Summary of National Guidance for Lipid Management for
Primary and Secondary Prevention of CVD

Greater than

20mmol/L

Refer to lipid clinic for urgent specialist review if not a result of

excess alcohol or poor glycaemic control. At risk of acute pancreatitis.

If non-fasting triglycerides are greater than 4.5mmol/L, repeat with

a fasting TG measurement Be aware that the CVD risk may be

underestimated by risk assessment tools, optimise the management

of other CVD risk factors present and seek specialist advice if non-

HDL-C concentration is > 7.5 mmol/litre.

• Check fasting triglycerides levels.

• Manage secondary causes of hypertriglyceridaemia.

• Consider icosapent ethyl (TA805) if patient has established cardiovascular disease

  (secondary prevention) and

    - on statins and fasting TG ≥ 1.7mmol/L and LDL-C* between 1.04^‡ and ≤2.6mmol/L

• See table above and refer as appropriate.

* LDL-C cannot be calculated using Friedewald’s formula if TG >4.5. Discuss with your lab. Consider using an alternative equation (eg Sampson, doi: 10.1001/jamacardio.2020.0013) or beta-quantification.

‡ labs don’t report calculated LDL-C beyond one decimal point

This guidance applies to new patients and may also be taken into consideration for those already on statins at their annual review. If 40% reduction of non-HDL-C, or target levels are not achieved, offer high intensity statins. Discuss with people who are stable on a low- or medium-intensity statin the likely benefits and potential risk of side effects if changed to a high-intensity statin when they have a medication review and agree with the person whether a change is needed.

Ezetimibe, alirocumab, evolocumab or inclisiran can be added when patients’ LDL-C levels are not lowered enough with the maximally tolerated dose of statins. If statins are contraindicated or not tolerated and ezetimibe alone does not control LDL-C well enough, bempedoic acid with ezetimibe is an option. Do not offer a fibrate, nicotinic acid, bile acid binder or omega-3 fatty acids alone or in combination with statin, for the prevention of CVD (check NICE NG238 and TA805 for exceptions).

• Rosuvastatin may be used as an alternative to atorvastatin if compatible with other

• drug therapy. Some people may need a lower starting dose (see BNF).

• Low/medium intensity statins should only be used if intolerance or drug interactions.

• Ezetimibe when combined with any statin is likely to give greater reduction in non-HDL-C

• or LDL-C than doubling the dose of the statin.

• PCSK9i (NICE TA393, TA394) alone or in combination with statins or ezetimibe produce

• an additional LDL-C reduction of approximately 50% (range 25-70%).

• Bempedoic acid when combined with ezetimibe (TA694) produces an additional LDL-C

• reduction of approximately 28% (range 22-33%).

• Inclisiran (TA733) alone or in combination with statins or ezetimibe produces an

• additional LDL-C reduction of approximately 50% (range 48-52%) but no clinical outcome

• evidence is currently available.

Scope of specialist service available locally may include; lipid clinic, PCSK9i clinic

(offering initiation and subsequent follow up), FH genetic diagnosis and cascade

testing, lipoprotein apheresis service. NICE eligibility criteria for PCSK9i and fasting

LDL-C thresholds are summarised below.

Primary non-FH or mixed

dyslipidaemia

LDL C > 4.0

mmoL/L

LDL C > 3.5

mmoL/L

Bempedoic acid/ezetimibe and inclisiran are available in primary care and do not

require initiation by specialist services.’ PCSK9i may be available for prescribing in

primary care: see local initiation pathways.

This guidance applies to new patients and may also be taken into consideration for those already on statins at their annual review. If 40% reduction of non-HDL-C, or target levels are not achieved, offer high intensity statins. Discuss with people who are stable on a low- or medium-intensity statin the likely benefits and potential risk of side effects if changed to a high-intensity statin when they have a medication review and agree with the person whether a change is needed.

Ezetimibe, alirocumab, evolocumab or inclisiran can be added when patients’ LDL-C levels are not lowered enough with the maximally tolerated dose of statins. If statins are contraindicated or not tolerated and ezetimibe alone does not control LDL-C well enough, bempedoic acid with ezetimibe is an option. Do not offer a fibrate, nicotinic acid, bile acid binder or omega-3 fatty acids alone or in combination with statin, for the prevention of CVD (check NICE NG238 and TA805 for exceptions).

• Rosuvastatin may be used as an alternative to atorvastatin if compatible with other

• drug therapy. Some people may need a lower starting dose (see BNF).

• Low/medium intensity statins should only be used if intolerance or drug interactions.

• Ezetimibe when combined with any statin is likely to give greater reduction in non-HDL-C

• or LDL-C than doubling the dose of the statin.

• PCSK9i (NICE TA393, TA394) alone or in combination with statins or ezetimibe produce

• an additional LDL-C reduction of approximately 50% (range 25-70%).

• Bempedoic acid when combined with ezetimibe (TA694) produces an additional LDL-C

• reduction of approximately 28% (range 22-33%).

• Inclisiran (TA733) alone or in combination with statins or ezetimibe produces an

• additional LDL-C reduction of approximately 50% (range 48-52%) but no clinical outcome

• evidence is currently available.