Statins

Question 1

What is the mechanism of action of statins?

Answer 1

Inhibit the action of HMG-CoA reductase, the rate limiting enzyme in hepatic cholesterol synthesis

Question 2

What are 3 key adverse effects of statins?

Answer 2

1. Myopathy: myalgia, myositis, rhabdomyolysis and asymptomatic raised creatine kinase
2. Liver impairment
3. May increase risk of intracerebral haemorrhage in those who’ve previously had a stroke

Question 3

What are 5 risk factors for myopathy (myalgias, rhabdomyolysis) when taking statins?

Answer 3

1. Advanced age
2. Female sex
3. Low BMI
4. Presence of multisystem disease e.g. diabetes mellitus
5. More common in lipophilic statins (simvastatins, atorvastatin) than relatively hydrophilic (rosuvastatin, pravastatin, fluvastatin)

Question 4

What monitoring is recommended when prescribing statins?

Answer 4

• LFTs: baseline, 3 months and 12 months

Question 5

When should treatment with statins be discontinued based on monitoring blood tests?

Answer 5

If serum transaminase (LFTs essentially) concentrations rise to and persist at 3 times the upper limit of the reference range

Question 6

What are 3 contraindications to statins?

Answer 6

1. Avoid in patients with history of intracerebral haemorrhage - risk of recurrence
2. Macrolides (e.g. erythromycin, clarithromycin) - important interaction, stop statins until course completed
3. Pregnancy

Question 7

What are 4 groups of people who should receive a statin?

Answer 7

1. All people with established cardiovascular disease: stroke, TIA, ischaemic heart disease, peripheral arterial disease
2. Anyone with 10 year cardiovascular risk >10% (QRISK)
3. Assess pts with T2DM with QRISK2 to determine whether to start
4. T1DM diagnosed > 10 years ago OR aged >40y OR have established nephropathy

Question 8

When should statins be taken and why?

Answer 8

At night - when the majority of cholesterol synthesis takes place

especially true for simvastatin - shorter half life than others

Question 9

What statin type and dose is recommended for primary and secondary prevention of cardiovascular disease?

Answer 9

1. Atorvastatin 20mg od for primary prevention
   
   • Increase dose if non-HDL has not fallen by >40% up to 80mg

• Atorvastatin 80mg od for secondary prevention

Question 10

What 2 categories can treatment with statins be divided into?

Answer 10

1. Primary prevention of CVD
2. Secondary prevention

Question 11

What are 3 scenarios when statins are used for primary prevention of CVD?

Answer 11

1. 10-year cardiovascular risk >10%
2. most type 1 diabetics
3. CKD if eGFR <60

Question 12

What are 3 examples of when statins can be used for secondary prevention of CVD?

Answer 12

1. Known ischaemic heart disease
2. Cerebrovascular disease
3. Peripheral arterial disease

Question 13

At what age should you start to assess for QRISK and therefore treatment with statins?

Answer 13

40 years

Question 14

What is the maximum age at which to use QRISK2 for CVD risk assessment and why?

Answer 14

84; >85 years are at high risk due to age

Question 15

What are 3 patient groups in whom the QRISK2 assessment tool should not be used and why?

Answer 15

1. type 1 diabetics
2. patients with an estimated glomerular filtration rate (eGFR) less than 60ml/min and/or albuminuria
3. patients with a history of familial hyperlipidaemia

Question 16

What are 4 patient groups in whom the QRISK2 assessment may underestimate CVD risk?

Answer 16

1. people treated for HIV
2. people with serious mental health problems
3. people taking medicines that can cause dyslipidaemia such as antipsychotics, corticosteroids or immunosuppressant drugs
4. people with autoimmune disorders/ systemic inflammatory disorders such as SLE

Question 17

What blood test should be checked before starting a statin and why?

Answer 17

NON-fasting full lipid profile, including triglycerides

Looking at total cholesterol : high-density lipoprotein ratio

Question 18

When should familial hyperlipidaemia be suspected and what should be done?

Answer 18

total cholesterol concentration >7.5mmol/l and there is family history of premature coronary heart disease

total cholesterol >9.0 mmol/l or non-HDL cholesterol of >7.5 mmol/l even in absence of first degree family history of premature coronary heart disease

if this is the case - refer

Question 19

Should you start a statin straight away if QRISK2 >10%?

Answer 19

Recommend we give patients option of having CVD risk reassessed after period of time before starting a statin

Question 20

What are 4 groups of type 1 diabetics who should be offered a statin?

Answer 20

1. >40 years old
2. Have had diabetes for more than 10y
3. have established nephropathy
4. have other CVD risk factors

Question 21

How are statins used in chronic kidney disease?

Answer 21

• Atorvastatin 20mg offered; increase dose if greater than 40% reduction in non-HDL cholesterol not achieved and eGFR >30ml/min.
• If eGFR <30ml/min renal specialist should be consulted before increasing dose

Question 22

What follow-up should be performed when people started on statins?

Answer 22

• at 3 months, repeat full lipid profile
• if non-HDL cholesterol has not fallen by at least 40%, concordance and lifestyle changes should be discussed with patient
• consider increasing to 80mg

Question 23

What are 10 elements of a cardioprotective diet - a form of lifestyle modification for hyperlipidaemia?

Answer 23

1. total fat intake should be <30% of total energy intake
2. saturated fats should be <7% of total energy intake
3. intake of dietary cholesterol should be <300mg/day
4. saturated fats should be replaced by monounsaturated and polyunsaturated fats where possible
5. replace saturated and monounsaturated fat intake with olive oil, rapeseed oil or spreads based on these oils
6. choose wholegrain varieties of starchy food
7. reduce their intake of sugar and food products containing refined sugars including fructose
8. eat at least 5 portions of fruit and veg a day
9. 2 portions of fish per week, including portion of oily fish
10. eat at least 4-5 portions of unsalted nus, seeds and legumes / week

Question 24

What are the recommendations for physical activity to advise patients with hyperlipidaemia? 2 points

Answer 24

1. aim for at least 150 min moderate intensity aerobic activity or 75 minutes of vigorous intensity aerobic activity or mix of moderate and vigorous
2. muscle strenghtening activities on 2 or more days a week that work all major muscle groups (legs, hips, back, abdomen, chest, shoulders and arms) in line with national guidance for genearl population

Question 25

What are 3 elements of the alcohol guidelines?

Answer 25

1. No more than 14 units a week for men and women 2. Spread evenly over 3 or more days 3. Good to have several alcohol free days

Question 26

Overall what are 4 lifestyle points to advise patients on with hyperlipidaemia?

Answer 26

1. Exercise 2. Cardioprotective diet 3. Alcohol 4. Stop smoking