• Offer lipid-modification therapy if the person's estimated 10-year risk of developing cardiovascular disease (CVD) is 20% or more. See the CKS topic on CVD risk assessment and management for information on how to estimate CVD risk.

In depth

• Manage other modifiable risk factors, such as smoking, high blood pressure, and obesity.
• Manage secondary causes of dyslipidaemia (e.g. hypothyroidism).
• Consider whether antiplatelet treatment is indicated (e.g. low dose aspirin — not licensed for primary prevention of CVD).
• Provide lifestyle and dietary advice such as increased physical activity, reduction of alcohol consumption, and adoption of a cardioprotective diet.
• For further information, see the CKS topics on CVD risk assessment and management and Antiplatelet treatment.

In depth

• Perform the following tests (if not already done as part of the cardiovascular risk assessment):
• Two lipid measurements (with one measurement based on a fasting sample).
• A liver function test.
• Fasting blood glucose.
• Renal function.
• Creatine kinase, if the person is at high risk of experiencing muscle toxicity.
• Serum thyroid stimulating hormone (if dyslipidaemia is present).

In depth

• A target for total cholesterol or low-density lipoprotein (LDL) cholesterol is not recommended.

In depth

• Prescribe a statin, unless this is contraindicated (i.e. active hepatic disease, transaminase levels three or more times the upper limit of normal, unexplained persistent elevations of transaminases, pregnancy, and lactation).
• 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).
• Do not offer higher intensity statin therapy (e.g. simvastatin 80 mg daily), or a combination of a statin and other lipid-modifying treatment.

In depth

• Repeat lipid measurement is unnecessary. However, clinical judgement and patient preference should guide the review of drug therapy and whether to review the lipid profile (e.g. to assess compliance).
• For people on a statin: recheck liver function tests (LFTs) within 3 months of starting treatment, and again at 12 months.
• 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.
• Note: people should be advised to seek medical advice and to stop the lipid-modifying drug if they develop unexplained muscle symptoms.
• Discontinue the statin and seek specialist advice if they develop unexplained peripheral neuropathy or presenting features of interstitial lung disease.

In depth

• Consider offering a fibrate or a bile acid sequestrant if a statin is contraindicated or not tolerated.
• Evidence supporting the use of these drugs for primary prevention is poor compared to statins.
• The decision to select a particular lipid-modifying drug should take into account patient preference and tolerability, comorbidities, multiple drug therapy, and the benefits and risks of treatment.

In depth

• Refer people with suspected familial hypercholesterolaemia (FH) or other monogenic familial disorders for specialist management.
• Consider seeking specialist advice in managing people with e.g. complex lipid disorders, multiple drug intolerance.

In depth