Session 5 - Group Work

Question 1

Indicate whether the drug increases, decreases or does not affect: LDL-Chol, HDL-Chol, TGs

Statin

Answer 1

LDL-Chol, HDL-Chol, TGs

Decrease, Increase, Decrease

Question 2

Indicate whether the drug increases, decreases or does not affect: LDL-Chol, HDL-Chol, TGs

Ezetimibe

Answer 2

LDL-Chol, HDL-Chol, TGs

Decrease, Increase, Decrease

Question 3

Indicate whether the drug increases, decreases or does not affect: LDL-Chol, HDL-Chol, TGs

Nicotinic acid

Answer 3

LDL-Chol, HDL-Chol, TGs

Decrease, Increase, Decrease

Question 4

Indicate whether the drug increases, decreases or does not affect: LDL-Chol, HDL-Chol, TGs

Cholestyramine

Answer 4

LDL-Chol, HDL-Chol, TGs

Decrease, Increase, Increase

Question 5

Indicate whether the drug increases, decreases or does not affect: LDL-Chol, HDL-Chol, TGs

Omega 3 FA

Answer 5

LDL-Chol, HDL-Chol, TGs

Increase, Increase, Decrease

Question 6

Indicate whether the drug increases, decreases or does not affect: LDL-Chol, HDL-Chol, TGs

Fibrates

Answer 6

LDL-Chol, HDL-Chol, TGs

Decrease, Increase, Decrease

Question 7

1) A 63-year-old man was admitted to CCU with an acute anterior MI. He received the usual treatment with thrombolysis, aspirin, beta blocker and ACE inhibitor.

His total cholesterol was found to be 7mmol/L with TG of 1.1 mmol/L.

a) What is the evidence that lowering cholesterol is likely to be beneficial to this patient?

Answer 7

For every 1 mmol/L you drop it you have 20% reduced risk of CVD.

Question 8

1) A 63-year-old man was admitted to CCU with an acute anterior MI. He received the usual treatment with thrombolysis, aspirin, beta blocker and ACE inhibitor.

His total cholesterol was found to be 7mmol/L with TG of 1.1 mmol/L.

b) The patient is prescribed a lipid-lowering drug.

What different agents could be used?

Answer 8

Statin
Ezetimibe
Nicotinic acid
Cholestyramine(?)
Fibrates

Question 9

1) A 63-year-old man was admitted to CCU with an acute anterior MI. He received the usual treatment with thrombolysis, aspirin, beta blocker and ACE inhibitor.

His total cholesterol was found to be 7mmol/L with TG of 1.1 mmol/L.

c) Atorvastatin is prescribed.

What is the mechanism of action of this group of drugs and where to they predominantly act?

Answer 9

Competitive inhibition of HMG-CoA reductase – rate controlling enzyme in mevalonate pathway

Upregulation of hepatic LDL receptors

Increased clearance of circulating LDL

Question 10

1) A 63-year-old man was admitted to CCU with an acute anterior MI. He received the usual treatment with thrombolysis, aspirin, beta blocker and ACE inhibitor.

His total cholesterol was found to be 7mmol/L with TG of 1.1 mmol/L.

d) What advice should the patient receive about statin therapy and explain why it is recommended to be taken NOCTE?

Answer 10

Avoid grapefruit juice (or grapefruit) because it affects CYP 3A4 and take it at night because the circadian rhythm upregulates LDL receptors so it has highest efficacy here

Question 11

1) A 63-year-old man was admitted to CCU with an acute anterior MI. He received the usual treatment with thrombolysis, aspirin, beta blocker and ACE inhibitor.

His total cholesterol was found to be 7mmol/L with TG of 1.1 mmol/L.

e) Would the absolute level of cholesterol affect the decision to use a lipid-lowering agent?

Answer 11

Yes, full lipid profile should be done and QRISK.

Question 12

1) A 63-year-old man was admitted to CCU with an acute anterior MI. He received the usual treatment with thrombolysis, aspirin, beta blocker and ACE inhibitor.

His total cholesterol was found to be 7mmol/L with TG of 1.1 mmol/L.

f) Once the treatment is initiated, what is the target cholesterol value?

