Hyperlipidaemia

Question 1

What is hyperlipidaemia?

Answer 1

High blood levels of cholesterol, triglycerides or both

Question 2

What does hyperlipidaemia cause?

Answer 2

Atherosclerosis 
CHD
Strokes
TIA
Peripheral arterial disease

Question 3

When is primary prevention of cardiovascular disease needed?

Answer 3

T1DM

T2DM if CVD risk > 10%

Question 4

When is secondary prevention of CVD needed?

Answer 4

When the patient has established CVD

Question 5

When is the QRISK score needed?

Answer 5

84 and under

10 year CVD risk score > 10% offer primary prevention

Question 6

When is QRISK unsuitable?

Answer 6

T1DM
Established CVD
85+
CKD
Familial hypercholesterolaemia

Question 7

What are the levels of total cholesterol needed for hyperlipidaemia to be diagnosed?

Answer 7

6mmol/L total cholesterol

Question 8

What are the cholesterol targets for healthy adults?

Answer 8

< 5 mmol/L total
< 3 mmol/L LDL
> 1 mmol/L HDL
< 1.7 mmol/L triglycerides

Question 9

What are the cholesterol targets for high risk adults?

Answer 9

< 4mmol/L total
< 2 mmol/L LDL
> 1 mmol/L HDL
< 1.7 mmol/L triglycerides

Question 10

What drugs cause hyperlipidaemia?

Answer 10

Antipsychotics
Immunosuppressants
Corticosteroids
Antiretrovirals

Question 11

What conditions cause hyperlipidaemia?

Answer 11

Hypothyroidism
Liver or kidney disease
Diabetes
Family history
Lifestyle

Question 12

What are the statins?

Answer 12

Atorvastatin
Simvastatin
Rosuvastatin
Pravastatin
Fluvastatin

Question 13

What are the fibrates?

Answer 13

Bezafibrate
Ciprofibrate
Fenofibrate
Gemfibrozil

Question 14

What are the bile acid sequestrants?

Answer 14

Colesevelam
Colestipol
Colestyramine

Question 15

What are the nicotinic acid group?

Answer 15

Acipimox
Nicotinic acid
Omega 3 fatty acid

Question 16

What are the other lipid regulating drugs?

Answer 16

Ezetimibe
Lomitapide
Alirocumab

Question 17

What is the mechanism of action of statins?

Answer 17

Lowers LDL cholesterol synthesis by the liver via inhibition of HMG-CoA reductase

Indirectly reduces triglycerides and increases HDL cholesterol

Question 18

Which statin does not need to be taken at night?

Answer 18

Atorvastatin

Question 19

What are high intensity statins used for?

Answer 19

Prevention of cardiovascular disease

Question 20

What are the high intensity statins?

Answer 20

Atorvastatin
- primary prevention 20mg OD
- secondary prevention 80mg OD
Rosuvastatin 10mg

Simvastatin 80 mg

Question 21

What is the MHRA warning for simvastatin 80mg?

Answer 21

High risk of myopathy

Only give if high risk of CVD complications or severe hypercholesterolaemia and treatment goals not achieved at a lower dose

Question 22

Are statins used for hyperlipidaemia?

Answer 22

Yes, first line

Question 23

What are secondary causes of dyslipidaemia?

Answer 23

Hypothyroidism
Uncontrolled diabetes mellitus
Nephrotic syndrome
Liver disease

Question 24

What are the side effects of statins?

Answer 24

Myopathy, myosotis, rhabdomyolysis
Interstitial lung disease
Diabetes

Question 25

What are the counselling points of statins?

Answer 25

Report tender, weak and painful muscles Report short breath, cough, weight loss Can raise HBA1c

Question 26

When is there an increased risk of muscle toxicity in statins?

Answer 26

History of muscle disorder High alcohol Renal impairment Hypothyroidism

Question 27

When is there an increased risk of myopathy with the use of statins?

Answer 27

Ezetimibe or fibrates | Fusidic acid - restart statin 7 days after last dose

Question 28

What are the monitoring requirements for statins?

Answer 28

``` Baseline lipids Renal function Thyroid function HBA1c Severe muscle symptoms - discontinue Creatinine kinase - discontinue if 5X normal ``` Liver function - discontinue if liver transaminases 3x normal

Question 29

What is the MHRA warning for amlodipine and statins?

Answer 29

Do not take more than 20mg simvastatin when taking amlodipine concomitantly

Question 30

What are the interactions with statins that causes an increase in statin levels?

Answer 30

``` Amiodarone Grapefruit juice CCBs Imidazole/triazole antifungals Macrolides Ezetimibe/fibrates Fusidic acid ```

Question 31

What are the counselling points needed for patients taking statins when they have been given a macrolide prescription e.g. Clarithromycin?

Answer 31

Stop taking statin until antibiotic course completed

Question 32

When do you restart statin after taking oral fusidic acid?

Answer 32

7 days after last fusidic acid dose

Question 33

What re the dose adjustments needed for simvastatin due to interactions?

Answer 33

Max 10 mg with fibrate Max 20mg with amiodarone, amlodipine, diltiazem, verapamil

Question 34

What is the dose adjustment required for atorvastatin when used with ciclosporin?

Answer 34

Max 10mg atorvastatin

Question 35

What is the dose adjustment required for rosuvastatin with clopidogrel?

Answer 35

Initially 5mg Max 20mg

Question 36

Can statins be taken in pregnancy?

Answer 36

NO - teratogenic Effective contraception during and 1 month after stopping Stop taking 3 months before conceiving and restart after breastfeeding finished

Question 37

What conditions can cause dyslipidaemia?

Answer 37

Hypothyroidism Uncontrolled diabetes mellitus Nephrotic syndrome Liver disease

Question 38

What is the mechanism of action of ezetimibe?

Answer 38

Reduces blood cholesterol by inhibiting the absorption of cholesterol by the small intestine Alternative to statin in familial and primary hypercholesterolaemia

Question 39

What is the interaction between statins and ezetimibe?

Answer 39

Myopathy (rhabdomyolysis)

Question 40

What is the mechanism of action of fibrates?

Answer 40

Lowers blood triglyceride levels by reducing the livers production of VLDL and by speeding up the removal of triglycerides from the blood

Question 41

What is severe hypertriglyceridaemia?

Answer 41

Levels above 10mmol/L

Question 42

What are the fibrates?

Answer 42

Bezafibrate Fenofibrate Ciprofibrate Gemfibrozil

Question 43

Which fibrate is contraindicated when used with a statin?

Answer 43

Gemfibrozil Do NOT use with statin as high risk of myopathy (rhabdomyolysis)

Question 44

What are the interactions between fibrates and statins?

Answer 44

Causes myopathy

Question 45

What happens if a patient has renal impairment and uses fibrates?

Answer 45

Can cause myopathy

Question 46

What is the mechanism of action of bile acid sequestrants?

Answer 46

Binds and sequesters bile acids Liver produces more bile acids to replace those that have been lost Cholesterol is used to make bile acids, reducing the amount of LDL cholesterol circulating in the blood

Question 47

What are the bile acid sequestrants?

Answer 47

Colesevelam Colestipol Colestyramine

Question 48

What are the interactions of the bile acid sequestrants?

Answer 48

Impairs absorption of fat soluble vitamins ADEK and other drugs

Question 49

When should you take bile acid sequestrants in relation to other drugs?

Answer 49

Take other drugs one hour before (4 hours for colesevelam) or 4 hours after bile acid sequestrants