Download Title Salford Guidelines for Lipid Control in

Title
Salford Guidelines for Lipid Control in Patients with Established
Cardiovascular Disease and Diabetes
Issue Status:
Issue Date: September 2007
Unique Identifier: MM11(05)
Issue No:
Scope Hospital and Primary Care Trusts
Classification: Guideline
Replaces Salford Guidelines for Lipid Control in Patients with Established Cardiovascular Disease and
Diabetes Oct 2005 Issue2A
Authors Name:
Dr M F Stewart,
Sister L Wong
Authors Title:
Consultant in Clinical Biochemistry
Diabetes Specialist Nurse
To be read in conjunction with the following documents: N/A
Authorised by: SRFT and Salford PCT
Medicines and Management Groups
Authorisation Date:
Review Date:
Issue
Salford Guidelines for Lipid Control in patients
with Established Cardiovascular Disease and
Diabetes
Page 1 of 5
SALFORD GUIDELINES FOR LIPID CONTROL IN PATIENTS WITH ESTABLISHED
CARDIOVASCULAR DISEASE OR DIABETES
INTRODUCTION
In the interest of brevity, these local guidelines do not restate in detail the extensive evidence base on which
the recommendations are based save for certain key papers, national and international expert panel
guidance which are referenced.
Grading of evidence is based on National Institute for Clinical Excellence (2001): The Guideline
Development Process – Information for National Collaborating Centres and Guideline Development Groups.
London, UK. Available from www.nice.org.uk.
TREATMENT ALGORITHM
Total cholesterol(TC)
LDL
HDL
Triglycerides
Evidence based
Treatment Goal
GMS Contract
Audit Goal
< 4.0 mmol/l
< 2.0 mmol/l
> 1.0 mmol/l (men)
> 1.2 mmol/l (women)
< 1.7 mmol/l
<5 mmol/l
<3 mmol/l
Patient with CVD – (coronary heart disease,
peripheral artery disease, cerebrovascular
atherosclerotic disease,)or acute coronary
syndrome or diabetes



Lipid treatment goals achieved –
continue and recheck annually
Lipid treatment goals not reached
despite titration to maximum dose statin
Total Cholesterol > 4.0 mmol/l
or LDL > 2.0 mmol/l
*OPTIONS:

Ezetimibe 10mg plus maximum
dose statin
Check baseline LFTs and CK then
Prescribe Simvastatin 40mg daily (unless
contraindicated; see below for alternative
effective statins)
Advice on diet, physical activity and other
modifiable risk factors should be given in line
with national recommendations.
Cholesterol/LDL treatment goals achieved
BUT:
HDL < 1.0 mmol/l (men)
< 1.2 mmol/l (women)
Triglycerides > 1.7 mmol/l
*OPTIONS:
Atorvastatin 20mg plus Fenofibrate or
Atorvastatin 20mg plus Nicotinic Acid MR
If Simvastatin 40mg is contraindicated because of drug
*Always consider possible interactions when prescribing statins.
Combination therapy increases the risk of adverse effects and
patients should be monitored closely for evidence of muscle
and/or liver toxicity-Refer to lipid clinic personnel.
Issue
interactions, a lower dose may be considered before switching
to an alternative.
Effective Statins
Simvastatin 40-80 mg
Atorvastatin 10 - 80 mg
Rosuvastatin 10 mg (combination therapy not recommended.
See also manufacturers warning about 40mg dose).
2 months after initiation of statin, and following each dose
titration, lipid profile and LFTS should be rechecked
Check CK if muscle symptoms develop
Salford Guidelines for Lipid Control in patients
with Established Cardiovascular Disease and
Diabetes
Page 2 of 5
KEY RECOMMENDATIONS

All patients with established cardiovascular disease (i.e. coronary heart disease, peripheral
artery disease and cerebrovascular atherosclerotic disease)OR an acute coronary syndrome OR
diabetes should be prescribed an effective dose of a statin drug (unless contraindicated). The
first choice of statin should be Simvastatin 40mg daily.
(Evidence Level Ib)
The Heart Protection Study (1) showed that adding Simvastatin 40mg daily to existing treatments
produces additional preventative benefits, irrespective of pre-treatment total and LDL cholesterol levels.
Equivalent doses of other available statins are: Atorvastatin 20mg daily or Rosuvastatin 10mg daily.

