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Lipid modification - primary and secondary CVD prevention - Management
What follow up are recommended after initiating a lipid modification therapy for secondary prevention of CVD?
- Repeat lipid measurement:
- For people with acute coronary syndrome:
- Perform a fasting lipid measurement around 3 months after initiating statin therapy.
- For all other people taking a statin or other lipid-modifying drugs for secondary prevention:
- Check lipid profile around 8 (+/– 4) weeks after initiation, and after each adjustment to treatment.
- Lipid profile should be reviewed annually once the individual has reached an optimal, achievable target.
- For people taking statins, recheck liver function tests (LFTs) within 3 months of starting treatment and again at 12 months. Further monitoring is not necessary unless clinically indicated (e.g. symptoms or signs of hepatotoxicity).
- Monitor for adverse effects of lipid modification therapy:
- If they develop unexplained muscle symptoms (pain, tenderness, weakness):
- Check creatine kinase (CK).
- Stop the lipid-modifying drug immediately if muscle symptoms are severe or if CK is five times or more the upper limit of normal.
- For further information on managing abnormal CK results with statins, see Raised creatine kinase.
- Note: people should be advised to seek medical advice and to stop the lipid-modifying drug if they develop unexplained muscle symptoms.
- For people on a statin:
- Discontinue the statin and seek specialist advice if they develop unexplained peripheral neuropathy.
- Advise them to seek medical advice if they develop presenting features of interstitial lung disease such as dyspnoea, non-productive cough, and deterioration in general health (e.g. fatigue, weight loss, and fever).
- For further information, see Adverse effects.
Clarification / Additional information
- Statins and other lipid-modifying drugs can rarely cause myopathy and rhabdomyolysis. The exact mechanism is uncertain, but risk factors include [CSM, 2004]:
- Underlying muscle disorders.
- Renal impairment.
- Untreated hypothyroidism.
- Alcohol abuse.
- Older age (more than 70 years of age).
- Concomitant use of other lipid-modifying drugs (i.e. fibrates, nicotinic acid).
- A history of myopathy with any lipid modification therapy.
- Drug interactions (e.g. with drugs inhibiting cytochrome P450 enzymes).
Basis for recommendation
- Repeat lipid monitoring:
- The recommendations for repeat lipid monitoring is based on expert opinion [Smellie, 2006; NICE, 2008a].
- Manufacturers of statins advise lipid monitoring should be done after an interval of at least 4 weeks, as the full effect usually occurs within this time.
- Repeat lipid monitoring for people with acute coronary syndrome (ACS) after statin initiation:
- The National Institute for Health and Clinical Excellence (NICE) recommends repeat lipid monitoring around 3 months after initiating statin therapy [NICE, 2008a].
- This recommendation is consistent with that recommended in the Joint British Societies guideline and is based on [British Cardiac Society et al, 2005]:
- At the time of ACS (especially myocardial infarction), total cholesterol, low-density lipoprotein cholesterol, and high-density lipoprotein cholesterol decrease (and triglycerides may increase).
- The reduction of total cholesterol following myocardial infarction generally lasts no longer than 6–8 weeks, but sometimes lasts longer if there is a complicated recovery.
- Consequently, a full fasting lipid profile should be performed around 3 months following the acute event (normally after statin treatment has been started). This should be used to assess response to therapy and investigate the presence of familial dyslipidaemia.
- Repeat liver function testing (after statin initiation):
- This recommendation is based on expert consensus of the NICE Guidance Development Group [NICE, 2008a]. Evidence for the monitoring of liver function is sparse.
- Repeat liver function testing is also recommended by other experts [Smellie, 2006; Bhatnagar et al, 2008].
- CKS did not find any evidence to support the need for long-term monitoring of liver function in people taking statins (for more than 12 months).
- Muscular events (rhabdomyolysis and myopathy):
- These are rare but serious adverse effects of lipid-modifying drugs.
- The Commission on Human medicines and NICE advise that people receiving statins should be asked to report muscle pain, weakness, or cramps immediately, and to stop treatment until this has been investigated [CSM, 2004; NICE, 2008a].
- CKS advises that the same warning should be applied to other lipid-modifying drugs (except for bile acid sequestrants) because rhabdomyolysis and myopathy have been reported for these drugs and the manufacturers advise similar warnings.
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