L30 Therapeutics of hyperlipidemia

Choose the incorrect statement.

Lifestyle modifications are recommended for everyone to reduce CV risk​: healthy diet, regular exercise, weight management, and smoking cessation​.

The current advice is for adults to do 90 minutes of moderate-intensity exercise at least 5 times a week​.

Primary prevention is for patients with no evidence of CHD or major atherosclerotic disease​, whereas secondary prevention is for patients who have already had a cardiac event.

Which of these is NOT a lipid lowering medicine?Five main classes of lipid lowering drugs available​

Statins are first line. They are HMG-CoA reductase inhibitors, meaning [blank_start]HMG-CoA reductase[blank_end] cannot reduce [blank_start]HMG-CoA[blank_end] to [blank_start]mevalonic[blank_end] acid, which is the precursor to cholesterol. They are very effective in lowering [blank_start]LDL[blank_end] and proven to decrease [blank_start]risk[blank_end] of CHD, stroke and death​.

Doubling the dose of a statin achieves a 20% additional average reduction​.

Cholesterol synthesis peaks overnight so [blank_start]short[blank_end] half life statins (e.g. [blank_start]simvastatin[blank_end]) are recommended to be taken at [blank_start]night[blank_end]​. Statins with a [blank_start]long[blank_end] half-life (e.g. [blank_start]atorvastatin[blank_end]) can be taken either in the morning or at night and have the same efficacy​,

Statins are well tolerated​ but ADRs may include elevated liver enzymes, myopathy and rhabdomyolysis​. - Increased liver [blank_start]enzymes[blank_end] reported in less than 2% of patients – obtain levels at baseline​ - Myopathy is muscle symptoms ([blank_start]pain[blank_end]) with a [blank_start]creatine[blank_end] kinase level x10 than normal​ - Rhabdomyolysis (rare) is muscle [blank_start]necrosis[blank_end] and the release of intracellular muscle constituents in the blood stream, presenting with muscle pain, elevated creatine kinase, brown [blank_start]urine[blank_end] and myoglobinuria​.

Statins can be used in pregnancy and when breastfeeding.

Fibrates decrease [blank_start]triglyceride[blank_end] levels (20%-50%) and increase [blank_start]HDL[blank_end] levels by (9%-30%)​. They work by reducing apoproteins [blank_start]B, C-111 and E[blank_end] and increasing apoproteins [blank_start]A-1 and A-11[blank_end]. Common side effects are dyspepsia, [blank_start]abdominal[blank_end] pain, diarrhoea, flatulence, rash, muscle pain and [blank_start]fatigue[blank_end]​. Myopathy and rhabdomyolysis can occur – the risk increases with [blank_start]renal[blank_end] insufficiency and concurrent use of statins. They [blank_start]cannot[blank_end] be given in pregnant or breastfeeding women.

Bile acid binding agents​ available in NZ are cholestyramine and colestipol. These are bile acid binding resins/sequestrants ​which [blank_start]bind[blank_end] to bile acids (produced from [blank_start]cholesterol[blank_end]) in the gut​. The resin-bile acid complex is then [blank_start]excreted[blank_end] in the faeces​. The loss of bile causes a ’[blank_start]compensatory[blank_end]’ response – conversion of hepatic cholesterol to bile (leading to reduction in hepatocellular stores)​. This drug is not absorbed so side effects are limited to the [blank_start]GI[blank_end] tract​. 20% of patients report constipation, bloating and flatulence, causing some to stop therapy​. You can increase [blank_start]fluid[blank_end] intake to minimize constipation​. Time until peak effect of these drugs is generally 2-4 [blank_start]weeks[blank_end]​. Patients taking other medications should be advised of the potential for [blank_start]decreased[blank_end] absorption of other medicines – space out dose​. Not suitable for pregnant and breastfeeding women.

Cholesterol absorption inhibitors: Ezetimibe Interacts with a cholesterol [blank_start]transporter[blank_end] in the intestinal [blank_start]membrane[blank_end], and stops cholesterol [blank_start]reabsorption[blank_end] from the GI tract.​ Ezetimibe should be prescribed either with a statin, fibrate or nicotinic acid derivative – [blank_start]rarely[blank_end] by itself​. It has a synergistic effect in lowering LDL levels when used with statin​. AVOID IN PREGNANCY AND BREASTFEEDING​