Management of Hyperlipidaemia

See the management of hyperlipidaemia flowchart for primary and secondary prevention of atherosclerotic vascular disease below.

For detailed guidance related to agents initiated by the Lipid Clinic, please refer to the main guideline on AthenA.

• Flowchart Hyperlipidaemia Management Flowchart

Notes 

• Check the BNF and manufacturer's summary of product characteristics (SPC) of specific statins for cautions, contraindications, clinically important drug interactions (e.g. clarithromycin), renal and hepatic impairment.
• Risk assessment tools for primary prevention: QRISK3 and ASSIGN. N.B. Risk calculators may under-estimate lifetime risk in younger patients. Adjustment may be particularly appropriate in those aged <50yrs, if 10-year risk >10%.
• Encourage smoking cessation (consider nicotine replacement therapy - see Appendix 1).
• Dietary and other lifestyle advice e.g. alcohol, obesity, physical activity, should be given.

Statin Intolerance

• It is important to emphasise to patients that the evidence for the use of statins is much stronger than for other agents for both primary and secondary prevention of cardiovascular disease.
• Patients who report statin intolerance may be re-challenged, initially with the same dose/same statin, unless there is significant CK elevation.
• If reported intolerance persists then an alternative statin should be offered.
• Ensure that there is a genuine statin intolerance before considering an alternative lipid-lowering drug. This should include trying different statin preparations and / or lower than usual doses.

For example:  

Atorvastatin oral 80mg daily -> Atorvastatin oral 10-40mg daily -> Rosuvastatin oral 10mg daily -> Rosuvastatin oral 5mg daily (can be alternate days)

If the patient is intolerant to statins or targets are not met then refer to Lipid Clinic.

Primary Prevention (those without established atherosclerotic disease): Ensure patient is truly intolerant of statin before any change in therapy (see above). Reinforce dietary and lifestyle measures. If familial hypercholesterolaemia is suspected then the patient should be referred to the Lipid Clinic for specialist advice.

Ezetimibe can be considered for primary prevention in patients at elevated CVD risk in whom statin therapy is contraindicated.

Secondary Prevention (those with established atherosclerotic disease): Ensure patient is truly intolerant of statin before any change in therapy (see above). Reinforce dietary and lifestyle measures. Consider alternative agents (e.g. ezetimibe) in addition to a statin, if necessary, but there is much less evidence for efficacy, and they are usually more expensive. The use of ezetimibe as monotherapy in secondary prevention is off-label use.

It may be appropriate to seek a specialist opinion via the Lipid Clinic if the patient is intolerant of two classes of lipid-lowering drugs for secondary prevention.

Failure to Reach Cholesterol Targets

Primary Prevention

• There is no primary prevention cholesterol target.
• Annual review should consider all risk factors, lifestyle interventions, tolerance of medications etc.  
• It is advisable to check lipids when checking LFTs at 3 months and if, after ensuring compliance with the statin, patients are not achieving expected LDL-C reductions, a higher dose or different statin can be considered.

Secondary Prevention

• If patients fail to achieve an LDL cholesterol of 1.8mmol/L or at least 40% reduction from baseline using atorvastatin 80mg, it may be appropriate to add in ezetimibe oral 10mg daily. Thereafter, if patient fails to reach target refer to Lipid Clinic.

Hypertriglyceridaemia

• Triglycerides can be measured on a random sample as part of a full lipid profile. Elevated triglyceride levels on a random sample may be due to the presence of dietary triglycerides. A raised triglyceride level should therefore be repeated on a fasting sample to confirm.
• Raised triglycerides are most commonly due to secondary causes e.g. obesity, diabetes, alcohol excess, medicines. These should be identified and managed.
• A Lipid Clinic referral should be arranged for any patient with a suspected familial dyslipidaemia.
• Moderately raised fasting triglycerides (e.g. 5 to 10 mmol/L):
  • Slight increase in cardiovascular risk due to the raised triglycerides alone.
  • Address secondary causes, especially blood glucose management, and consider statin treatment at lower risk threshold (e.g. 15%).
• Markedly raised triglycerides (e.g. >10 mmol/L):
  • Address secondary causes and consider referral to lipid clinic if triglycerides persistently >10 mmol (urgent referral if >20 mmol/L unless due to alcohol excess or poor glycaemic control).

• For medical advice from the Lipid Clinic, please email: Clinical_Specialty_Biochemistry_MedicalStaff@aapct.scot.nhs.uk