Joint statement on the use of lipid lowering agents in Grampian - December 2010


GENERIC SIMVASTATIN IS THE PREFERRED INITIAL AGENT
THE OPTIMAL DOSE IS REGARDED AS 40mg AT NIGHT
 
For secondary prevention (patients with established vascular disease), if simvastatin 40mg fails to achieve the desired outcome some patients may require a second-line agent, atorvastatin is the second-line choice statin. 
Atorvastatin is shortly to go off patent and it is predicted that it will become cheaper than rosuvastatin.  The use of generic atorvastatin is thought to represent a potential saving to NHSG.  It is not envisaged that rosuvastatin will be removed from the formulary but is now only recommended when atorvastatin is either ineffective or poorly tolerated.
 
IN PRIMARY PREVENTION:
  • Drug therapy should now be used routinely for individuals with a risk >20% over 10 years.  This assessment should be ideally done using an online comprehensive risk assessment tool and not on cholesterol levels alone.
  • Simvastatin 40mg at night is the recommended therapy.
  • Except in the case of familial hypercholesterolemia there is no evidence for more aggressive therapy and this is not a requirement for QoF.
  • Focussed attention to improving general lifestyle measures is always an essential component of primary prevention.
  • Diabetic patients over the age of 40 should be treated following the "secondary prevention" recommendations below; younger patients should be considered for primary prevention therapy.
  • There is currently no robust outcome data for the use of fibrates although pragmatically they could be used with discretion. 
  • Ezetimibe is not currently recommended in NHSG.
  • If triglycerides (or initial total cholesterol) are >10mmol/L then expert advice should be obtained.
IN SECONDARY PREVENTION:
  • An initial dose of simvastatin 40mg at night is recommended for most patients.  Simvastatin 80mg is not recommended in view of significant adverse effects.
  • If patients are complying with therapy and targets cannot be achieved on 40mg simvastatin, then a switch to atorvastatin is recommended.  This can be increased to 80mg if required.  Lower doses should not be used routinely; there is no advantage to starting new patients on atorvastatin 10mg.
  • If atorvastatin 80mg is poorly tolerated or is not as effective as desired then rosuvastatin 10mg may be an alternative.  Higher rosuvastatin doses should not be used for initiation.
  • Fluvastatin and pravastatin should no longer be routinely prescribed.
  • Fibrates can be used when a patient is intolerant of any statin.
  • Nicotinic acid preparations may also be of benefit for statin intolerant patients. Currently they are not approved locally for use with either statins or fibrates.
  • Ezetimibe is not currently recommended in NHSG.
  • If trigycerides (or initial total cholesterol) are >10mmol/L then expert advice should be obtained.
Version 4.1 December 2010