NHS Greater Glasgow & Clyde Area Drug and Therapeutics Committee
Greater Glasgow and Clyde Medicines
Medicines Update

GGC Lipid Guideline Update

What’s new?

The GGC primary and secondary prevention of coronary heart disease and stroke guideline has recently been updated. Atorvastatin is now recommended as the statin of choice for both primary and secondary prevention. There is also a new section on the management of hypertriglyceridaemia. Refer to the guideline for full information.

A summary of the main changes include:

Primary Prevention
(including all patients >40 years with diabetes and all patients with chronic kidney disease (CKD) 3-5)

Updated guidance Previous guidance
Atorvastatin 20mg daily* Simvastatin 40mg daily

*Maintenance of existing statin therapy is an acceptable alternative for patients already established on treatment

Secondary prevention

Updated guidance Previous guidance
Atorvastatin 40-80mg daily (80mg for high risk ACS/stroke)  Simvastatin 40mg daily
Target cholesterol <4 mmol/L or a >40% reduction from baseline Target cholesterol <5 mmol/L or a >25% reduction from baseline
Ezetimibe 10mg daily is an option in addition to a statin for patients not reaching target cholesterol levels on a maximum tolerated statin dose Ezetimibe non-formulary

Why change?

The changes are based on NICE guidance (CG181 2014). This guidance recommends the routine use of high intensity statins, defined as statins expected to produce a >40% reduction in LDL cholesterol. The following table defines the doses of statins considered high intensity:

High intensity statin Comments
Atorvastatin 20–80mg daily Included in updated GGC guideline
Rosuvastatin 10–40mg daily Restricted in GGC for use only in patients for secondary prevention who fail to reach target lipid levels or are intolerant of other statins. Doses of 40mg or higher should only be initiated by, or on the advice of a specialist
Simvastatin 80mg daily Associated with an increased risk of myopathy and therefore is not recommended

Overall the anticipated magnitude of benefit resulting from a switch to high intensity statins, (+/- addition of ezetimibe) would be a 10-20% relative reduction in adverse cardiovascular events, with a potential mortality benefit of a similar magnitude.