QuestionSBA
QuestionChoice
Statins are unlikely to confer much prognostic benefit at his age. Primary prevention dose statins are prescribed usually on the basis of QRISK score >10% (risk of a cardiac event within next 10 years). The QRISK tool cannot be used for people >84 years old, but NICE suggests using holistic clinical judgement as to whether to prescribe in this case, taking into account comorbidities, polypharmacy, general frailty, and life expectancy.
61998
a
Atorvastatin 20mg OD
QuestionChoice
This is for BPH and therefore likely to be offering symptomatic benefit
62002
e
Finasteride 5mg OD
QuestionChoice
This patient may still have an active sex life despite his age and therefore may be important to continue. Also, as this is a PRN medication, if he is not taking it, stopping it would not significantly reduce polypharmacy.
61999
b
Sildenafil 50mg PRN
QuestionChoice
This is for pain likely related to his arthritis, and is therefore likely to be of symptomatic benefit
62001
d
Paracetamol 1g QDS
QuestionChoice
This is for hypertension and should be continued in this case
62000
c
Amlodipine 5mg OD
Concept
Chapter
# Definition

Hypercholesterolaemia is the term used to denote raised serum levels of one or more of total cholesterol.

# Causes

Causes can primary or secondary.

Secondary causes include:

- Familial dyslipidaemias
- Familial hypercholesterolaemia
- Apoprotein disorders
- Medical conditions
	- Hypothyroidism
	- Obstructive jaundice
	- Cushings syndrome
	- Nephrotic syndrome
	- Chronic Kidney Disease
- Drugs e.g. thiazide diuretics, glucocorticoids, ciclosporin
- Pregnancy
- Obesity 
- Alcohol abuse


# Physicial signs

Diagnosis is usually biochemical. 

There are two key physical signs which may indicate familial hypercholesterolaemia

 - Premature arcus senilis
 - Tendon xanthomata

# Investigations

- Lipid profile 
- Fasting blood glucose
- Renal function
- Liver function tests
- Thyroid function tests

# Management


## Statins

- Statins are the first line treatment of high cholesterol. 
- They are HMG-CoA reductase inhibitors. 
- This enzyme plays a key role in the production of cholesterol, so inhibiting it reduces the cholesterol in the body.
- In patients with high cholesterol, the QRISK score is used to see if they would benefit from statins as primary prevention against cardiovascular disease. 
- If an adult is under 80 years old and their QRISK is greater than 10% then a statin should be offered. 
- For primary prevention of CVD aim for a greater than 40% reduction in non-HDL cholesterol
- For secondary prevention of CVD, aim for low-density lipoprotein (LDL) cholesterol levels of 2.0 mmol per litre or less, or non-HDL cholesterol levels of 2.6 mmol per litre or less.

## Doses

- Atorvastatin 20mg is the usual starting dose for primary prevention.
- For patients who need a statin as secondary prevention, e.g following a stroke, heart attack, peripheral arterial disease or angina, atorvastatin at 80mg starting dose should be used.

## Side effects of statins


Common side effects of statins include muscle pain, abdominal pain, constipation and headache.

If a patient is struggling with significant myalgia, this may indeed indicate a myositis. Creatinine Kinase can be measured and  if it is 5-10 times the upper limit of normal, the statin should be stopped. 

Statins can also cause abnormal liver function so this should be monitored with a repeat blood test in 4-6 weeks time. If the transaminases (ALT, AST) are 3 times the upper limit the statin should be stopped.

Offer ezetimibe instead of a statin to people for whom statins are contraindicated/cause abnormal blood test results.

# NICE Guidelines

[NICE Guidelines - Cardiovascular disease: risk assessment and reduction, including lipid modification ](https://www.nice.org.uk/guidance/ng238/chapter/Recommendations)
1799
1994
Hypercholesterolaemia
Topic
60
General Practice
12461
A 92 year old male is undergoing a medication review at the GP surgery. He is frail, has a past medical history of hypertension, chronic kidney disease 3, osteoarthritis, osteoporosis, erectile dysfuction, and benign prostatic hyperplasia. His conditions and symptoms are well controlled.

Which of the following medications would be reasonable to discontinue due to lack of clinical benefit?
a