Answer 12

LDL level should be <2.0 mmol/L and total cholesterol should be <4.0 mmol/L

Question 13

2) A 25-year-old gentleman presented with vague aches and pains in his arms. Two years before, he was diagnosed with Familial Hypercholesterolemia and had received treatment.
a) What could be the cause of his symptoms?

Answer 13

Adverse drug reaction to the statins - myalgia and rhabdomyolysis

Question 14

2) A 25-year-old gentleman presented with vague aches and pains in his arms. Two years before, he was diagnosed with Familial Hypercholesterolemia and had received treatment.
b) How would the diagnosis be confirmed?

Answer 14

Take him off the statins and give him an alternative e.g. fibrates or nicotinic acid - check symptoms disappear

If not then serum transaminase and CK levels. K levels LFT and U&E’s.

Question 15

2) A 25-year-old gentleman presented with vague aches and pains in his arms. Two years before, he was diagnosed with Familial Hypercholesterolemia and had received treatment.
c) What alternative therapy could be used to treat his condition?

Answer 15

Fibrates
Nicotinic acid
Ezetimibe

Question 16

2) A 25-year-old gentleman presented with vague aches and pains in his arms. Two years before, he was diagnosed with Familial Hypercholesterolemia and had received treatment.
d) How does the mechanism of action differ in this alternative therapy to statins?

Answer 16

This prevents the absorption from the gut rather than the formation of the cholesterol

Question 17

3) A 30-year-old man was found unconscious in his home and transferred to Casualty. On examination, he was shivering, unresponsive to pain, and breathing rapidly. His skin was dry and veins poorly filled. There was a fluctuant mass in his thigh. His vital signs:

Pulse 110/min
BP 90/55
Respiratory rate 26/min
Temperature 39 C
Blood gases show a pH of 7.01, standard bicarbonate of 15 mmol/L, pCO2 2.1 kPa
Plasma glucose is 25 mmol/L
Creatinine 180 umol/L, Na+ 148 mmol/L, K+ 6.7 mmol/L

a) What treatment should be prescribed as an emergency?

Answer 17

Insulin
Calcium gluconate
Salbutamol - drives potassium into cells (also quicker to get your hands on on a ward)

Calcium resonium - in practice, however, this is rarely given because it is generally an oral tablet, but most patients who are hyperkalaemic are too poorly to take an oral tablet

Abscess - caused by Staphs and Streps, so you need to give him Flucloxacillin
Also need to drain the abscess so the pus can come out

Question 18

3) A 30-year-old man was found unconscious in his home and transferred to Casualty. On examination, he was shivering, unresponsive to pain, and breathing rapidly. His skin was dry and veins poorly filled. There was a fluctuant mass in his thigh. His vital signs:

Pulse 110/min
BP 90/55
Respiratory rate 26/min
Temperature 39 C
Blood gases show a pH of 7.01, standard bicarbonate of 15 mmol/L, pCO2 2.1 kPa
Plasma glucose is 25 mmol/L
Creatinine 180 umol/L, Na+ 148 mmol/L, K+ 6.7 mmol/L

b) How should his progress and response be monitored?

Answer 18

Regular monitoring of Obs
Sepsis Six Bundle

Hyperglycaemic:

• could be a first presentation of T1DM, where an infection unmasks it
• sepsis

Urine dipstick - looking for elevated glucose, ketones

Man is in DKA (diabetic ketoacidosis)
- treat with sliding scale of insulin

Question 19

3) A 30-year-old man was found unconscious in his home and transferred to Casualty. On examination, he was shivering, unresponsive to pain, and breathing rapidly. His skin was dry and veins poorly filled. There was a fluctuant mass in his thigh. His vital signs:

Pulse 110/min
BP 90/55
Respiratory rate 26/min
Temperature 39 C
Blood gases show a pH of 7.01, standard bicarbonate of 15 mmol/L, pCO2 2.1 kPa
Plasma glucose is 25 mmol/L
Creatinine 180 umol/L, Na+ 148 mmol/L, K+ 6.7 mmol/L

After 2 days of treatment, he was conscious and afebrile. Blood glucose was 6 mmol/L and he felt hungry. The abscess in his thigh was less tender.

c) What treatment should now be considered?

