Login

RCHT Lipid Service


Referrals only: A completed Family history questionnaire must be attached, or referral will be rejected.

 

PRIOR TO LIPID CLINIC REFERRAL / A&G request

  • If referring for FH genetic cascade screening, refer to relevant section under ‘referral criteria’ (advice below is not required for referral)
  • If triglycerides greater than 4.5 mmol/L, refer to the relevant section under ‘referral criteria’ for initial management, but incorporate the lifestyle modifications (they are still part of management)

 

Please do not refer a patient on the basis of one abnormal lipid profile

(Familial diagnoses require evidence of persistence after secondary causes are excluded, and initial management of primary CVD prevention is lifestyle, with the need for medication considered after that (Refer to AAC guidance under ‘useful links’))

 

 

Always repeat on a FASTING blood sample AND exclude/manage potential secondary causes including:

  • Profound hypothyroidism
  • Undiagnosed or poorly controlled diabetes mellitus
  • Excessive alcohol intake
  • Poor diet              
  • Obesity
  • Medications (e.g. thiazide diuretics, ciclosporin)
  • Pregnancy
  • Nephrotic syndrome

 

  • Advise lifestyle changes (and weight loss if required); most patients’ lipid profiles start to improve following 2-3 months of lifestyle modifications.
     
  • Direct patient to HEART UK website for information, lifestyle and diet recommendations (https://www.heartuk.org.uk/healthy-living/introduction)

 

  • Lifestyle modifications generally include:
    • Healthy eating (Mediterranean style is recommended)
    • Reducing dietary saturated fat intake and swapping to unsaturated fats e.g. from butter to plant-based spread
    • Reduce sugar intake
    • Alcohol intake as per UK guidelines
    • Encourage exercise 
    • Weight loss (if required) is recommended to achieve a healthy BMI

 

Investigations prior to referral

  • Lipid profile (ensure at least two to show persistence)
  • Liver profile
  • TSH
  • Renal profile
  • HbA1c
  • CK (if relevant)
  • Lp(a) – ONLY if patient is in the following cohort:
    •  A personal or family history of premature atherosclerotic cardiovasculardisease (< 60 years of age)
    • First degree relatives with raised serum Lp(a) levels (> 200 nmol/l)
    • Familial hypercholesterolemia (FH), or other genetic dyslipidaemias
    • Calcific aortic valve stenosis
    • A borderline increased (but<15%) 10-year risk of a cardiovascularevent

 

REFERRAL CRITERIA(1)(2)


Familial Hypercholesterolaemia (FH) genetic cascade screening (Irrespective of lipid profile)

  • PLEASE make the patient aware we can only genetically cascade screen if we have the following information (to ensure genetics laboratory can screen for the correct mutation):

 

EITHER: a copy of their relatives’ genetics report

    OR:         their relatives’ details (name, date of birth, NHS number) and the genetics laboratory their FH genetic test was performed at (at the top of their genetics report)

 

 

Suspected Familial Hypercholesterolaemia

 

  • If fasting triglycerides >3 mmol/L, refer to high triglyceride management
  • EXCLUDE secondary causes including advising lifestyle change, then repeat the lipid profile to ensure the hyperlipidaemia is persistent.

 

  • Consider referral if:

Total Cholesterol > 9 mmol/L or non-HDL cholesterol > 7.5 mmol/L

OR

Cholesterol > 7.5 mmol/L when age under 30

OR

Fulfils the Simon Broom Criteria (see Below)

           OR

Dutch Lipid Clinic Score >5

 

            please use one of the following calculators:

 

 

If fulfils any of the above criteria, consider commencing treatment aiming for reduction in LDLc >50%.

[In untreated FH CVD risk is high; 50% of men and 30% of women will have had an MI by age 60

(BJGP 2009;59:777)]

 

 

 

 

STATIN INTOLERANCE

Steps used in statin intolerance (unless contraindicated):

  • Patient to have tried a minimum of 2 but ideally 3 statins (Rosuva, Atorva & (Prava or Simva (Prava maybe better tolerated))
    • Lipid-soluble statins: Atorvastatin, Simvastatin
    • Water-soluble statins: Rosuvastatin, Pravastatin

 

  • Must have included Atorva &/or Rosuva at low dose (20mg & 5mg respect.) and low dosing frequency e.g. 2-3x/week
    • Suggest commencing at 1-2x/week with the patient increasing dosing frequency every 1-2 weeks aiming for once daily or their highest tolerated frequency if once daily not tolerated. Many tolerate low dose at lower dosing frequency.
    • Statins are important (even with low dosing frequency) for plaque stabilisation benefits – sometimes helps for the patient to be aware of this (esp. those who are secondary prevention)

 

