Hyperlipidaemia - OBSOLETE

Overview

For full guidelines please see BNSSG Management of Blood Lipid Levels  (scroll down to Lipid Guidance at the bottom of the page to find the up to date pathways).

Baseline Lipid testing

Indications for baseline lipid testing include:

• Age - as part of a NHS health check a cholesterol level will be checked in patients aged 40-74. NHS health checks are offered every 5 years.
• Risk factors - including personal history of cardiac disease, cerebrovascular disease, dementia, chronic kidney disease, hypertension, diabetes, peripheral vascular disease, obesity, rheumatoid arthritis, mental health disorders
• Family history - if there is a family history of high cholesterol or early death from cardiovascular disease (i.e. in a first degree relative aged <60 - NICE guideline CG71)

Measure full lipid profile ( a random sample is ok) at least once. If elevated, then exclude secondary causes ( check UE, LFT, TSH, fasting glucose or HbA1c) and assess cardiovascular risk i.e.QRISK3 before commencing lipid lowering therapy.

Offer diet and lifestyle advice to all patients, but do not delay initiation of drug treatment in patients with established CVD, or with severe hypertriglyceridaemia.

Primary prevention (NICE CG 181)

In patients aged <85 without established cardiovascular disease, estimate cardiovascular risk using a QRISK3 calculator. Offer a statin if 10 year risk is >10% or multiple risk factors present (NHSE/AAC Summary of National Guidance for Lipid Management). Address lifestyle risks with all patients

Also consider statin treatment in the following groups:

• Type 2 Diabetes - if QRISK3 score 10% or more.
• Type 1 Diabetes - if one of more of the following: age >40, diabetes >10 years, nephropathy, other CVD risk. (regardless of QRISK3 score).
• Chronic Kidney Disease - if eGFR < 60 ml/min/1.73m² and/or albuminuria. (regardless of QRISK3 score)
• Age ≥85 years - QRISK3 score only validated in patients aged up to 85. Consider treatment regardless of risk if appropriate considering comorbidities, frailty & life expectancy.

Use intensive statin first line (BNSSG guidelines advise Atorvastatin 20mg daily or Rosuvastatin if contraindicated).

Repeat lipid levels (and ALT - see liver monitoring below) at 3 months.

Aim for a >40% reduction in Non-HDL cholesterol and titrate up dose every 3 months until this target is reached (maximum dose of Atorvastatin 80mg).

Monitor lipids annually after this.

See BNSSG Management of Blood Lipid Levels for complete guidelines and advice.

Secondary prevention

Secondary prevention should be given to all patients with established vascular disease (e.g. ischaemic heart disease, peripheral vascular disease, cerebrovascular disease).

Target lipid levels:

• Non-HDL cholesterol - aim for a >40% reduction in non-HDL cholesterol from baseline and,
• LDL level - target an LDL <1.8mmol/L (or non-HDL level <2.5mmol/L if LDL not measured)

Use high dose intensive statin first line (Atorvastatin 80mg daily).

If targets not reached then use a combination (if necessary) of intensive statin, and Ezetimibe or Inclisiran (choice depends on LDL levels while on maximum dose of statin). See BNSSG Inclisiran Clinical Guidelines for further guidance on initiating these additional treatments. Inclisiran can be prescribed and initiated in primary care.

Cardiovascular and all cause mortality increase rapidly if statin therapy is discontinued in patients with established CVD. Do not discontinue statin unless unacceptable side effects or severely limited life expectancy.

Liver (ALT) monitoring with statins

Repeat ALT at 3 months after statin initiation and each up-titration, then at 12 months, but not again thereafter unless clinically indicated. Manage elevations in ALT according to NHSE/AAC Summary of National Guidance for Lipid Management

Intolerance to statins or failure to meet target cholesterol

See the NHS Statin intolerance pathway (england.nhs.uk) - this includes when to suspect statin related muscle toxicity and when to measure CK levels if this is suspected.

Consider requesting Lipid Advice and Guidance via eRS.

Familial Hypercholesterolaemia

Possible Familial Hypercholesterolaemia (FH)

FH should be suspected in an adult if (see Case finding and diagnosis - NICE CG71):

• Total cholesterol concentration is greater than 7.5 mmol/L and/or
• There is a personal or family history of premature CHD (an event before 60 years in an index person or first-degree relative [parents, siblings, children]).

If FH is suspected (from BNSSG Management of Blood Lipid Levels) :

• Take 2 fasting measurements of low-density lipoprotein (LDL) cholesterol.
• The person should be assessed for clinical signs of FH, such as tendon xanthomata.
• Secondary hypercholesterolaemia should be excluded (check UE, LFT, TSH, fasting glucose or HbA1c).
• The Simon Broome criteria should be used to make a clinical diagnosis of FH in primary care.

All people with a clinical diagnosis of FH and/or suspected FH meeting criteria for referral  (see 'Who to Refer' section below) should be referred to the Lipid Clinic for confirmation of the diagnosis and initiation of cascade testing (which involves identification of affected relatives by DNA testing).

For patients with suspected Familial Hypercholesterolaemia a Desktop review pathway must be completed prior to referral. (see 'Before Referral' section below).

Do not use QRISK tools if FH is suspected, additional risk factors, or triglycerides (fasting or non-fasting) greater than 4.5 as result will be an underestimate of actual risk.

If FH is confirmed by Lipid Clinic

The Lipid Clinic nurse will co-ordinate family screening.