Answer 19

Prescribe insulin regime

Question 20

3) A 30-year-old man was found unconscious in his home and transferred to Casualty. On examination, he was shivering, unresponsive to pain, and breathing rapidly. His skin was dry and veins poorly filled. There was a fluctuant mass in his thigh. His vital signs:

Pulse 110/min
BP 90/55
Respiratory rate 26/min
Temperature 39 C
Blood gases show a pH of 7.01, standard bicarbonate of 15 mmol/L, pCO2 2.1 kPa
Plasma glucose is 25 mmol/L
Creatinine 180 umol/L, Na+ 148 mmol/L, K+ 6.7 mmol/L

After 2 days of treatment, he was conscious and afebrile. Blood glucose was 6 mmol/L and he felt hungry. The abscess in his thigh was less tender.

d) Who should be involved in his education?

Answer 20

Himself

Family/NOK in case it happens again (emergency)

Diabetic nurse - how to manage it day-to-day; e.g. sick day rules - if you’re poorly and can’t eat

(Endocrinologist at some point)

Question 21

3) A 30-year-old man was found unconscious in his home and transferred to Casualty. On examination, he was shivering, unresponsive to pain, and breathing rapidly. His skin was dry and veins poorly filled. There was a fluctuant mass in his thigh. His vital signs:

Pulse 110/min
BP 90/55
Respiratory rate 26/min
Temperature 39 C
Blood gases show a pH of 7.01, standard bicarbonate of 15 mmol/L, pCO2 2.1 kPa
Plasma glucose is 25 mmol/L
Creatinine 180 umol/L, Na+ 148 mmol/L, K+ 6.7 mmol/L

After 2 days of treatment, he was conscious and afebrile. Blood glucose was 6 mmol/L and he felt hungry. The abscess in his thigh was less tender.

e) What advice should he be given regarding his prescription?

Answer 21

Sick day advice

Check his feet

Alcohol

Fasting/exercise

Question 22

4.1) An Asian man attended his GP surgery complaining of recent weight loss, polyuria blurring of vision, and tingling in his feet. On examination, he was obese, his BP was 164/84 mmHg, loss of sensation in a glove and stocking distribution and fundoscopy revealed hard exudates in both eyes.

Please use the NICE guidelines (NG28) for type 2 diabetes in adults to help answer the questions below:
https://www.nice.org.uk/guidance/ng28

a) What is the likely cause of all these symptoms?

Answer 22

Type 2 diabetes mellitus

Question 23

4.1) An Asian man attended his GP surgery complaining of recent weight loss, polyuria blurring of vision, and tingling in his feet. On examination, he was obese, his BP was 164/84 mmHg, loss of sensation in a glove and stocking distribution and fundoscopy revealed hard exudates in both eyes.

Please use the NICE guidelines (NG28) for type 2 diabetes in adults to help answer the questions below:
https://www.nice.org.uk/guidance/ng28

b) How would you plan this man’s management? Answers should include non-pharmacological approaches.

Answer 23

Pharmacological:

• Metformin
• ACE inhibitor
• Statin
• Ezetimibe
• Anti-platelet (warfarin)
• Refer to podiatry and optometry

Non-pharmacological:

• Lose weight (diet and exercise)
• Exercise

Question 24

4.1) An Asian man attended his GP surgery complaining of recent weight loss, polyuria blurring of vision, and tingling in his feet. On examination, he was obese, his BP was 164/84 mmHg, loss of sensation in a glove and stocking distribution and fundoscopy revealed hard exudates in both eyes.

Please use the NICE guidelines (NG28) for type 2 diabetes in adults to help answer the questions below:
https://www.nice.org.uk/guidance/ng28

c) How would you monitor his progress?

