2.12 Lipid-regulating drugs


Choice	Drug	Dose
Formulary choices	Atorvastatin tablets 20mg, 40mg, 80mg	Aim for doses below (see BNF for full dosage information). Note: starting dose of 20mg once daily is not licensed for the primary prevention of cardiovascular events, but is in line with NICE NG238. Primary prevention (including type 1 and 2 diabetes): 20mg daily Secondary prevention: 80mg daily* Primary and secondary prevention of CKD: 20mg daily** use a lower dose if potential drug interactions, high risk of adverse effects or patient preference. *increase the dose if the lipid target for primary or secondary prevention of CVD is not achieved and eGFR ≥30ml/min. Agree the use of higher doses with a renal specialist if eGFR < 30ml/min.
		or
		Rosuvastatin tablets 5mg, 10mg, 20mg, 40mg (note: rosuvastatin capsules higher cost)	Refer to BNF
			Refer to BNF

Prescribing Notes

Refer to NICE NG238 and Lipid Management Pathways for NI (Lipid Management Pathway and Statin Intolerance Pathway).
Other statins (simvastatin, pravastatin, fluvastatin) may occasionally be used if there are tolerability issues or, under secondary care guidance, for complex lipid management
Simvastatin 80mg is no longer recommended due to the risk of adverse effects. People currently taking simvastatin 80mg should be advised to contact their doctor to arrange a switch to an alternative statin, usually atorvastatin. See MHRA.
For place in therapy of ezetimibe, refer to Lipid Management Pathways | NI Formulary. Ezetimibe should be considered for use in combination therapy for all patients, in particular those who do not meet target LDL-C levels on statin treatment alone or where statin therapy is not tolerated or contra-indicated.
Bempedoic acid is available for patients who meet the criteria outlined in NICE TA694. See NI Managed Entry decisions.

- Bempedoic acid with ezetimibe can be used as separate tablets or a fixed-dose combination. The fixed-dose combination is the same price as bempedoic acid.

Inclisiran is available for patients who meet criteria in SMC2358. See NI Managed Entry decisions.
Two PCSK9 inhibitors are available (alirocumab and evolocumab) for patients who meet criteria outlined in NICE TA 393/ 394.

- Alirocumab is an AMBER list medicine. A GP information sheet is available on the Interface Pharmacy website.
- Evolocumab is an AMBER list medicine. A GP information sheet is available on the Interface Pharmacy website.

Cautions

Caution should be exercised when prescribing other drugs with statins. Statins interact with many drugs including azole anti-fungals, macrolide antibiotics, HIV protease inhibitors, amiodarone, verapamil, grapefruit juice, and warfarin. See BNF for full details of drug interactions.
Statins have been associated with new onset diabetes. See MHRA for further information.
There have been some suspected (very infrequent) reports of new-onset or aggravation of pre-existing myasthenia gravis or ocular myasthenia associated with statin use. See MHRA for further information.