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Lipid Disorders – Information for GPs

Definition

Patient who has an abnormal lipid profile and is thought to have familial hyperlipidaemia OR is being treated because they are considered to be at high risk of or have existing cardiovascular disease and have not responded to maximally tolerated doses of a high intensity statin will require referral to specialist lipid clinic (see table below).

Exclusion

People under the age of 16.

General points

It is expected that the majority of people with lipid disorders will be managed in the community and do not require specialist referral.

  • The majority of people with high cholesterol levels do not have an underlying cause for this however abnormal lipid profiles are associated with diabetes, metabolic syndrome, thyroid disease, liver disease, excess alcohol intake, nephrotic syndrome and some medications especially steroids and antipsychotics and these should be excluded before referral.
  • There are common genetic disorders causing high cholesterol alone (Familial Hypercholesterolemia) or a mixed pattern with elevated triglyceride and cholesterol. These are associated with accelerated cardiovascular disease and benefit from early referral to a lipid clinic for specialist management and consideration of genetic testing.
  • A full family history for premature cardiovascular disease should be taken especially for first-degree relatives, to identify people with possible familial hyperlipidaemia (FH). Premature is considered to be age < 55 in a man and < 65 in a woman.
  • In primary non-familial hypercholesterolaemia, a number of genes interact with dietary and other factors such as smoking and lack of exercise to cause high cholesterol levels. This affects an estimated 1.5 million people in England.
  • Primary heterozygous-familial hypercholesterolaemia (FH) is an inherited condition caused by a faulty gene and affects about 106,000 people in England. People with this condition have raised cholesterol levels from birth.

Investigation and assesment

  • A non-fasting total, HDL cholesterol and non HDL cholesterol is used to estimate CVD risk. A fasting sample is required to rule out hypertriglyceridemia.
  • To identify a metabolic cause please arrange TFT, HbA1C, urea and electrolytes and test (dipstick) urine for protein.
  • When total cholesterol is > 7.5 mmol/l, or Non HDL > 4.9 mmol/l AND there is a family history of premature heart disease consider Familial Hyperlipidaemia and check for lipid deposits in the tendons (xanthomata) both achilles and hands, and around the eyes (xanthelasma) and a corneal arcus.

Management guidelines

  • Lifestyle advice in the context of weight optimization, with diet and exercise and smoking cessation should be an integral part of the consultation
  • Improving diabetes control and reducing alcohol intake should be a target for management.
  • NICE Guidelines do not recommend the use of fibrates, omega 3 fatty acids, plant stanols or sterols in the context of cardiovascular risk reduction in high-risk individuals.

Use of Statins and other lipid lowering agents for Cardiovascular Risk Reduction

  • As a class, statins are the most highly studied therapy and have revolutionised the prevention and management of cardiovascular disease
  • NICE Guidance recommends the use of a high intensity statin; atorvastatin where the decision has been made with the patient to use medication to lower cholesterol. This does not need to be taken at night to improve concordance.
  • NICE Guidance recommends the target of a 40% reduction in non HDL cholesterol in non- familial hyperlipidemia.
  • Scarborough and Ryedale Clinical recommendation is to start with 20mg atorvastatin for primary prevention (43% lowering of LDL cholesterol is achieved when on 40mg) and 80mg for secondary prevention (a 49% lowering of LDL cholesterol), titrating down to 40mg if not tolerated.
  • For people with FH, NICE guidelines recommend the addition of ezetimibe to the maximal tolerated dose of a high intensity statin.
  • PCSK 9 inhibitors injections may be indicated in some patients.

Information to include in referral letter

  • Detailed family history- both positive and negative for CVD.
  • Include previous lipid profiles particularly if samples have been sent to another laboratory.
  • Recent fasting lipid profile (including LDL and triglycerides), U&Es, LFT, TSH and HbA1c.
  • Details of all previous lipid lowering therapy and up to date prescriptions.
  • In case of statin intolerance include the details of statins tried and side effects.
  • Referrals to the lipid clinic are made via the RSS by selecting. Speciality: Endocrinology and Metabolic Disorders and Clinic type: Lipid Disorders

Table: Indications to request a consultant opinion from the specialist lipid clinic (not cardiology)

Table

Patient information leaflets/ PDAs

References

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