Management of Lipids

This episode was recorded in Quarter 4 2025. The information provided in this podcast is for educational and informational purposes only. The views and opinions expressed by hosts and their guests are their own and do not necessarily reflect those of the Irish College of GPs. By listening to this podcast, you acknowledge that no party is liable for any director and direct consequences resulting from the use of the information provided. More information can be found in the show notes or at Irishcollegep.ie. The numbers needed to treat in primary prevention is in around 40 or less. That's a quite a significant benefit in terms of reducing the chances of something that could cause death or significant morbidity in the future. So I think there's no doubt about it that our current obsession with managing LDL and getting it to target comes with significant benefits. Hello and a very warm welcome to the GP podcast from the Irish College of GPs with me, Dr. John Marr. The European Society of Cardiology recently published a full-custom date of the 2019 guidelines for the management of the Slippidinius and this presented an opportunity to review the importance of appropriate management as well as newer tests and management options. And to help me today, I'm joined by two experts. Here they are. So Aiman O'Shea is my name. I'm a work as a GP in Galway City and I am the cardiovascular lead with the Irish College of GPs. I'm David McConaughey and GP in Salons County of the Air and I'm Irish College of GPs prevention lead. In today's comprehensive review of lipid management and primary care, David and Aiman discussed topics such as the positive impact of managing elevated lipids on cardiovascular risk, focusing on LDL cholesterol targets for different risk groups. The initiation of lipid lowering therapy and management of side effects, including considerations for women of childbearing age. The opportunity presented by the HSC GP OCF, APP and CDM programs to review LDL levels and ensure therapy is optimised to reach target based on risk stratification, as well as newer developments including how and when to initiate benpatoic acid, the role of integrated care hubs and the emerging measurement of lipoprotein A as an independent risk factor. As usual, you'll find links to resources mentioned during our conversation, along with chapter markers and a transcript of the episode in the show notes. Aiman began by explaining how to stratify patients into risk categories to ensure management reaches the appropriate LDL target. If we start from high to low, we're all probably aware of people that are a case of secondary prevention so they've already had an event unfortunately. The European Society of Cardiology would advise that their LDL of that patient should be less than 1.4. But included in that very high risk group, including included with secondary prevention people, would be people with chronic kidney disease within EGF-4-1-30. Patients with type 1 diabetes over the age of 40. Patients with type 2 diabetes who have moderate CKD, so an EGF-4-1-45. Any case with proven familial hypercholestralemia, and anybody with a Q-risk 3 of over 30%. So those are all people who we should be really trying to aggressively control their LDL to under 1.4. The next group is the group who are considered to be at high risk. So that is people with a Q-risk 3 of between 15 and 29%. People with CKD stage 3A, so that's within EGF-4-1-45. Type 2 diabetes is but without target organ damage. And that group of people have a risk of a target LDL of 1.8 or less. And lastly, then you've got your moderate risk group, which I suppose includes. Most of the people we're looking after is that their LDL target is 2.6 or less, and that is your people with a Q-risk of between 5 and 14%. So that's the way I look at it. I think of 1.4 for the very high risk, including people who have already got disease, 1.8 for people who are high risk. And then the moderate risk group is 2.6. And I guess given the fact that for some of those cohorts in the high risk groups, many of those are going to be captured at some point in a GP CDM review. Absolutely. And I think one of the things I've often talked to colleagues at work about is that we see these people on a very regular basis. And I think people need to consider the LDL. And when they're looking at the LDL result on the CDM patient in front of them, just double check, where do they stand in those bands? Is this somebody who's already had an event? So therefore we're really looking for a sharp control under 1.4. Are there people maybe who haven't had an event but have a Q-risk that's relatively high? Between 15 and 29% we should be looking for 1.8 with them and anybody else then it's 2.6. So think of that. Those targets when you're looking at your CDM patient. I have that chart that has come from the ESC on my desktop and I consulted on a regular basis. Okay, that's going to be useful for my own practice. I must say. So thanks for that. David, taking aim in starting point, I've got