page181
FRESH FROZEN PLASMA
Fresh frozen plasma is prepared from the supernatant
liquid obtained by centrifugation of one donation of
whole blood
Indications
to replace coagulation factors or other
plasma proteins where their concentration or func-
tional activity is critically reduced
Cautions
need for compatibility
Contra-indications
circulatory overload; avoid use as
a volume expander
Side-effects
allergic reactions including chills,
fever,
bronchospasm; adult respiratory distress syndrome
Available from Regional Blood Transfusion Services
Note
A preparation
of
solvent/detergent
treated
human
plasma (frozen) from pooled donors is available from Octa-
pharma (
Octaplas
c
)
PROTEIN C CONCENTRATE
Protein C is prepared from human plasma
Indications
congenital protein C deficiency
Cautions
hypersensitivity to heparins
Side-effects
very rarely
fever, bleeding, dizziness, and
hypersensitivity reactions
Available from Baxter (
Ceprotin
c
)
2.12
Lipid-regulating drugs
Preventative measures should be taken in individuals
with a high risk of
developing cardiovascular disease
(primary prevention)
and to prevent
recurrence
of
events in those with established cardiovascular disease
(secondary prevention).
Individuals at high risk include those who already have
atherosclerotic disease,
those with diabetes
mellitus
aged over
40 years,
and those with familial
hyper-
cholesterolaemia.
The risk also increases
with age;
those over 75 years are at particularly high risk,
espe-
cially if they smoke or have hypertension.
Preventative measures are also required for other indi-
viduals who may be at high risk of developing athero-
sclerotic cardiovascular disease;
those with a 10-year
risk of cardiovascular disease
1
of 20% or more stand to
benefit most from drug treatment.
The risk is assessed
on the basis of
lipid concentration as well
as smoking
status,
blood pressure,
gender,
and age;
other risk fac-
tors,
such as premature menopause,
ethnicity,
obesity,
triglyceride
concentration,
chronic
kidney
disease,
impaired glucose tolerance,
and a family history of
premature
cardiovascular
disease,
should
also
be
taken into account
when assessing risk in individual
patients.
Patients with hypothyroidism should receive adequate
thyroid
replacement
therapy
before
assessing
the
requirement for lipid-regulating treatment because cor-
recting hypothyroidism itself
may resolve
the
lipid
abnormality.
Untreated hypothyroidism increases the
risk of myositis with lipid-regulating drugs.
Lowering the concentration of
low-density lipoprotein
(LDL)
cholesterol
and raising high-density lipoprotein
(HDL)
cholesterol
slows
the progression of
athero-
sclerosis and may even induce regression.
All
patients
at high risk of cardiovascular disease should be advised
to make lifestyle modifications that
include beneficial
changes to diet,
exercise,
weight management,
alcohol
consumption,
and smoking cessation.
Lipid-regulating
drug treatment must be combined with advice on diet
and lifestyle measures,
lowering of
raised blood pres-
sure (section 2.5),
the use of
low-dose aspirin (section
2.9),
and management of diabetes (section 6.1).
A statin (see p.
162) reduces the risk of cardiovascular
disease events,
irrespective of
serum cholesterol
con-
centration,
and is the drug of
first
choice for primary
and secondary prevention of cardiovascular disease.
If
statins are contra-indicated or not
tolerated,
a fibrate
(p.
166)
or
a bile acid sequestrant
(p.
164)
may be
considered for
primary
or
secondary
prevention;
nico-
tinic acid (p.
168)
is
also an option for
secondary
prevention. Fibrates, bile acid sequestrants, or nicotinic
acid should not be used in combination with a statin for
primary
prevention of
cardiovascular disease.
In sec-
ondary prevention of
cardiovascular events,
if
a total
cholesterol concentration of less than 4 mmol/litre
or
a
LDL-cholesterol concentration of less than 2 mmol/litre
is not achieved with initial treatment,
consider treating
patients with a ‘high-intensity’ statin (e.g. simvastatin or
atorvastatin)—a ‘high-intensity’
statin is one that
pro-
duces a greater LDL-cholesterol
reduction than simva-
statin 40 mg;
see also risk of
Muscle Effects,
p.
162.
Patients with an acute coronary syndrome should also
receive treatment
with a ‘high-intensity’
statin where
appropriate.
A statin is also the drug of
first
choice for
treating
hypercholesterolaemia and moderate hypertriglyceri-
daemia.
Severe hyperlipidaemia not
adequately con-
trolled with a maximal
dose of
a statin may require
the use of
an additional
lipid-regulating drug such as
ezetimibe or
colestyramine;
such treatment
should
generally be supervised by a specialist.
A number of conditions, some familial, are characterised
by very high LDL-cholesterol concentration, high trigly-
ceride
concentration,
or
both.
Fenofibrate may be
added to statin therapy if
triglycerides
remain high
even after the LDL-cholesterol
concentration has been
reduced adequately; nicotinic acid may also be used to
further lower triglyceride or LDL-cholesterol concentra-
tion.
Combination of a statin with a fibrate or with nicotinic
acid carries an increased risk of side-effects (including
rhabdomyolysis—see Muscle Effects below) and should
be used under specialist supervision; monitoring of liver
function and creatine kinase should also be considered.
The concomitant
administration of
gemfibrozil
with a
statin increases the risk of
rhabdomyolysis consider-
ably—this combination should not be used.
A statin is recommended for all
patients with familial
hypercholesterolaemia.
A ‘high-intensity’
statin (e.g.
rosuvastatin (initiated by a specialist),
simvastatin,
or
atorvastatin) should be considered in order to achieve
the recommended reduction in LDL-cholesterol
con-
centration of
greater than 50% from baseline;
a ‘high-
intensity’
statin is one that
produces a greater
LDL-
cholesterol reduction than simvastatin 40 mg—see also
1.
Cardiovascular disease risk may be determined from the
chart issued by the Joint British Societies (
Heart
2005;
91
(Suppl
V):
v1–v52)—see inside
back cover.
The Joint
British Societies’
‘Cardiac Risk Assessor’
computer
pro-
gramme may also be used to determine cardiovascular
disease risk.
BNF 61
2.12 Lipid-regulating drugs
161
2
Cardiovascular system