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Lipid modification - primary and secondary CVD prevention - Management
What tests are recommended before starting lipid modification therapy?

  • Perform the following tests (if not already done as part of the cardiovascular risk assessment):
    • Two lipid measurements — at least one fasting lipid sample taken to measure total cholesterol, low-density lipoprotein (LDL) cholesterol, high-density lipoprotein (HDL) cholesterol and triglycerides.
    • A liver function test (transaminases): if these results are abnormal, further investigation is required to determine the cause of the abnormal test results (e.g. alcohol abuse).
      • People who have liver enzymes that are elevated, but are less than three times the upper limit of normal, should not be routinely excluded from statin therapy.
    • Renal function: chronic kidney disease does not preclude the use of a statin. However, the dose of some statins should be adjusted in people with moderate or severe renal insufficiency.
    • Fasting blood glucose.
    • Creatine kinase is recommended if the person is at high risk of muscle toxicity (e.g. older people, or when combining a statin with a drug known to increase myotoxicity) but this is not routinely necessary in other people.
    • Serum thyroid stimulating hormone (if dyslipidaemia is present).
Basis for recommendation
  • These recommendations are based on guidance from the National Institute for Health and Clinical Excellence (NICE) and the Scottish Intercollegiate Guidelines Network (SIGN) [SIGN, 2007; NICE, 2008a].
  • Repeated lipid measurement:
    • The NICE Guidance Development Group (GDG) recognized that there is variability in lipid measurement due to day-to-day physiological, laboratory, and statistical variation [National Collaborating Centre for Primary Care, 2008a].
    • Because of the individual variation in a single lipid measurement, repeated measurement will give greater precision. However, NICE accepted that, in routine practice, serial replicate testing is not feasible and clinicians often base monitoring decisions on one measurement, and treatment decisions on two measurements, accepting the imprecision.
  • Need for a fasting lipid measurement before starting lipid modification treatment:
    • This is based on the expert opinion of the NICE GDG which acknowledged that there was no substantive evidence to support the view that a fasting specimen is advantageous before starting treatment [National Collaborating Centre for Primary Care, 2008a].
    • However, they recognized that many clinicians view low-density lipoprotein (LDL) cholesterol and triglycerides as an important adjunct to clinical management because they may inform diagnosis and are a baseline against which the progress and effectiveness of treatment can be judged.
  • Liver function:
    • This is to exclude possible contraindication to treatment with statins or other lipid–modifying drugs. Statins are contraindicated in people with active liver disease or persistently abnormal liver function tests.
  • Pretreatment baseline creatine kinase (CK) only for people at high risk of muscle toxicity:
    • NICE does not make any recommendation regarding the need for pretreatment, baseline CK measurement [NICE, 2008a].
    • This recommendation is based on that from SIGN [SIGN, 2007], following the consensus recommendations issued by the National Lipid Association Statin Safety Task Force [McKenney et al, 2006; SIGN, 2007]. This recommendation was based on assessment of evidence from the US Food and Drug Administration (FDA), cohort and clinical trials, and administrative claims database information.
  • Fasting blood glucose:
    • Although it is not required for cardiovascular risk calculation, it is recommended for diagnosis of impaired glucose regulation and diabetes [British Cardiac Society et al, 2005].
  • Serum thyroid stimulating hormone should be checked if dyslipidaemia is present because:
    • Hypothyroidism is a recognized cause of dyslipidaemia [BTA et al, 2006].
    • In addition, untreated hypothyroidism increases the risk of statin-induced myopathy [Bar et al, 2007].

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