a patient and I've set my target whether that's 1.4, 1.8 or 2.6. Could you walk me through how you go about starting patients when you review them on what to do when things are going wrong in terms of side effects? So when you make a decision that we're going to initiate the lipid lowering therapy, the first thing is to explain to the patient that rationale behind it. So I would explain to them that, yeah, you're at increased risk. We're doing something positive now to stop something negative happening. I explained to them. Usually it's that ends we start first line and I explained to them how the medication works when you take it. And then patients often have some preconceived thoughts on statins. They may have read that they cause muscle aches. They're worried about them causing diabetes, demands there as well. And so we sort of discussed that through the figures on muscle aches are that 1 and 200 people will get muscle ache from a statin. So that means that 199 of those 200 won't. I often ask them, do they have muscle aches to start? Many people in midlife and beyond. And sometimes younger have already have some aches and explained them that if it's down to the statin, you'll be unlucky for it to happen. And it'll be a worse than where you are at baseline as well. And then we make sort of the decision then to prescribe for primary prevention, 8th of a statin, 20 milligrams or Rolesuva statin, 10 milligrams are a good place to start. One time of the day and then we will schedule them to come back then for recheck lipids, liver function and a CPK after about 12 weeks would be the recommendations then. At that stage, if they weren't below target, you increase the statin. And you might well be also at that stage asking them, are they experiencing any side effects? The muscle aches being the one or you might find that their CPK has gone very high with the muscle aches or their liver function is quite off. You may have to modify then. But to be honest in my day to day practice, it's very unusual for me to have to stop a statin on a patient because of liver function changes or muscle aches. It's an exception rather than the real. So David, if somebody is not tolerating the statin that you commenced them on and you're thinking about stopping, are there any alternative strategies before you pivot towards something like his atom? So some of our patients will not tolerate the statin. Your choices then are that you move to a different statin. So if they run, receive a statin, try a tar of a statin. I often find that if one of these is intolerated, the other sometimes is another strategy is to start at with two days a week statin. So perhaps start them off Monday and Friday for a few weeks, then up to Monday, Wednesday, Friday and then virtually over the period of four to six weeks, build them back up to seven days of statin. And often this works as a strategy as well. Sometimes lower potency statin, so system of statin will be better tolerated. In the same way with hypertension, there are some of our patients who might not reach their target systolic blood pressure. and there may be some of our patients who do not reach their target LDL and The important take home here is that some statin is better than no statin and then also the Bumperdoic acid and the Zeta Mibar two others that you might consider using as well In these cases Thanks David Amen out of interest would you ever like set from mind or is renting like that on patient charts where you've recognized that somebody's high risk Are very high risks that if somebody else is opening it and they don't realize that they're diabetic with you know end organ consequences Are there any quick tips like that that can add that can align a practice to make sure this stuff is managed on an ongoing basis? Yeah, if my colleagues in practice who might be listening to this podcast would start laughing at this point because you can get a degree of Reminder fatigue sometimes I I went stone mad and remind us for a while and I'm actually caught in back a little bit Yes, it's useful. I think This the CDM program obviously is a key one like I think that's where I'm sharpen enough when when I'm seeing a CDM patient or an annual preventive program patient I'm looking up my little reminder on the desktop. What LDL should this patient be at and I'm thinking of it that way I I do think that you've touched on a point that there are people the younger group who are asking to get their cholesterol checked Generally speaking as well as we wouldn't have encouraged that generally but if there is a family history of premature heart disease in the family or a family history of Of high lipids so they might come to you and say actually my brother and my sister has had a check and they were told they're high their lipids were high Then I think it is worthwhile checking us in somebody under 40 And does it have a podcast on familial hyper cholesterolemia but very briefly If you if you if there is a significant family history our exam findings are indeed a strikingly high cholesterol