Lipid disorders

Patient has an abnormal lipid profile or is being treated because they are considered to be at high risk of or have existing cardiovascular disease.

Cardiovascular disease includes angina, heart attack, stroke, TIA and peripheral vascular disease.

People under 16
People who are allergic to statins
People with an estimated life expectancy of less than 2 years
Statins are contraindicated in pregnancy and should be discontinued 3 months before pregnancy and restarted after breastfeeding has finished.

High cholesterol causes cardiovascular disease and accounts for a third of all heart attacks.
Lifestyle change is key to cholesterol lowering. Where this is ineffective or in people at highest risk (e.g. pre-existing CVD or familial hypercholesterolaemia (FH)), drug therapy with statins and other medications is very effective.
Every 1mmol/l reduction in low-density lipoproteins (LDL) cholesterol reduces risk of a cardiovascular event by 25% (Ref: Lancet, 2016, Interpretation of the evidence for the efficacy and safety of statin therapy, Collins et al)
People with high cholesterol who also have other risk factors (e.g. high blood pressure, diabetes, smoking) are at significantly greater risk of CVD and have most to gain from a reduction in cholesterol.
People with high triglycerides exclude secondary causes: excess alcohol intake, poorly controlled/ new diabetes, metabolic syndrome, certain medicines eg corticosteroids, estrogens, tamoxifen, psychotropic medicines, isotretinoin.

Management of lipids should be in the context of a formal risk assessment made using QRISK3 or JBS3 and medication started in the context of risk reduction according to the patient's informed opinion.
Cardiovascular risk assessment tools should not be used in people with Type 1 diabetes, CKD with eGFR <60ml/min/1.73m2, known Familial Hyperlipidaemia and existing CVD.
Lifestyle advice in the context of weight optimisation, diet, physical activity, smoking cessation are an integral part of the consultation; however for the majority, a low-fat diet will have only a minor (<10%) effect on lipid levels.
Improving diabetes control and reducing alcohol intake should be a target for management.
NICE Guidelines do not recommend the use of fibrates, omega 3 fatty acids, plant stanols or sterols in the context of cardiovascular risk reduction.

As a class, statins are the most highly studied therapy and have revolutionised the prevention and management of cardiovascular disease.
NICE Guidance recommends the use of a high-intensity statin when the decision has been made with the patient to use medication.
NICE guidance recommends the use of atorvastatin for those estimated to be at >10% ten-year risk, people with CKD, those over the age of 40 with type1 diabetes, people with type 2 diabetes over 10% risk, and those with established cardiovascular disease.
North Yorkshire and York APC recommendation:
Secondary Prevention = 80mg of atorvastatin
Primary prevention = 40mg of atorvastatin
- Use a lower dose of Atorvastatin if there is a potential drug interaction, high risk of experiencing adverse effects, or patient preference.
- Offer Atorvastatin 20mg if CKD (people with GFR< 60 mL/min/1.73m2).

It is important to discuss the risks and benefits of statin therapy and individualise the advice
Community pharmacists can offer support when new prescriptions are issued in the form of the New Medicines Service.
NICE guidance recommends follow up at 3 months after commencing a statin, with lipid profile and liver enzymes (ALT). This does not need repeating unless dose has increased, or kidney function has declined.
If the target of > 40% non-HDL lowering is not achieved:
- Discuss adherence
- Optimise diet and lifestyle measures (including alcohol intake)
- Consider increasing the dose if taking less than atorvastatin 80mg and at high risk
If statin is not tolerated, follow statin intolerance pathway and consider alternative lipid lowering medicines such as ezetimibe etc in line with the treatment pathway.

Hospital lipid clinic	Referral Criteria
Severe hypercholesterolaemia	Cholesterol >9.0 mmol/L (or non HDL-C > 7.5 mmol/L) regardless of existing heart disease / family history
Suspected familial hypercholesterolaemia (FH)	Cholesterol>7.5 mmol/L and LDL-C >4.9 mmol/L AND Premature CVD (age < 60 years old) in the patient OR Family history: 1st degree relative MI < 60 years old , 2nd degree relative MI OR Presence of tendon xanthomata
Family screening	Cascade screening from identified patient with familial hypercholesterolaemia with a genetic diagnosis of FH
Severe Hypertriglyceridemia	Triglyceride > 20 mmol/L OR Triglyceride 10 -20 mmol/L which persists on a fasting lipid profile (2 samples 1 week apart) OR Triglyceride 4.5 -9.9 mmol/L WITH non-HDL cholesterol > 7.5 mmol/L
Secondary prevention of CVD	Unable to meet target reductions in LDL-C or non HDLC despite maximal doses of statins and other lipid lowering medications.
Statin intolerance	Intolerance of 3 or more statins

Adverse events per 10,000 people taking statin for 5 years	Events avoided
Avoidance of major CVD events in patients with pre-existing CVD & a 2mmol/l reduction in LDL	1000
Avoidance of major CVD events in patients with no pre-existing CVD & a 2mmol/l reduction in LDL	500

Adverse events per 10,000 people taking statin for 5 years	Adverse events
Myopathy	5
Haemorrhagic Strokes	5-10
Diabetes Cases	50-100

Statin dose mg/day	5	10	20	40	80-
	Approximate reduction in LDL-C (%)
Fluvastatin			21	27	33
Pravastatin		20	24	29
Simvastatin		27	32	37	42
Atorvastatin		37	43	48	55
Rosuvastatin	38	43	48	53
Atorvastatin + Ezetimibe		52	54	57	61

Ezetimibe	19
Bempedoic Acid	23
Inclisiran	52
PCSKis	60