Diabetes – Lipid Management Care Pathway

Review in progress

Disclaimer: The guidance contains helpful primary care information for management of referrals and up to date referral criteria. These guidelines are locality specific to best reflect local services. This guidance does not override or replace the individual responsibility of healthcare and social care professionals involved in the delivery of care to make informed professional judgements appropriate to the circumstances of the individual.

Scope

This guidance refers to:

  • The assessment and management of lipids which is fundamental to the treatment of Type 2 diabetes to reduce the risk of coronary events and mortality.

This guidance does not cover:

  • Diabetes in children and adolescents
  • Maturity onset diabetes of the young (MODY) and neonatal diabetes
  • Population screening for asymptomatic diabetes

Assessment

Each patient should be clinically assessed and their individual risk should be discussed.

Caution - Do not forget secondary causes of hyperlipidaemia in patients with diabetes such as:

  • Hypothyroidism
  • Primary biliary cirrhosis
  • Alcohol excess
  • Nephrotic syndrome
  • Chronic renal failure
  • Drugs


Investigations

All adults with diabetes should have their blood lipids checked at the time of diagnosis and every year thereafter.

Management

All people with Type 2 Diabetes should receive lifestyle advice:

Lipid Lowering
  • Statin therapy remains the best and only effective lipid modifying agent to lessen the CVD risk in people with Type 2 diabetes
  • Statin therapy should be recommended for people with Type 2 diabetes over 40 years of age, irrespective of cholesterol value
  • Intensive statin therapy is recommended for diabetes patient with existing CVD and those with persistent proteinurea or CKD with eGFR 30-60ml/min. Intensive statin treatment is also recommended for patients who do not achieve non-HDL cholesterol targets
  • Statins should also be considered for people with diabetes who are younger than 40 years, if there is evidence of persistent albuminurea eGFR <60ml/min, proliferative retinopathy, treated high BP or autonomic neuropathy
  • Fibrates used in monotherapy or in combination therapy have not been shown to provide overall CVD benefit in Type 2 diabetes and should not be prescribed for CVD risk reduction (JBS 3 2014)
Treatment
  • Atorvastatin 20mg daily
  • Discuss lifestyle modification with the patient and optimise the management of all other modifiable CVD risk factors
Monitoring
  • Measure the total cholesterol, HDL and non HDL following three months of treatment aiming for greater than 40% reduction in non HDL. If this is not achieved discuss adherence and the timing of the dose, optimise diet and lifestyle measures
  • Consider increasing the dose of Atorvastatin to 80mg daily if the patient is judged to be at a higher risk because of comorbidities, risk score or clinical judgement
  • Measure ALT at 3 months and again at 12 months and NOT again unless clinically indicated
  • Measure lipid profile annually
    • If ALT >3 times the upper limit or other abnormality- stop or reduce the dose of the statin (recheck full LFT within 4- 6 weeks)
    • If patient reports unexplained muscle pain check creatinine kinase (CK) consider statin drug interactions

Note: less than half of the treatment population will achieve a total cholesterol of less than 4mmol/l or LDL less than 2mmol/l even when prescribed atorvastatin.

If there is a possibility of a woman becoming pregnant do not use statins unless the issues have been discussed with the woman and agreement has been reached.

Supporting Information

Shared Decision Making

  • Patients have a right to make decisions about their care and should be fully informed about the options they face. They should be provided with reliable evidence-based information on the likely benefits and harms of interventions or actions, including any uncertainties and risks, eliciting their preferences and supporting implementation.

Patient information/Public Health/Self Care

Evidence/Additional Information

Assurance & Governance

  • This guidance was developed on: 07.2017
  • This guidance was ratified by: The OSCAR Assurance Group
  • Date ratified: 07.2017
  • Publication Date: 07.2017
  • Review Date: 07.2019
  • Ref No: END6 - 2.2017
Any feedback or suggestions to improve this guidance should be sent to: oscaradmin@this.nhs.uk
Only the electronic version is maintained, once printed this is no longer a controlled document

 

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