Answer 24

• Glucose diaries
• HbA1c (long-term marker of compliance to treatment)
• GP appointments
• Regular check ups, blood tests
• Diabetic foot clinics

Question 25

4.1) An Asian man attended his GP surgery complaining of recent weight loss, polyuria blurring of vision, and tingling in his feet. On examination, he was obese, his BP was 164/84 mmHg, loss of sensation in a glove and stocking distribution and fundoscopy revealed hard exudates in both eyes. Please use the NICE guidelines (NG28) for type 2 diabetes in adults to help answer the questions below: https://www.nice.org.uk/guidance/ng28 He deteriorates further and you are unable with initial treatment to achieve fasting blood glucose under 9 mmol/L d) What further treatment would you consider?

Answer 25

- Sulfonylurea if the metformin doesn't work | - Conventional diet; if not low-calorie diet (600-800 calories)

Question 26

4.1) An Asian man attended his GP surgery complaining of recent weight loss, polyuria blurring of vision, and tingling in his feet. On examination, he was obese, his BP was 164/84 mmHg, loss of sensation in a glove and stocking distribution and fundoscopy revealed hard exudates in both eyes. Please use the NICE guidelines (NG28) for type 2 diabetes in adults to help answer the questions below: https://www.nice.org.uk/guidance/ng28 He deteriorates further and you are unable with initial treatment to achieve fasting blood glucose under 9 mmol/L e) What side effects should you warn this man about?

Answer 26

- Weight gain because it stimulates appetite | - Hypoglycaemia

Question 27

4.1) An Asian man attended his GP surgery complaining of recent weight loss, polyuria blurring of vision, and tingling in his feet. On examination, he was obese, his BP was 164/84 mmHg, loss of sensation in a glove and stocking distribution and fundoscopy revealed hard exudates in both eyes. Please use the NICE guidelines (NG28) for type 2 diabetes in adults to help answer the questions below: https://www.nice.org.uk/guidance/ng28 He deteriorates further and you are unable with initial treatment to achieve fasting blood glucose under 9 mmol/L f) What other therapies should you consider, in order to prevent future cardiovascular complications of the disease?

Answer 27

Statins

Question 28

4.2) See stem for q4 Calculating CVD risk often forms part of screening and decision making regarding the course of action in patients presenting with co morbidities and or risk factors. Using the patient data below calculate the CVD risk for this patient. Consider why changing the parameters in parentheses alters the calculated risk making associations with the underlying pathology and public health evidence. a) Male

Answer 28

An important take home message here is that CVD risk is not fixed, it is modifiable both through pharmacological and lifestyle interventions. Although there is considerable familial association with some of the contributing risk factors, many can be targeted and reduced. https: //qrisk.org/three/index.php 33. 6%

Question 29

4.2) See stem for q4 Calculating CVD risk often forms part of screening and decision making regarding the course of action in patients presenting with co morbidities and or risk factors. Using the patient data below calculate the CVD risk for this patient. Consider why changing the parameters in parentheses alters the calculated risk making associations with the underlying pathology and public health evidence. b) 69 years old (50 years old)

Answer 29

An important take home message here is that CVD risk is not fixed, it is modifiable both through pharmacological and lifestyle interventions. Although there is considerable familial association with some of the contributing risk factors, many can be targeted and reduced. 69 years old = 33.6% 50 years old = 17%

Question 30

4.2) See stem for q4 Calculating CVD risk often forms part of screening and decision making regarding the course of action in patients presenting with co morbidities and or risk factors. Using the patient data below calculate the CVD risk for this patient. Consider why changing the parameters in parentheses alters the calculated risk making associations with the underlying pathology and public health evidence. c) White

Answer 30

An important take home message here is that CVD risk is not fixed, it is modifiable both through pharmacological and lifestyle interventions. Although there is considerable familial association with some of the contributing risk factors, many can be targeted and reduced. 33.6%

Question 31

4.2) See stem for q4 Calculating CVD risk often forms part of screening and decision making regarding the course of action in patients presenting with co morbidities and or risk factors. Using the patient data below calculate the CVD risk for this patient. Consider why changing the parameters in parentheses alters the calculated risk making associations with the underlying pathology and public health evidence. d) LE1 7RH (try your family home postcode)

