High intensity statins – a dose of atorvastatin 20mg daily – is the first line recommendation for primary prevention of CVD. For the general population, NICE indicates this is in “people aged 84 years and younger if their estimated 10-year risk of developing CVD using the QRISK assessment tool is 10 per cent or more and lifestyle modification is ineffective or inappropriate”.³³

Lipid modification therapy is recommended for all people with type 1 diabetes, while in type 2 diabetes, the threshold is a 10 per cent or greater 10-year risk of developing CVD.

If a statin is contraindicated or unsuitable, ezetimibe may be appropriate to inhibit the intestinal absorption of cholesterol.^33,34

For secondary prevention, for example in people with established CVD, first-line recommendations are not to delay high-intensity statin treatment, starting at atorvastatin 80mg daily if the person is willing. For someone already on simvastatin 80mg daily, which carries an increased risk of myopathy (muscle weakening), patients are advised to switch to atorvastatin (up to) 80mg daily. People who were prescribed rosuvastatin 10mg, 20mg or 40mg daily can continue with that treatment.³³

Blood LDL-cholesterol levels should be monitored and treatment stepped up if necessary. Liver function tests should be carried out after three months and then annually. Creatinine kinase testing is advised if adverse effects such as muscle pain, tenderness or weakness occur.