For primary prevention of cardiovascular disease (CVD):

• Offer lipid modification therapy if the person's estimated 10-year risk of developing cardiovascular disease (CVD) is 20% or more.
• Prescribe a statin, unless this is contraindicated. Simvastatin 40 mg daily is the first-line choice.
• Consider a lower dose of simvastatin or an alternative statin (e.g. pravastatin 40 mg daily) if there are potential drug interactions or simvastatin 40 mg is contraindicated.
• Consider offering a fibrate or a bile acid sequestrant if a statin is not suitable.
• Evidence supporting the use of these drugs for primary prevention is poor compared to statins.
• Repeating lipid measurement is unnecessary. A target for total or low-density lipoprotein (LDL) cholesterol is not recommended.

For secondary prevention of CVD:

• Offer lipid-modification therapy to all adults with cardiovascular disease.
• Prescribe a statin, unless this is contraindicated. Simvastatin 40 mg daily is the first-line choice.
• Consider a lower dose of simvastatin or an alternative statin (e.g. pravastatin 40 mg daily) if there are potential drug interactions or simvastatin 40 mg is contraindicated (e.g. in people with renal impairment).
• Higher intensity statins (simvastatin 80 mg or atorvastatin 80 mg) should only be considered first-line for people with acute coronary syndrome.
• Offer a fibrate, nicotinic acid or a bile acid sequestrant if a statin is not suitable.
• Evidence supporting the use of these drugs for secondary prevention is poor compared to statins.
• Consider the use of higher intensity lipid-modifying treatment if a target total cholesterol of less than 4 mmol/L, or an LDL cholesterol of less than 2 mmol/L, has not been achieved.
• Any decision to offer a higher intensity statin should take into account the person's preference and tolerability, comorbidities, multiple drug therapy, and the benefits and risks of treatment.

Advice:

• Advise the person to seek medical advice and to stop the lipid-modifying drug if they develop unexplained muscle symptoms (pain, tenderness, weakness).
• Check creatine kinase.
• Stop the lipid-modifying drug immediately if muscle symptoms are severe or if creatine kinase is five times or more the upper limit of normal.

When to refer:

• Refer people with suspected familial hypercholesterolaemia or other monogenic familial disorders for specialist management.
• Considering specialist advice when managing people e.g. with complex lipid disorders.