Answer 31

An important take home message here is that CVD risk is not fixed, it is modifiable both through pharmacological and lifestyle interventions. Although there is considerable familial association with some of the contributing risk factors, many can be targeted and reduced. LE3 7RH

Question 32

4.2) See stem for q4 Calculating CVD risk often forms part of screening and decision making regarding the course of action in patients presenting with co morbidities and or risk factors. Using the patient data below calculate the CVD risk for this patient. Consider why changing the parameters in parentheses alters the calculated risk making associations with the underlying pathology and public health evidence. e) Ex-smoker

Answer 32

An important take home message here is that CVD risk is not fixed, it is modifiable both through pharmacological and lifestyle interventions. Although there is considerable familial association with some of the contributing risk factors, many can be targeted and reduced.

Question 33

4.2) See stem for q4 Calculating CVD risk often forms part of screening and decision making regarding the course of action in patients presenting with co morbidities and or risk factors. Using the patient data below calculate the CVD risk for this patient. Consider why changing the parameters in parentheses alters the calculated risk making associations with the underlying pathology and public health evidence. f) Type 2 diabetes (non diabetic)

Answer 33

An important take home message here is that CVD risk is not fixed, it is modifiable both through pharmacological and lifestyle interventions. Although there is considerable familial association with some of the contributing risk factors, many can be targeted and reduced.

Question 34

4.2) See stem for q4 Calculating CVD risk often forms part of screening and decision making regarding the course of action in patients presenting with co morbidities and or risk factors. Using the patient data below calculate the CVD risk for this patient. Consider why changing the parameters in parentheses alters the calculated risk making associations with the underlying pathology and public health evidence. g) On blood pressure treatment

Answer 34

An important take home message here is that CVD risk is not fixed, it is modifiable both through pharmacological and lifestyle interventions. Although there is considerable familial association with some of the contributing risk factors, many can be targeted and reduced.

Question 35

4.2) See stem for q4 Calculating CVD risk often forms part of screening and decision making regarding the course of action in patients presenting with co morbidities and or risk factors. Using the patient data below calculate the CVD risk for this patient. Consider why changing the parameters in parentheses alters the calculated risk making associations with the underlying pathology and public health evidence. h) Cholesterol/HDL ratio 4.5 (3)

Answer 35

An important take home message here is that CVD risk is not fixed, it is modifiable both through pharmacological and lifestyle interventions. Although there is considerable familial association with some of the contributing risk factors, many can be targeted and reduced.

Question 36

4.2) See stem for q4 Calculating CVD risk often forms part of screening and decision making regarding the course of action in patients presenting with co morbidities and or risk factors. Using the patient data below calculate the CVD risk for this patient. Consider why changing the parameters in parentheses alters the calculated risk making associations with the underlying pathology and public health evidence. i) Systolic blood pressure 150 mmHg (140)

Answer 36

An important take home message here is that CVD risk is not fixed, it is modifiable both through pharmacological and lifestyle interventions. Although there is considerable familial association with some of the contributing risk factors, many can be targeted and reduced.

Question 37

4.2) See stem for q4 Calculating CVD risk often forms part of screening and decision making regarding the course of action in patients presenting with co morbidities and or risk factors. Using the patient data below calculate the CVD risk for this patient. Consider why changing the parameters in parentheses alters the calculated risk making associations with the underlying pathology and public health evidence. j) Height 170 cm

Answer 37

An important take home message here is that CVD risk is not fixed, it is modifiable both through pharmacological and lifestyle interventions. Although there is considerable familial association with some of the contributing risk factors, many can be targeted and reduced.

Question 38

4.2) See stem for q4 Calculating CVD risk often forms part of screening and decision making regarding the course of action in patients presenting with co morbidities and or risk factors. Using the patient data below calculate the CVD risk for this patient. Consider why changing the parameters in parentheses alters the calculated risk making associations with the underlying pathology and public health evidence. k) Weight 85 kg

Answer 38

An important take home message here is that CVD risk is not fixed, it is modifiable both through pharmacological and lifestyle interventions. Although there is considerable familial association with some of the contributing risk factors, many can be targeted and reduced.