Statins should be up-titrated if the patient does not reach a total cholesterol of <4mmol/L or LDLcholesterol <2mmol/L on the initial dose(2)
(Evidence Level IV)
The Joint British Societes Guidelines (JBS2) (3) and the European Joint Task Force Guidelines (4) include
detailed discussion of the extensive trial evidence (Levels 1a and 1b) for lipid lowering in both primary
and secondary prevention of CVD.

Some patients will have total cholesterol > 4.0 mmol/l and LDL cholesterol < 2.0 mmol/l because of high
levels of cardioprotective HDL cholesterol. In these cases, use LDL cholesterol to guide therapy.

In the event of inadequate response to maximal dose statin, the following additional steps are
recommended:

Ezetimibe 10mg daily may be added to statin therapy to achieve further reduction in total and LDL
cholesterol. CVD outcome data is lacking for this agent. Published randomised control trials are of short
duration, examining efficacy (in respect of lipid lowering) and safety. Ezetimibe is not recommended in
combination with fibrates. A health technology appraisal of this agent is due to be published by NICE in
November 2007.

No specific treatment goals are defined for triglycerides and HDL-cholesterol. Markers of increased CVD
risk are:
Fasting triglycerides >1.7 mmol/L
HDL cholesterol
<1.0 mmol/L (men)
<1.2 mmol/L (women)
High triglycerides levels also increase the risk of acute pancreatitis and therefore require treatment.
The combination of Atorvastatin 20mg daily together with a fibrate drug (eg micronised fenofibrate) or
nicotinic acid MR should be considered in these patients.
Doses in excess of Simvastatin 10mg or Atorvastatin 20mg daily increase the risk of interaction with
drugs which are inhibitors of cytochrome P450 (CYP3A4). These include fibrates and nicotinic acid.
Rosuvastatin is not extensively metabolised but because of its potency, combination with fibrates or
nicotinic acid is not recommended.
Combination therapy increases the risk of adverse effects and patients should be warned about this and
monitored closely for evidence of muscle or liver toxicity.
Issue
Salford Guidelines for Lipid Control in patients
with Established Cardiovascular Disease and
Diabetes
Page 3 of 5
It is recommended that these patients be referred to the Lipid Clinic.
There are no published trials of combination therapy of sufficient size and duration to demonstrate
additional reductions of cardiovascular disease morbidity and mortality.
 Patients who are treated with statins should be advised to seek medical advice if they develop
muscle symptoms(pain, tenderness or weakness).
 Statins should be discontinued in people who develop an unexplained perpleral neuropathy and
further advice from a specialist should be sought.
Please refer to SRFT guidelines on management of acute coronary syndromes for other secondary
prevention measures
REFERENCES
1.
Heart Protection Study Collaborative Group. MRC/BHF Heart Protection study of cholesterol
lowering with Simvastatin in 20,536 high-risk individuals: a randomised placebo-controlled trial.
Lancet 2002; 360: 7-22
2.
NICE Guidances:Cardiovascular Risk Assessment: The Modification of Lipids for the Primary and
Secondary Prevention of Cardiovascular Disease. NICE Guideline Draft for Consultation. June
2007
3.
JBS2: Joint British Societes’ Guidelines on Prevention of Cardiovascular Disease in Clinical
Practice. Heart 2005 91 Suppl V.
4.
European Guidelines on cardiovascular disease prevention in clinical practice. Third Joint Task
Force of European and other societes on cardiovascular disease prevention in clinical practice. De
Backer G, Ambrosion E, Borch-Johnson K at al. Eur J Cardiovasc Prev & Rehab 2003; 10 suppl. 1:
51-578.
SEE ALSO:
5. Bandolier Extra, April 2004.
Cholesterol and Statins
www.ebandolier.com
6. Anonymous. Third Report of the National Cholesterol Education Program (NCEP) Expert panel on
Detection, Evaluation and Treatment of High Blood Cholesterol in Adults (Adult Treatment Panel III)
final report. Circulation 2002; 106:3143-3421.
7. La Rosa JC, He J, Vupputuri S. Effects of statins on risk of coronary disease. A meta-analysis of
randomised controlled trials. JAMA 1999; 282: 2340-2346.
8. Statins and cytochrome P450 interactions. MRHA/CSM current problems in Pharmacovigilance
2004; 30: 1-2.
Issue
Salford Guidelines for Lipid Control in patients
with Established Cardiovascular Disease and
Diabetes
Page 4 of 5
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[July 2004]
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