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2.12 Lipid lowering drugs

Cholestyramine powder
Colestipol powder
Colesevelam tablets (second line treatment of bile salt malabsorption)   
Simvastatin tablets
Pravastatin tablets
Atorvastatin tablets
Ezetimibe tablets - see note
Fenofibrate- first-line therapy only in patients with isolated severe hypertriglyceridaemia
Rosuvastatin tablets - see note
Alirocumab injection - see NICE TA393
Evolocumab injection - see NICE TA394
Omega-3 fatty acid compound (Omacor) - after consultant lipid specialist recommendation in patients with severe hypertriglyceridaemia (triglycerides >10mmol/L) after a trial of statin ± fibrates.
Concentrations above which alirocumab or evolocumab are recommended as options
The Derbyshire Guidelines for Lipid modification and Familial Hypercholesterolaemias / Lipid modification in non-Familial Hyperlipidaemia should be followed.


1.When a decision is made to prescribe a statin, NICE recommends using a statin of high intensity and low acquisition cost.

NICE guidance on lipid modification makes recommendations on the care and treatment of people at risk of cardiovascular disease (CVD) and people who have had previous CVD. This includes people with chronic kidney disease, and type 1 and type 2 diabetes. See guidance

2. Primary prevention of cardiovascular disease
Before offering statin treatment for primary prevention of CVD, NICE recommends discussing the benefits of lifestyle modification with the person and, if possible, the management of all other modifiable CVD risk factors should be optimised. NICE recommends offering atorvastatin 20 mg daily for primary prevention to people who have a 10% or greater 10-year risk of developing, including those with type 2 diabetes and CKD. Among people with type 1 diabetes, primary prevention with statins may be considered in all adults and should be offered to adults who are older than 40 years, or who have had diabetes for more than 10 years, or who have established nephropathy, or who have other CVD risk factors. In adults with type 1 diabetes, treatment should be started with atorvastatin 20 mg daily.

3. Secondary prevention of cardiovascular disease
NICE recommends that statin treatment for people with CVD (secondary prevention) should usually start with atorvastatin 80 mg daily. However, in people with CKD the initial dose should be 20 mg daily, and in other people a dose lower than 80 mg daily should be used if there are potential drug interactions with existing therapy, a high risk of adverse effects or the person prefers a lower dose.

4. NICE guideline on the management of Familial Hypercholesterolaemia recommends trying to achieve a reduction in LDL-C concentration of greater than 50% from baseline by prescribing a high-intensity statin (with a low acquisition cost) at the maximum licensed or tolerated dose e.g. atorvastatin 20-80mg daily, simvastatin 80mg daily. However, the MHRA advises that there is an increased risk of myopathy associated with simvastatin 80 mg daily, and that this dose should be considered only in people with severe hypercholesterolaemia and high risk of cardiovascular complications who
have not achieved their treatment goals on lower doses, when the benefits are expected to outweigh the potential risk. 

5. Ezetimibe use is restricted to monotherapy of primary hypercholesterolaemia (FH) where statin use is limited by intolerance or contraindications; or co administration with statin therapy when serum total or LDL cholesterol is not appropriately controlled either after appropriate dose titration of initial statin therapy or because dose titration is limited by intolerance to the statin (See NICE TA 385).

6. Bile acid sequestrants, nicotinic acid, fibrates and omega-3 fatty acid compounds should generally not be offered.

7. If a patient is not able to tolerate a high-intensity statin, the aim should be to treat with the maximum tolerated dose. The patient should be informed that any statin at any dose reduces CVD risk. If someone reports adverse effects when taking high-intensity statins, the following strategies should be discussed with them:

  • stopping the statin and trying again when the symptoms have resolved to check if the symptoms are related to the statin – many people who have discontinued statins because of side effects, especially muscle pain, are able to restart the same or a different statin

  • reducing the dose within the same intensity group

  • changing the statin to a lower intensity group.


Drug Safety Advice

i). Statin benefits and risks - see the Drug Safety Update May 2014

ii). Statin interactions - see the  Drug Safety Update January 2008

iii). Simvastatin interactions - see the Drug Safety Update August 2012 & Drug Safety Update October 2012

iv).Statins: risk of hyperglycaemia and diabetes

Statins may be associated with new onset diabetes. Risk factors include patients already at developing diabetes, as well as history of hypertension, raised triglycerides and raised BMI. Patients at risk should be monitored both clinically and biochemically according to national guidelines. See January 2012 Drug Safety Update

v). Fibrates - see MHRA Fibrates: new prescribing advice November 2007

Fibrates should be used as first-line therapy only in patients with isolated severe hypertriglyceridaemia. In patients who also have raised cholesterol, fibrates may be considered only when a statin or other effective treatments are contraindicated or not tolerated.

For link to BNF section: 2.12 Lipid-regulating drugs