Lipid modification therapy

A summary of the NICE lipid modification guideline 2014 on A4Medicine.

CV risk assessment-  Estimate CV risk using CV risk factors already known People > 40 yrs – risk assessment on ongoing basis Formal risk assessment if CV risk > 10 % or more Routinely record 
(a) ethnicity 
(b) BMI 
(c) family hx of premature CV dis in medical records Assess readiness to change lifestyle



Risk assessment calculators

https://qrisk.org/three/

https://www.escardio.org/Education/Practice-Tools/CVD-prevention-toolbox/SCORE-Risk-Charts

http://www.cvriskcalculator.com/

Risk calculators QRisk2 etc-  Provide approximate value consider factors that may
 (a) predispose the person to premature CV dis 
 (b) not be included in calculated risk score
 Risk score will underestimate risk in people with
 HIV treatment serious mental health problems medications which can cause dyslipidaemia 
( antipsychotics , corticosteroids or immunosuppresants ) auto-immune disorders such
( SLE & other systemic inflammatory disorders )
 CV risk will be underestimated if already on anti-hypertensives and lipid modification therapy or recently stopped smoking 
 BMI > 40 ↑↑ CVS risk People > 85 consider ^ risk of CV disease



When not to use – Type 1 diabetes – consider all adults for
statin therapy If estimated GFR < 60 and or albuminuria- already 
↑↑ risk of CV disease Pre-existing CV diseases Known familial hypercholesterolaemia or other inherited disorders of lipid metabolism

Causes of dyslipidemia- Hypothyroidism Nephrotic syndrome Primary biliary cirrhosis Anorexia nervosa Diabetes mellitus Chronic kidney disease Alcoholism Pregnancy Hyothyroidism Diabetes mellitus Cig smoking Obesity

Measurement-Measure TLC , HDL cholesterol and non-HDL cholesterol (HDL minus TLC ) and triglyceride concentrations A fasting sample is not required Consider familial hypercholesterolaemia if TLC > 7.5 mmol/ L & a family hx of premature CAD

Non HDL-C Non HDL-C measures the cholesterol content of all atherogenic lipoproteins including LDL Easily calculated ( total cholesterol minus HDL-C) Can be measured from non fasting sample Currently thought to be best predictor for CAD events and strokes- has replaced LDL cholesterol as the primary target for reducing CV risk with lipid modifying treatment ( NICE 2014 )

Lipid clinic referral-If TLC > 9.0 mmol/L and or a non-HDL C conc of > 7.5 mmol/ L even in absence of a 1st degree family hx of premature CAD People with cholesterol of > 7.5 mmol/L and a family h/o premature CAD –> consider familial hypercholesterolemia If triglyceride conc of > 20 mmol/ Ltr ( exclude excess alcohol and poor glycaemic control

Triglycerides-Raised triglyceride is a risk factor for CVD and is independent of total cholesterol

Before starting treatment-Risks and benefits of treatment consider comorbidities , polypharmacy , general frailty and life expectancy
 Include the following in assessment
 smoking status alcohol consumption Blood pressure BMI TLC , non HDL C , HDLC and triglycerides HBA1c Renal function and GFR Transaminase level ( AST and ALT do not exclude statins if Transaminase levels raised but less than 3 times normal ) TSH ↑ in primary hypothyroidism

Lifestyle –Dietary reduction in total and saturated fat Replace saturated and monosaturated fats with olive oil , rapeseed oil or spreads based on these oils Choose wholegrain varieties of starchy food Reduce intake of sugar & food products containing refined sugars incl fructose 5 portions of fruit and vegetables/ day Two portions of fish/ week 
4-5 servings of unsalted nuts , seeds and legumes/ week Weight loss Aerobic exercise Addition of plant stanols / sterols Smoking cessation advice , support and referral

Consider a dietitian referral – if implementation of dietary changes likely to be difficult.Any statin at
 at any dose reduces CVD 
risk

