2.12 Lipid-regulating drugs
|1st choice||Atorvastatin tablets 20mg, 40mg, 80mg||Aim for doses below (see BNF for full dosage information):|
Primary Prevention: 20mg daily
Primary Prevention Type 1 Diabetes: 20mg daily
Primary Prevention Type 2 Diabetes: 20mg daily
Secondary Prevention: Atorvastatin 80mg daily*
* Use a lower dose if potential drug interactions, high risk of adverse effects or patient preference
- Please refer to NICE CG 181 Lipid Modification and Nothern Ireland’s Lipid Management Pathway.
- Other statins (simvastatin, pravastatin, fluvastatin, rosuvastatin) may occasionally be used if there are tolerability issues or, under secondary care guidance, for complex lipid management.
- Rosuvastatin should not be routinely prescribed.
- Simvastatin 80 mg 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.
- Ezetimibe in addition to statin therapy may be considered for secondary prevention when lipids are not adequately controlled despite the maximally tolerated statin dose. Every effort should be made to reach lipid goals by statin monotherapy before considering ezetimibe.
- Ezetimibe in addition to statin therapy for primary prevention should only be used under guidance from secondary care (for example in patients with familial hypercholesterolaemia) and only if lipids are not adequately controlled despite the maximally tolerated statin dose.
- Ezetimibe monotherapy is only recommended as an option for patients who would otherwise be initiated on statin therapy but who are unable to do so because of contraindications to initial statin therapy, or because of intolerance of statin therapy e.g. tried at least 3 different statins.
- Do not routinely offer fibrates for the prevention of CVD.
- Do not offer omega-3 fatty acid compounds, nicotinic acid or bile acid sequestrants (anion exchange resins) for the prevention of CVD.
- Inform patients there is no evidence that omega-3 fatty acids help to prevent CVD.
- Two PCSK9 inhibitors are available (alirocumab and evolocumab) for patients who meet criteria outlined in NICE TA394.
- Evolocumab is an AMBER list medicine. A GP information sheet is available on the Interface Pharmacy website
- Alirocumab is currently a RED list medicine and therefore should not be prescribed in primary care
- 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.
- Courses of antifungals may cause an increase in the drug levels of statin. The increase in drug levels occurs to different degrees depending on the drugs taken so consult the product SPC for specific advice. A dose reduction, temporary withdrawal of the statin and/or extra clinical monitoring may be required. For example, in patients taking atorvastatin, it may be appropriate to reduce to atorvastatin 10mg if itraconazole is prescribed.
- MHRA Drug Safety Update advised that there is sufficient evidence to support an association between statin use and new onset diabetes. The bulletin contains full details of this alert along with advice for healthcare professionals.