(See NICE CG71 – Familial Hypercholesterolaemia: Identification and management for further details. Also CKS for FH; and NHS Long Term Plan 2019 section 3.68)

FH should not be confused with Familial Combined Hyperlipidaemia - see below:

Familial Combined Hyperlipidaemia (FCH)

Triglycerides (TG) are usually normal in Familial Hypercholesterolaemia (FH). If they are raised, FH is unlikely unless a secondary factor is also present that may explain elevated TG.  Genetic testing is therefore rarely indicated in patients with high TG (>5 mmol/l). A more likely genetic cause is Familial Combined Hyperlipidaemia (FCH). This is autosomal dominant, but the gene has not yet been identified so no formal genetic testing is currently available, and referral is not necessarily required.

In these patients, consider statin treatment and screen first degree relatives and adult children with full fasting lipid profile.

If you are not sure consider obtaining Lipid advice and guidance (via eRS).

Hypertriglyceridaemia

See the BNSSG formulary page for the Management of Hypertriglyceridaemia in Primary Care

Hypertriglyceridaemia is classified as follows:

• Mild -  TG 1.8 - 4.9 mmol/l - manage in primary care
• Moderate - TG 5.0 - 9.9 mmol/l - manage in primary care
• Severe - TG >20 mmol/l or two or more results ≥10 mmol/L - refer. See pathway and consider Red Flags.

Treatment

Treatment should be given with lifestyle advice for all and drug treatment depending on CVD risk as outlined in the pathway above.

Referral

Refer patients with severe hyperglyceridaemia to lipid clinic via eRS.

Consider advice and guidance request via eRS or telephone discussion with Lipid Clinic for advice if you are not sure.

For urgent advice telephone UHB Clinical Biochemistry (Lipid Clinic) Secretary on 0117 3427708, Clinical Biochemistry Registrars on 0117 3427766 or Dr Wycliffe Mbagaya WAHT secretary on 01934 881006.

Red Flags

Severe Hypertriglyceridaemia

Patients with severe hypertriglyceridaemia (>20 mmol/L) require urgent assessment of secondary causes (e.g. alcohol excess & poorly controlled diabetes), and prompt treatment to reduce triglycerides & minimise the risk of acute pancreatitis. Repeat fasting lipids within a week, assess for pancreatitis, and seek advice from lipid clinic (see Hyperlipidaemia section above). 

Who to Refer

Please refer patients in the following groups:

• Clinical suspicion of Familial Hypercholesterolaemia (FH) (Case finding and diagnosis - NICE CG 71). Note that the high cholesterol reading can be at any time in the past and is not negated by a subsequent low reading - the patient will still need to be referred. However, for all patients the Desktop review pathway must be completed before referral.*
• Patient or relative with high Lipoprotein(a) - or Lp(a) for short
• Intolerant of multiple statins (please follow statin intolerance pathway before referral)
• Not at target despite maximum treatment or recurrent CVD event despite maximum treatment
• Hypertriglyceridaemia - TG>20mmol/l or persistently above 10mmol/l. Some patients with CVD and TG 5-10mmol/l may also be referred. Please see the Formulary for the local triglyceride pathway - Management of Hypertriglyceridaemia in Primary Care

Please do not routinely refer patients with suspected FCH (Familial Combined Hyperlipidaemia) rather than suspected FH (Familial Hypercholesterolaemia) - see FH section above. Clinical judgement is needed based on how strong the family history is as well as blood lipids. As a rule the higher the triglycerides the more likely a patient is to have FCH and the less likely they are to have FH. FCH patients still need treatment and relatives need screening with a full lipid profile but they don't need genetics (none available for FCH - it's a clincial/biochemical diagnosis) and therefore they don't automatically need referral. The local lipids clinics have taken a pragmatic cut off of TG>5 and suggest excluding these patients from referral. 

Before Referral

Please consider the following before referral:

• Ask about family history of hyperlipidaemia or premature coronary disease (<60).
• Unless rhabdomyolysis or severely abnormal liver function, try low dose Rosuvastatin (5mg weekly titrated up to 5mg OD) before referral for statin intolerance.
• For patients with suspected Familial Hypercholesterolaemia a Desktop review pathway must be completed prior to referral.
• Consider advice and guidance request or telephone discussion with Lipid Clinic for advice:
• Advice & Guidance request via e-RS (See Lipids A&G page)
• Telephone Dr Eloise Willis or Dr Andrew Day via Clinical Biochemistry (Lipid Clinic) Secretary on 0117 3427708.Consider advice and guidance request or telephone discussion with Lipid Clinic for advice

Referral

For patients with suspected Familial Hypercholesterolamia a Desktop review pathway must be completed prior to referrals under IIF criteria -CVD-04 (2)

For all referrals please complete a Lipid Clinic referral proforma. Referrals sent without a completed proforma may be rejected.

Child Parent Screening for FH

Detecting Familial Hypercholesterolaemia is a key part of the NHS Long-Term Plan (LTP). Health Innovation West of England is seeking GP practices to participate in Child-Parent Screening, a programme supported by NHS England and currently the best model for FH detection. 

With parental consent, a child is tested for FH at their routine one-year immunisation appointment using a heel prick capillary test. Participating practices will receive:

• free training and support for all staff  
• £10 per patient screened 
• support from a consultant lipidologist  

For further information and to express an interest please contact amy.bowden4@nhs.net

Efforts are made to ensure the accuracy and agreement of these guidelines, including any content uploaded, referred to or linked to from the system. However, BNSSG ICB cannot guarantee this. This guidance does not override the individual responsibility of healthcare professionals to make decisions appropriate to the circumstances of the individual patient, in consultation with the patient and/or guardian or carer, in accordance with the mental capacity act, and informed by the summary of product characteristics of any drugs they are considering. Practitioners are required to perform their duties in accordance with the law and their regulators and nothing in this guidance should be interpreted in a way that would be inconsistent with compliance with those duties.

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