Aim is to achieve a greater than 40 % reduction in baseline non-HDL cholesterol levels

Statin intolerance-Up to 10 % patients may be intolerant 
( particularly muscular symptoms ) Changing from one statin to another may help Alternate day dose with or without ezetimibe Consider fibrates in statin intolerant patients with mixed dyslipidemia
 Ezetemibe monotherapy is an option in treating primary heterozygous – familial and non-familial hypercholesterolaemia in adults in whom initial statin therapy is contraindicated / not tolerated ( NICE Feb 2016 )
 Seek advice for people with high risk of CVD or established CVD who are intolerant to 3 different statins


LFTs and statins

INFORMATION FOR PATIENTS

BHF Should I take statins https://www.bhf.org.uk/informationsupport/heart-matters-magazine/medical/ask-the-experts/statin-uncertainty

John Hopkins – how statins protect your heart https://www.hopkinsmedicine.org/health/wellness-and-prevention/how-statin-drugs-protect-the-heart

American Heart Association https://www.heart.org/en/health-topics/cholesterol/prevention-and-treatment-of-high-cholesterol-hyperlipidemia/cholesterol-medications

RESOURCES FOR CLINICIANS

NICE decision aid tool for statins https://www.nice.org.uk/guidance/cg181/resources/patient-decision-aid-pdf-243780159

NICE GUIDELINE – https://www.nice.org.uk/guidance/cg67

2019 ESC/EAS Guidelines for the management of dyslipidaemias: lipid modification to reduce cardiovascular risk: The Task Force for the management of dyslipidaemias of the European Society of Cardiology (ESC) and European Atherosclerosis Society (EAS) https://academic.oup.com/eurheartj/article/41/1/111/5556353

Risk assessment calculators

https://qrisk.org/three/

https://www.escardio.org/Education/Practice-Tools/CVD-prevention-toolbox/SCORE-Risk-Charts

http://www.cvriskcalculator.com/

ASCVD Risk estimator Plus http://tools.acc.org/ASCVD-Risk-Estimator-Plus/#!/calculate/estimate/

GOV UK on statins https://www.gov.uk/drug-safety-update/statins-benefits-and-risks

 

References

1. Pokhrel B, Yuet WC, Levine SN. PCSK9 Inhibitors. [Updated 2020 Mar 29]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2020 Jan-. Available from: https://www.ncbi.nlm.nih.gov/books/NBK448100/
2. Cardiovascular disease: risk assessment and reduction, including lipid modification
https://www.nice.org.uk/guidance/cg181
3. QRisk calculator https://www.qrisk.org/
4. Lipid modification therapy for Cardiovascular Diseases ; http://pathways.nice.org.uk/pathways/cardiovascular-disease-prevention/
5. Lipid-modification-therapy-for-preventing-cardiovascular-disease Primary prevention with lipid lowering drugs and long term risk of vascular events in older people : population based cohort study BMJ 2015 ; 350:h2335
6. NICE Clinical Knowledge Summaries Lipid modification – CVD prevention
7. Lipid modification : cardiovascular risk assessment and modification of blood lipids for the primary and secondary prevention of cardiovascular disease National Guideline Clearinghouse 2014
8. Primary and Secondary Prevention of Coronary Artery Disease EMedicine March 2017
9. Cardiovascular risk assessment and lipid modification ; NICE guideline Br J Gen Pract 2015 ; 65 ( 636 ): 378-380
10. Hypercholesterolaemia BMJ Best Practice
11. Ezetimibe for treating primary heterozygous-familial and non-familial hypercholesterolemia Technology appraisal guidance ( TA385) NICE Feb 2016
12. Lipid modification and cardiovascular risk assessment for the primary and secondary prevention of cardiovascular disease : summary of updated NICE guidance BMJ 2014 :349:g4356
13. PCSK9 inhibitors: an alternative to statins? from British Heart foundation https://www.bhf.org.uk/for-professionals/healthcare-professionals/news-and-analysis/analysis/pcsk9-inhibitors