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2.12 Lipid regulating drugs

2.12 Lipid regulating drugs

2.12 Lipid regulating drugs

              
Drug therapy should be combined with dietary control. Statins should be prescribed in line with NICE guidance CG181. 
This guideline updates and replaces the previous NICE guideline on lipid modification (CG67) . It offers  
evidence-based advice on the care and treatment of people at risk of cardiovascular disease and people who have had
previous cardiovascular disease.
 
A summary flow chart for cardiovascular risk assessment and the modification of blood lipids for the primary                           
and secondary prevention of cardiovascular disease in East Lancashire  is available here
 
Atorvastatin is now the first line agent – see lipid modification guidelines before prescribing 
Statins   
First line                               
GREEN      Generic Atorvastatin tablets 10mg, 20mg, 40mg, 80mg
GREEN      Simvastatin tablets 20mg, 40mg               
GREEN      Pravastatin tablets 20mg, 40mg    
GREEN       Rosuvastatin 20mg
Simvastatin and Atorvastatin are associated with some significant drug-drug interactions

The table below provides information and advice on managing these interactions.      
 

Interacting drug or food  

Simvastatin prescribing  advice      

Atorvastatin prescribing advice  

Potent CYP3A4 inhibitors, including itraconazole, ketoconazole, erythromycin, clarithromycin, telithromycin, and HIV protease inhibitors. 

All are contraindicated with simvastatin. 

Avoid if possible: consider temporary suspension of atorvastatin if interacting drug is taken for short period.                       Itraconazole: do not exceed 40mg atorvastatin daily.                                 Clarithromycin: do not exceed 20mg atorvastatin daily.                    HIV protease inhibitors: monitor lipid levels to ensure lowest necessary dose of atorvastatin is used. 

Ciclosporin* 

Contraindicated with simvastatin. 

Do not exceed 10mg generic atorvastatin daily. 

Danazol 

Contra-indicated with simvastatin.  

No restriction in Summary of Product Characteristics. 

Verapamil, amiodarone. 

Do not exceed 20mg simvastatin daily.  

Monitor lipid levels to ensure lowest necessary dose of atorvastatin is used. 

Diltiazem 

Do not exceed 20mg simvastatin daily.  

Monitor lipid levels to ensure lowest necessary dose of atorvastatin is used.  

Amlodipine Do not exceed 20mg simvastatin daily Monitor lipid levels to ensure lowest necessary dose of generic atorvastatin is used.  

Grapefruit juice 

Avoid grapefruit juice. 

Limit intake of grapefruit juice to very small quantities (or avoid altogether). 

Warfarin/courmarins† 

Monitor INR before starting treatment and regularly during treatment, especially with dose changes. 

Monitor INR before starting treatment and regularly during treatment, especially with dose changes.  

Fibrates† 

Increased risk of myopathy when used with fibrates; do not exceed 10mg simvastatin daily (except with fenofibrate); gemfibrozil increases systemic exposure to simvastatin. 

Increased risk of myopathy when used with fibrates; gemfibrozil increases systemic exposure to atorvastatin. 

Ezetimibe† 

Additive risk of myopathy cannot be ruled out. 

Additive risk of myopathy cannot be ruled out. 


*Ciclosporin interacts with all statins and is contraindicated with rosuvastatin. 
 †Warfarin/courmarins, fibrates and ezetimibe are important potential interactions to consider for all statins.
 
Intolerance of statins   
If a person is not able to tolerate a high‑intensity statin aim to treat with the maximum tolerated dose. Tell the person that  
any statin at any dose reduces CVD risk. If someone reports adverse effects when taking high‑intensity statins discuss the 
following possible strategies with them:   
       >     stopping the statin and trying again when the symptoms have resolved to check if the symptoms are related to the
              statin
       >     reducing the dose within the same intensity group.
       >     changing the statin to a lower intensity group.
       >     Seek specialist advice about options for treating people at high risk of CVD such as those with CKD, type 1 diabetes,  
              type 2 diabetes or genetic dyslipidaemias, and those with CVD, who are intolerant to 3 different statins.
 
Fibrates in CVD -updated in line with NICE CG181  
Do not routinely offer fibrates for the prevention of CVD to any of the following:
       >     people who are being treated for primary prevention
       >     people who are being treated for secondary prevention 
       >     people with CKD 
       >     people with type 1 diabetes 

       >     people with type 2 diabetes 

GREEN       Fenofibrate (Supralip®) tablets 160mg 

Ezetimibe             
People with primary hypercholesterolaemia should be considered for exetimibe treatment in line with Ezetimibe for            
treating priimary heterozygous-familial and non-familial hypercholesterolaemia as per NICE TA358 (replaces NICE TAG132)            
 
GREEN      Ezetimibe tablets 10mg
 
Alirocumab (NICE TAG393) and Evolocumab (NICE TAG394) are recommended as options  for treating primary
            
hypercholesterolaemia or mixed dyslipidaemia
 
RED          Alirocumab (Praluent®)  Solution for injection 75mg/mL, 150mg/ml                                          (CCG commissioned)  
RED          Evolocumab (Repatha®) 
 
Nicotinic acid group  
Do not offer nicotinic acid (niacin) for the prevention of CVD to any of the following:  
 
Omega-3-acid ethyl esters   
BLACK        Omega-3-acid ethyl esters - Post Myocardial Infarction.  
NHS England has identified this product as an item that should not be routinely prescribed in primary care. Available to purchase
over the counter. Click herefor the  Position Statement for Omega-3-acid ethyl ester prescribing in CVD  
BLACK        Omega-3 fatty acid compounds for preventing CVD   
NHS England has identified this product as an item that should not be routinely prescribed in primary care. Available to purchase
over the counter.
 
Recommendations in this section update and replace recommendations 1.10.4.1 and 1.10.4.2 from Type 2 diabetes 
(NICE clinical guideline 87).  
Do not offer omega‑3 fatty acid compounds for the prevention of CVD to any of the following:
 
       >     people who are being treated for primary prevention
       >     people who are being treated for secondary prevention 
       >     people with CKD 
       >     people with type 1 diabetes 
       >     people with type 2 diabetes
 There is no evidence that omega‑3 fatty acid compounds help to prevent CVD
 
Omega-3-acid ethyl esters - Hypertriglyceridaemia   
NHS England has identified this product as an item that should not be routinely prescribed in primary care. Available to purchase
over the counter.
BLACK     Omega-3-acid ethyl ester capsules 1g.   
 
Anion-exchange resins  
Do not offer a bile acid sequestrant (anion exchange resin) for the prevention of CVD to any of the following:
       >     people who are being treated for primary prevention
       >     people who are being treated for secondary prevention 
       >     people with CKD 
       >     people with type 1 diabetes 
       >     people with type 2 diabetes
 
Combination therapy for preventing CVD 
Do not offer the combination of a bile acid sequestrant (anion exchange resin), fibrate, nicotinic acid or omega-3 fatty acid 
compound with a statin for the primary or secondary prevention of CVD.