  • If lipid targets not achieved on the statin, or patient completely intolerant of statins then consider adding/starting other lipid-lowering agents

 

Consider referral for:

  • patients with FH who are intolerant of statins or who have not achieved their LDLc target
  • patients requiring secondary prevention who are intolerant of statins but eligible for a monoclonal PCSK9 inhibitor (Alirocumab, Evolocumab)

 

** For intolerance in non-FH patients (primary & secondary) who aren’t eligible for monoclonal PCSK9 inhibitor; follow the AAC guidance to use other lipid lowering agents where eligible, requesting A&G if required**

 

Hypertriglyceridaemia/Combined hyperlipidaemia (FASTING triglycerides >4.5 mmol/L)

 

**Those with triglycerides persistently greater than 10mmol/L are at risk of acute pancreatitis**

 

  • Refer to the link below for the initial management pathway

https://www.heartuk.org.uk/downloads/health-professionals/neeli-guideline-february-2022.pdf

  • (local version in progress)Refer to yellow section: hypertriglyceridaemia to undertake the initial management.  Important to determine if the patient requires referral to the lipid service, and suggests when to use a fibrate instead of a statin)

 

  • Repeat fasting triglycerides 5-14 days later (after secondary causes addressed)
  • Consider commencing fenofibrate or statin (as per NEELI guidance) and refer to Lipid Service if the fasting triglycerides persist greater than 10 mmol/L once secondary causes excluded (including poor glycaemic control, alcohol, poor diet), or triglycerides 4.5 – 9.9 mmol/L with non-HDLc >7.5 mmol/L

 

NOTE:

In most, significant reduction of the triglycerides (& secondarily the cholesterol) is seen within days with immediate management of:

  • lifestyle changes (if required)
  • improving glycaemic control (may need DSN/Endocrine A&G)
  • reducing alcohol if excessive  

 

In those who have a propensity to develop a dyslipidaemia of any kind, tend to have a more exaggerated deterioration in the lipid profile with ‘negative’ lifestyle changes (weight gain, highsaturated fat intake, reduced exercise, poor glycaemic control) & can also be less tolerant of the advised max. weekly alcohol intake of 14 units.

 

  • Please direct them to the HEART UK website for info about lifestyle changes & info about triglycerides:

https://www.heartuk.org.uk/cholesterol/triglycerides

https://www.heartuk.org.uk/healthy-living/introduction

 

 

Other occasions to consider A&G or referral:

  • Patient has premature corneal arcus (guide: any arcus (partial or full) by age 35, full circle arcus before 50) AND high cholesterol or family history of premature coronary disease

 

  • Patient has xanthelasma AND high cholesterol or family history of premature coronary disease

 

  • Patient has had a significant side effect to lipid-lowering medication

                        e.g. ALT >3x ULN or CK >5x ULN (ULN- upper limit normal)

 

  • If unsure if A&G or referral – submit A&G

 

 

 

POST REFERRAL

  • New patient will either be offered an outpatient ‘face-to-face’ appointment or virtually reviewed (paper review) via video/telephone as per patient choice
  • telephone review for all follow up appointments

 

The lipid clinic aims to:

1)      Identify patients with familial dyslipidaemia and confirm the correct diagnosis

2)      Optimise treatment

3)      Implement cascade screening of relatives

 

 

References:

  1. Morrell J, Wierzbicki T. (2009). 10 Steps before you refer for: Lipids. Br J Cardiol 2009; 16:242-5. Available from: https://bjcardio.co.uk/2009/09/10-steps-before-you-refer-for-lipids/
  2. National Institute for Clinical Excellence guidance. Familial Hypercholesterolaemia: identification and management (CG 71). London: NICE, 2017. Available from: https://www.nice.org.uk/guidance/cg71

 

 

 

 

USEFUL LINKS:

  • Guidance for lipid management in Primary and Secondary prevention

https://www.england.nhs.uk/aac/publication/summary-of-national-guidance-for-lipid-management/

 

  • Guidance for managing statin intolerance

https://www.england.nhs.uk/aac/publication/statin-intolerance-pathway/

 

  • Initial management of hypertriglyceridaemia (go to the yellow section in the following section), a local version of this pathway will be developed)

https://www.heartuk.org.uk/downloads/health-professionals/neeli-guideline-february-2022.pdf

 

  • Inclisiran does not need lipid clinic review prior to initiating, please see the guidance for starting Inclisiran on the Cornwall Joint Formulary:

https://www.eclipsesolutions.org/cornwall/info.aspx?paraid=157

 

  • HEART UK information about cholesterol, lowering medications;

https://www.heartuk.org.uk/getting-treatment/treatment-intro

 

  • HEART UK healthy eating guidance

healthy-eating-guide.pdf (heartuk.org.uk)