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Lipid-lowering therapy should be started if high CV risk (5 year CV risk ≥ 10%) or any of the following irrespective of CV risk with a target LDL cholesterol (LDLc) < 1.4 mmol/L:
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Previous CV event
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Established CV disease including known asymptomatic coronary and carotid disease
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Type 2 diabetes with any microvascular complication e.g. diabetic eye, chronic kidney disease (eGFR < 60 mL/min and/or UACR > 3 mg/mmol)
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UACR ≥ 30 mg/mmol
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eGFR < 45 mL/min
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UACR 3 – 29 mg/mmol and eGFR 45 – 59 mL/min
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Age > 50 years and UACR > 3 mg/mmol and/or eGFR < 60 mL/min
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Familial hypercholesterolaemia
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For others lipid-lowering therapy is strongly recommended if moderate CV risk (5 year CV risk 5 -<10%) with a target LDLc < 1.8 mmol/L, particularly if any significant risk factors.
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Direct family history of CVD < 40 years of age
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Onset of CKM disease at < 40 years of age
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Severe mental illness particularly with antipsychotic use
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Cardiac calcium score ≥ 100
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Gout
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MASLD
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Lipid lowering therapy should be still considered if low CV risk (5 year CV risk < 5%) if any risk factors, particularly if 5 year CV risk ≥ 3% and/or LDLc > 4 mmol/L, but is largely driven by patient preference. Statins are generally not recommended if low CV risk without any risk factors.
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Direct family history of CVD < 40 years of age
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Onset of CKM disease at < 40 years of age
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Severe mental illness particularly with antipsychotic use
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Cardiac calcium score ≥ 100
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Gout
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MASLD
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Previous gestational diabetes and/or preeclampsia
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Lipid lowering therapies
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Lifestyle management is always important in managing dyslipidaemia, particularly hypertriglyceraemia
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Even 5% total body weight loss will significantly improve dyslipidaemia if overweight
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Atorvastatin and rosuvastatin are first line pharmacotherapy to achieve LDLc targets in CKM:
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Rosuvastatin is preferred if previous CV event but mismatch with special authority criteria
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Current special authority requires previous failures of atorvastatin or simvastatin to reach LDLc target unless Māori or Pacific ethnicity
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Maximise rosuvastatin use in Māori and Pacific peoples given funded and their high CV risk
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Other ethnicities may choose to self-fund rosuvastatin without trialling atorvastatin as cost is $12 per week
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Usual dose range is atorvastatin is 10 – 80 mg daily and rosuvastatin 5 – 40 mg daily
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At least 40 mg atorvastatin or 10 mg rosuvastatin daily is typically required to achieve a 50% reduction in LDLc
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Consider starting rosuvastatin 5 mg daily if South East Asian ancestry due to a common genetic polymorphism that increases rosuvastatin levels
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Recent studies show statins have low and potentially no teratogenicity - so statins should now be used in women of child-bearing age without fear. At present, advice is to still stop statins in pregnancy and breastfeeding, but discuss with secondary care if established cardiovascular disease and/or familial hypercholestraemia as it may be safest to continue statin use.
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Measure LDLc at least 3 monthly and titrate statin to reach LDLc target or maximal tolerated dose
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90% of LDLc lowering evident within 2 weeks so do not need to wait 3 months before titrating
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Repeat testing may be barrier to optimising treatment so consider starting statin at or rapidly titrating statin to estimated dose to reach LDLc target
| Mean % reduction in LDLc for statin dose |
|---|
| 34% | 41% | 48% | 55% | 60% |
| Atorvastatin | 10 mg | 20 mg | 40 mg | 80mg | - |
| Rosuvastatin | - | 5 mg | 10 mg | 20 mg | 40 mg |
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Switch atorvastatin to rosuvastatin if LDLc is above target on 80 mg daily or maximal tolerated dose
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Maximum dose of rosuvastatin is 10 mg daily once eGFR < 30 mL/min
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Consider trialling pravastatin if intolerant of low dose atorvastatin and rosuvastatin
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Statins are typically well tolerated with most adverse effects only minor
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Many reported adverse effects of statins may be due to the nocebo effect, particularly fatigue and muscle aches. Indeed, statin-induced myopathy predominantly affects the shoulder and hip girdle rather than generalised muscle pain. Rhabdomyolysis and hepatotoxicity are extremely rare.
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Only 50% of reported mild adverse effects and/or mild derangement of liver enzymes recur on re-trialling the same statin or a different statin. Statins are also useful agents in people with MASLD.
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Therefore, it is important to determine if true statin intolerance if mild to moderate symptoms due to the significant benefits of statins.
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The benefits of statins almost always outweigh the rare deleterious effects on hyperglycaemia in people with CKM and should not prevent treatment.
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Consider ezetimibe 10 mg daily if LDLc above target despite maximal tolerated dose of statin
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NB: Ezetimibe no longer requires special authority approval
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Consider alirocumab or inclisiran if LDLc still above target but require SC injection (2-4 weekly or 6 monthly), are not funded and are expensive. They will reduce LDL on average by a further 50% from baseline.
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Consider bezafibrate if persistently elevated triglycerides (TGs) and LDLc still above target
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Target TG < 1.7 mmol/L if previous CV event
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Target TG < 5.7 mmol/L if no previous CV event
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The guidance in this section is predominantly based on the European Society of Cardiology Guidelines on Dyslipidaemias (Management of), which can be accessed at www.escardio.org/Guidelines/Clinical-Practice-Guidelines/Dyslipidaemias-Management-of#