1. Lipid target TC <4, LDL <2 (1.8), TG <1.7 non HDL cholesterol <2.5
2. Lipid management guideline (based on NHS 2022, last nice guideline 2014)
- Measure first ‘non fasting lipid profile’, measure BMI, check secondary causes of hyperlipidemia
- 3 pathways- primary prevention, secondary prevention, Mx of Severe hyperlipidemia
Lipid levels
– Primary prevention → QRISK >10% ie cvd risk 10% in 10 yr +/- T2DM
→ T1DM if >40yr, 10yr of disease length, nephropathy, other cvd risk
(NICE guideline→ consider statin for all T1DM)
→ CKD (gfr <60) or albuminuria (20mg, 10)
→ age >85
→ Before Tx → Look for obesity, ask for smoking, diet, alcohol,
physical activity, measure BP, HbA1C
also check for additional risk factor eg on HIV/mental disease Tx,
IGT, systemic inflammatory disease (eg SLE, RA etc)
→ Tx 20mg Atorvastatin (if diet, lifestyle modification fail)
↓
Recheck lipid after 3 months → target nonHDL >40% reduction
↓
Increase dose every 2-3 month
↓
Secondary prevention
CVD (cardio/cerebrovascular disease or revascularisation)
↓
Before Tx→Look for obesity, ask for smoking, diet, alcohol,
physical activity, measure BP, HbA1C
↓
Ezetimibe 10mg od Add ezetimibe non HDL >2.5mmol/L
↓ 10mg/day
Ezetimibe 10mg + ↓
Bempedoic acid 180mg if still nHDL-C >2.5
Combination ↓
Test fasting LDL-C
↓
Inclisiran→ if fasting LDL-C >2.6
PCSK9i→ evolocumab, alirocumab
- If FH → it maybe treated in primary prevention setting or secondary prevention setting
→ if LDL-C >5 in 10 or >3.5 in 20 despite maximum statin and ezetimibe
Very high risk of CHD (already CVD/ 2 risk factor of
↓
Refer to specialist center or PCSK9i
*older nice guideline→ if statin intolerance, refer to specialist rather than starting ezetimibe
→ ezetimibe only indicated if initial statin therapy is contraindicated
3. Don’t give omega 3 fatty acid, fibrate, nictonic acid, bile acid binder alone
