Cholesterol Guidelines

These guidelines are from FATS 5 (First Affordable Treatment Strategy 4), a district policy developed in 2009 following on from FATS 4. This is a lipid lowering drug strategy which should only be used within an overall lifestyle and clinical management strategy.

People with symptomatic or prior occlusive vascular disease

measure lipid profile (total cholesterol, HDL cholesterol and triglycerides)
measure ALT/AST at baseline (and after 3 months if high dose statin)
if ALT/AST < 2 fold normal, prescribe a statin as below:-
- In acute coronary syndrome/ acute MI - atorvastatin 80 mg od
- In all others; Initiate simvastatin 40 mg od and consider titration to simvastatin 80 mg od (additional benefit is small and risks increase)
- for those intolerant of simvastatin, consider pravastatin. alternative is fenofibrate 200mg increasing to 267mg, taken with food or ezetemibe.
repeat lipid profile 8 weekly until TC < 4 mmol/l, or LDL-C (fasting) < 2 mmol/l, or non-HDL-C < 2.8 mmol/l or maximum drug flow reached
higher risk people ie diabetes, disease in > 1 arterial bed (CHD, cerebrovascular, PAD), after CABG and recurrent spontaneous acute CVD events within a year, consider titration to atorvastatin 80 mg od / simvastatin 40 mg plus ezetimibe 10 mg od

Notes:

Consider familial hypercholesterolaemia (FH) if total cholesterol > 7.5 mmol/l, LDL cholesterol > 4.9 mol/l. Suspected FH or if triglycerides > 4.5 mmol/l, treat individually, consider discussion with local advisor Dr Neely e-mail: fatsinfo@nuth.nhs.uk or tel: 2824554
Remember secondary causes of raised fat levels - alcohol excess, thyroid disease, diabetes, nephrotic syndrome.
Simvastatin potentiates warfarin - initiate 3-5 days before INR check
Start with a lower dose if at increased risk of adverse events or if treated with other drugs which may interact (eg verapamil, diltiazem, amiodarone, fibrates, ciclosporin) - see supporting notes/BNF. Temporarily stop simvastatin if treated with erythromycin, clarithromycin, some antifungals
Review concordance and lifestyle if cholesterol falls less than 1 mmol/l
Older people could be expected to get benefit up to the age of 90. People with occlusive vascular disease and diabetes / IGT should be offered treatment irrespective of age. Others over 75 are at increased risk and should be considered for treatment depending on general health and patient preference.

People with diabetes or impaired glucose tolerance

Consider drug treatment in people with

Type 1 or type 2 diabetes with microalbuminuria/proteinuria
Type 1 diabetes with other high risk features; 2+ features of the metabolic syndrome, or other risk factors (see supporting notes)
Type 1 diabetes / type 2 diabetes / impaired glucose tolerance aged > 40 years
Type 2 diabetes / IGT aged < 40 years if 10 year CVD risk > 20% (see risk calculation below) and by clinical judgement
drugs, monitoring and notes as above. treatment with simvastatin only unless established CVD.

High risk people without symptomatic or prior occlusive vascular disease and without diabetes or IGT

FATS advice is based on risk not cholesterol

In people at high risk of developing vascular disease

measure lipid profile (non-fasting acceptable)
estimate 10 year CVD risk
if definite LVH on ECG, double estimated 10 year CVD risk (if not already included)
consider other additional risk factors:

family history of premature CVD (men < 55 yrs, women < 65 yrs)
South Asian race
CKD eGFR < 45 ml/min/1.73m²
fasting triglycerides > 1.7 mmol/l
high level of deprivation
premature female menopause aged < 45 years
Other conditions (eg inflammatory arthritis, connective tissue disease, severe mental illness, other severe inflammatory conditions)

consider drug treatment if 10 year CVD risk > 20%
drugs, monitoring and notes: see under "people with symptomatic or prior occlusive vascular disease"
if metabolic syndrome or impaired fasting glycaemia, ensure intensive therapeutic lifestyle interventions (see supporting notes)

July 2009