Normal total cholesterol levels should be around
5mmol/L.
- Higher levels of cholesterol >6mmol/L = hyperlipidaemia.
high risk of developing cardiovascular disease
Individuals with medical conditions (diabetes, hypertension, old age, CKD, smokers, etc.) are at a high risk of developing cardiovascular disease and will benefit from using lipid-regulating drugs (primary prevention).
Hyperlipidaemia
- Patients with a 10 year risk of CVD >10% are usually treated with a lipid-regulating drug for primary prevention.
- Individuals with CVD including angina, MI and stroke should be treated with a lipid-regulating drug for secondary prevention.
Statins vs fibrates
Statins are superior at reducing LDL-cholesterol whereas fibrates are better at reducing triglyceride levels.
Statins
- Atorvastatin is the best to start with
Statins are the first-line treatment option for primary (low intensity) and secondary prevention (high).
Atorvastatin + Rosuvastatin can be taken at any time of the day.
Simvastatin is taken at NIGHT (Cholesterol levels are highest at night). It interacts with bezafibrate (maximum dose is 10 mg), amiodarone, verapamil, diltiazem and amlodipine (maximum dose is 20 mg). It also interacts with clarithromycin, carbamazepine and grapefruit juice.
Before initiating statin treatment measure:
Before initiating treatment, a full lipid profile must be obtained plus HbA1C, TSH, eGFR + LFTs. Treating previously uncontrolled diabetes, liver disease and thyroid problems can control cholesterol without the need for statins.
Mode of action: Statins
Statins inhibit HMG Co A reductase (enzyme involved in cholesterol synthesis)
Avoid statins in
- Avoid in Pregnancy as congenital abnormalities have been observed.
- Statins are linked with muscle pain… higher risk with higher doses and patients with a history of muscle pain, alcoholism, renal impairment, hypothyroidism and advance age. Monitor creatinine kinase.
- Statins are linked with altered liver function: leading to hepatitis, jaundice + liver failure
- If patients develop: SOB, cough + weight loss seek medical attention (interstitial lung disease)
Atorvastatin and simvastatin interactions
- Atorvastatin interacts with clarithromycin, verapamil and fibrates (increasing plasma concentration).
- Simvastatin interacts with bezafibrate (maximum dose is 10 mg), amiodarone, verapamil, diltiazem and amlodipine (maximum dose is 20 mg). It also interacts with clarithromycin, carbamazepine and grapefruit juice.
Ezetimbe
- inhibits intestinal absorption of cholesterol
- can be used alone or with a statin (although risk of muscle effects is increased with statin) if statin is failing/unsuitable)
Statins & enzyme inhibitors
- Increased risk of myopathy
- Examples: Amiodarone, grapefruit juice, macrolides (eg clarithromycin)
- If a patient is prescribed a macrolide they should stop the statin for the duration of antibiotic and then can restart
Statins and ezitimbe and fibrates
- Increased risk of myopathy if a statin is given with ezitimibe or fibrates, expecially gemfibrozil. Therefore AVOID concomitant use of gemfibrozil
Statins and oral fucidic acid
- increased risk of myopathy therefore stop the statin during oral fusidic acid treatment and do not restart for 7 days after the course is complete
Dose adjustments due to statin interaction
Simvastatin:
- MAX 10mg with fibrate
- MAX 20mg with amiodarone, amlodipine, diltiazem, verapamil, ranolozine
- MAX 40mg with ticrelor, lometipide
Atorvastatin:
- MAX 10mg with ciclosporin (interacts with all statins, C/I with rosuvastatin)
Rosuvastatin:
- Initially 5mg, Max 20mg with clopidogrel
Statins and pregnanacy
Teratogenic therefore MUST use effective contraception and during and for 1 month after treatment.
Stop statin 3 months before conceiving and restart after breastfeeding is complete.
Fibrates
- Usually specialist use
- Usually used as an alternative to statins or when triglyceride very high >10mmol/L
- Increased risk of myopathy when taken with statin and also in RI patients
- Gemfibrozil must be AVOIDED with statins
Bile acid sequestrants
(col)
- Colesevelam
- Colestipol
- Cholestryamine
Side effects of statins:
- Myopathy, myositis, rhabdomyolysis
- Interstitial lung disease
- Hyperglycaemia: caution in diabetic patients or those at risk of diabetes
