

Answer 4

if triglycerides remain high even after the LDL-cholesterol concentration has been reduced adequately.

Question 5

When are PCSK9 inhibitors used in hypercholesterolaemia? Examples?

Answer 5

patients with primary heterozygous familial hypercholesterolaemia whose LDL-cholesterol has not been adequately controlled on maximum tolerated lipid-lowering therapy

alirocumab and evolocumab

Question 6

What is the lipid reduction target?
- high risk patients: LDL-C and non-HDL-C

Answer 6

LDL-C < 2mmol/L

non-HDL-C < 2.6mmol/L

Question 7

When are statins CI?

Answer 7

pregnancy and breastfeeding

active liver disease
unexplained raised transaminases

Question 8

What is the MHRA warning for statins?

Answer 8

new-onset, or exacerbation of pre-existing, myasthenia gravis or ocular myasthenia associated with statin use

symptoms: weakness in the arms or legs that worsens after activity, double vision, drooping of the eyelids, difficulty swallowing, or shortness of breath

Question 9

Which statins can be taken at any time of day?

Answer 9

atorvastatin
rosuvastatin

Question 10

What are the cautions for statin use?

Answer 10

muscle toxicity

hypothyroidism: should be managed before starting statin use

Question 11

What are the main side effects for statins?

Answer 11

muscle effects: myalgia, myopathy, myositis, and rhabdomyolysis
- muscle pain, weakness, or cramps
- measure creatine kinase: if > 5x the upper limits then discontinue

diabetes: can raise blood glucose concentration
- do not discontinue as benefit > risk

interstitial lung disease: dyspnoea, cough, and weight loss
- red flag, seek help

Question 12

Can statins be used in pregnancy?

Answer 12

contraception is required during treatment and for 1 month afterwards

avoid during pregnancy: discontinue 3 months before attempting to conceive

Question 13

How does hepatic impairment affect statin use?

Answer 13

avoid in active liver disease, unexplained raised transaminase > 3x upper limit, discontinue

Question 14

What counselling points are needed for statins?

Answer 14

interstitial lung disease
- report dyspnoea, cough, and weight loss

myopathy, myalgia, rhabdomylosis
- report muscle pain, weakness, or cramps

Question 15

What monitoring is needed for statins?

Answer 15

baseline lipid profile: repeated 2–3 months after starting or changing treatment

baseline TSH
renal function

liver function: before starting treatment with statins, repeated 2–3 months after starting or changing treatment, and then at 12 months

fasting blood glucose: before starting statin treatment, and then repeated after 3 months.

Question 16

When should creatine kinase be measured during statin use?

Answer 16

before use IF: persistent, generalised, unexplained muscle pain, tenderness or weakness

during use if they DEVELOP: unexplained muscle pain, tenderness or weakness

discontinue if repeated >5x the upper limit

Question 17

What are the main drug interactions for statins?

Answer 17

enzyme inhibitors: increased statin concentration therefore increased myopathy risk

macrolide antibiotics: stop taking statins until course is finished

fusidic acid: restart after last dose

rosuvastatin + warfarin: increased anticoagulant effect/bleeding risk

Question 18

When should simvastatin be dose reduced?

Answer 18

bezafibrate, ciprofibrate: max 10mg OD

amiodarone, amlodipine, ranolazine: max 20mg OD

verapamil, diltiazem: max 20mg OD

ticagrelor, lomitapide: max 40mg OD

Question 19

When should atorvastatin be dose reduced?

Answer 19

ciclosporin: max 10mg OD

antivirals: max 20mg OD

Question 20

When should rosuvastatin be dose reduced?

Answer 20

leflunomide: max 10mg OD

clopidogrel: initially 5mg OD then max 20mg OD

Question 21

When are fibrates CI?

Answer 21

gallbladder disease
pancreatitis

Question 22

What is the target level for healthy vs high risk patients?
total cholesterol
LDL-C
HDL-C
non-HDL
triglycerides

Answer 22

total cholesterol
- <5mmol/L vs <4mmol/L

LDL-C
- <3mmol/L vs <2mmol/L

HDL-C
- >1mmol/L (M), >1.2mmol/L (F)

non-HDL
- <4mmol/L vs <2.6mmol/L

triglycerides
- <1.7mmol/L
- < 2.3mmol/L (fasting TG)