Hyperlipidaemia Flashcards by Rowene Ng

What is considered very high risk which requires secondary prevention?

ASCVD

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What is considered very high/high risk which requires primary prevention?

Familial hypercholesterolaemia (FH), DM, CKD

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What should you do if there are no very high or high risk factors?

Calculate 10 year risk score using SG-FRS

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Using the SG-FRS, what risk score is considered:
- high risk
- intermediate risk
- borderline risk
- low risk

high risk: > 20%
intermediate risk: 10-20%
borderline risk: 5-<10%
low risk: <5%

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If no comorbidities and LDL-C < 4.9, what is the target LDL-C for patients of:
- high risk
- intermediate risk
- borderline risk
- low risk

high risk < 1.8 mmol/L
intermediate risk < 2.6 mmol/L
borderline risk: < 3.4 mmol/L
low risk: < 3.4 mmol/L

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If no comorbidities and LDL-C < 4.9, what is the preferred treatment for patients of:
- high risk
- intermediate risk
- borderline risk
- low risk

high risk: maximally-tolerated statin +- ezetimibe
intermediate risk: moderate-intensity statin esp if risk enhancers present
borderline risk: risk-benefit discussion for a statin if risk enhancers present
low risk: lifestyle intervention, risk-benefit discussion if LDL-C persistently > 4.1

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If ASCVD & LDL-C > 4.9, what is the target LDL-C? (different conditions)

with ACS (MI, unstable angina): < 1.4 mmol/L
without ACS: < 1.8 mmol/L

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If ASCVD & LDL-C > 4.9, what is the preferred treatment?

maximally-tolerated statin +- ezetimibe
PCSK9 inhibitor if LDL-C ≥ 1.8 despite first option, esp post-ACE, recurrent ASCVD, polyvascular disease or FH

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If FH & LDL-C > 4.9, what is the target LDL-C? (different conditions)

if >40y or additional CV risk factor (DM, HTN, smoking etc): < 1.8 mmol/L
if ≤40y & no additional CV risk factor: < 2.6 mmol/L

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If DM & LDL-C > 4.9, what is the preferred treatment? (different conditions)

additional DM-specific risk factors (CKD, multiple microvascular complications, DM > 10y, glycemic level persistently above target despite optimal tx): maximally-tolerated statin +- ezetimibe
no additional DM-specific risk factors: at least moderate-intensity statin

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If CKD & LDL-C > 4.9, what is the preferred treatment?

moderate-intensity statin +- ezetimibe in non-dialysis dependent pts

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If FH & LDL-C > 4.9, what is the preferred treatment?

maximally-tolerated statin +- ezetimibe
PCSK9 inhibitor if LDL-C ≥ 2.6 despite first option

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If DM & LDL-C > 4.9, what is the target LDL-C level? (diff conditions)

additional DM-specific risk factors (CKD, multiple microvascular complications, DM > 10y, glycemic level persistently above target despite optimal tx): < 1.8 mmol/L
no additional DM-specific risk factors: < 2.6 mmol/L

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If CKD & LDL-C > 4.9, what is the target LDL-C?

eGFR < 60 +/ ACR ≥3: < 2.6 mmol/L

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If LDL-C > 4.9 but not FH (no other comorbidities), what is the target LDL-C?

Calculate 10y SG-FRS to determine target

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If LDL-C > 4.9 but not FH (no other comorbidities), what is the preferred treatment?

at least moderate-intensity statin

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How much do the following statins reduce LDL-C by:
- high-intensity statin
- moderate-intensity statin

and give examples

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high intensity: ≥50% reduction (atorvastatin 40-80mg, rosuvastatin 20-40mg)
moderate intensity: 30-49% (atorvastatin 10-20mg, lovastatin 40-80mg, rosuvastatin 5-10mg, simvastatin 20-40mg)

MOA of statins?

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Inhibit HMG-CoA reductase -> inhibit cholesterol synthesis in liver -> liver takes up more LDL to be destroyed (up regulation of LDL receptor) -> reduce LDL in bloodstream

Should statins be used in pregnancy?

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No (generally avoided)

Lifestyle modifications for lipid management?

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healthy diet (avoid trans fat, replace saturated fat with polyunsaturated fat, reduce calories/refined sugar)
physical activity
healthy weight
smoking cessation
limit alcohol intake (abstain if TG ≥ 4.5 or history of pancreatitis)

Rank the potency of statins from weakest to strongest

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lovastatin < simvastatin < atorvastatin < rosuvastatin

PCSK9 inhibitors MOA and examples?

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MOA: inhibit PCSK9 (which breaks down LDL receptors) -> more cellular uptake of LDL from plasma

Examples: evolocumab, alirocumab

Rank the potency of lipid therapies from lowest to highest LDL lowering

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ezetimibe < statin < PCSK9 inhibitor

What is considered ASCVD? (8)

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history of ACS (MI, unstable angina)
stable IHD
ischaemic stroke
TIA (transient ischaemic attack)
PAD (peripheral artery disease)
AAA (abdominal aortic aneurysm)
post-CABG (coronary artery bypass graft)
post-PCI (percutaneous coronary intervention)

Why need to adjust statin dose for advanced CKD and at what eGFR cut-off?

Minimise risk of myopathy eGFR <30

At what TG level should fibrates be added and what risk does it lower?

TG ≥ 4.5 mmol/L Lower risk of pancreatitis

If patient is on a statin, should fenofibrate or gemfibrozil be added and why? What should patient be monitored for?

Fenofibrate, lower risk of DDI resulting in severe myopathy Monitor liver function due to risk of hepatotoxicity

SE of statin?

- statin-associated muscle sx (SAMS) - liver transaminase elevation (>3x ULN) - new onset DM

CK levels of SAMS?

- myalgias: normal CK (<10x ULN) - myopathy/myositis: CK >10x ULN - rhabdomyolysis: CK >40x ULN

If patient has intolerable symptoms (CK ≤3x ULN) or CK >3-≤10x ULN, what are the different options to restart statins?

- reduced dose - different statin - alternate-day dosing of atorvastatin or rosuvastatin

Dose of ezetimibe? (only one)

10mg daily

SE of ezetimibe?

- URTI - joint pain, limb pain - diarrhoea

Which fibrate is the only one that has been used together with ezetimibe?

Fenofibrate

What CrCl/eGFR is fibrates contraindicated?

CrCl <30 (fenofibrate & gemfibrozil)

SE of fibrates?

N/V/D, flatulence fenofibrate: liver transaminases increase gemfibrozil: skin reactions, constipation

Frequency and SE of PCSK9 inhibitors?

Frequency: Q2w or Q1m (diff dose) SE: injection site reaction, URTI, pruritus, arthralgia, back pain

Major DDI with statins?

- CYP3A4 inhibitors (atorvastatin, simvastatin): macrolides, azoles, grapefruit & its juice - CYP2C9 (rosuvastatin) - increase SAMS: colchicine (monitor), fenofibrate (monitor), gemfibrozil (avoid)

When to monitor lipids and ALT?

8-12w after starting or dose adjustment

Statin contraindications?

- pregnancy & lactation - active liver disease - persistently elevated liver transaminases

Which lipid-lowering meds do not require renal dose adjustment?

Simvastatin, atorvastatin, ezetimibe

Administration of gemfibrozil?

Gemfibrozil: take 30min before meals

Hyperlipidaemia Flashcards

(41 cards)