result that would be time to pull up the The Dutch criteria score for familial hyper cholesterolemia, but we won't go in so too much detail today because there's a separate public I stand that but And sure a man if if somebody has as David said they've been titrated But you're not getting to target which was statin and you're you're looking towards is that my and benpidoric acid Maybe you could tell me what kind of a difference they make and Particularly for benpidoric acid which I think might be a bit less familiar to some GPs How to go about prescribing that please? Yeah, so so it is relatively new and I suppose more and more we are coming across patients who either can tolerate statins or Or in whom we're struggling to get to target with The kind of higher doses of the high intensity statins So if you think put it into perspective And this again is from the recent update of the European Society cardiology guidelines And Updated this year. So your high intensity statin said that's your atarva statin or a suva statin that are relatively high dose That'll get your LDL down to about half water baths that will get it down to about 50% Is etymide on its own we get it down a further 20% I'm the benpidoric acid is a little bit more than that it'll get it down by 23% Um if you get if let's say somebody can't tolerate this dot in at all If you manage to get them on is etymide benpidoric acid together That'll bring it down to about 38% so it's not far off the 50% that we we've Been kind of trying to get done with the high intensity statin. So they're good agents They're very well tolerated at scenes although they're all they're the benpidoric acid certainly is relatively new One of the problems I guess with benpidoric acid is that At the moment we're limited in that there has to be an application done to the PCRS to get it funded And a lot of GPs might feel that that is something that they prefer referred to cardiology to get done all be it can be done online through the PCRS um And what they want is they'll have they'll want proof that the person first has um Had reasonably high dose of a statin um and that their LDL hasn't come down with that Or that they haven't tolerated it so they'll usually want proof of the LDL level both um Three months ago when you maybe tried to keep up the line of higher dose statin and um now In terms of these etymide benpidoric acid is there anything in particular that I should Tell my patients to look out for in terms of side effects if I do manage to go through PCRS for the For the benpidoric acid or if I'm starting on as etymide They tend to be reasonably well tolerated um benpidoric acid if you if you look it up it will mention um An effect on increasing blood pressure and increasing thirst and appetite and a lot of appetite And nausea but it tends to from Limited enough experience that have to admit that they're reasonably well tolerated and is that unlike the same um I certainly in practice haven't come across people um complaining of much from use of it um So certainly if you compare it to the amount of people that complain of of side effects related to the statins And both seem to be pretty pretty clean from that point of view And forgive my ignorance because again, I wouldn't have much in experience with benpidoric acid Do you know is it a medication that you start low on titrate or is it a single single dose One dose one dose yeah Okay David Aiming briefly mentioned the Is that if your statin and your zedymide is Not getting you to target Some gps may elect to make that application for the benpidoric acid and others might decide that's the time for cardiology input Which might be a good time to mention the ongoing role as of the cardiology integrator hubs Yeah, we're very far too nationally that there's been considerable investment in these integrated care hopes Um, which should be there in every c-tual area Um, not all of them are overrunning at the moment but in many parts of the country you'll find that there is a cardiology hope um Available to you if um Or if not it's cardiology i patients in your your local hospital I think as well as it's worth point to note that um LDL lipids they're all one part of the whole overall cardiovascular risk and Often these patients may well have um, you know pre-diabetes hypertension um as well the family history And sometimes when I find that you know I've taken the statin as high as a can be tolerated Um, I've added in a set of my or the older agents And we're not getting to the LDL targets that we wish once we've confirmed compliance as well. It's very important tablets won't work in the box They have to be taken and at that stage I'll often refer to secondary care for an overall sort of cardiovascular workup as well um And I think the plan is that we will have in the coming 12 to 18 months um a lipid service in the integrated care hubs nationally as well When you compare us to our international peers Northern Ireland and it's just gotten we have a fewer lipid Specialists in secondary care per capita and but this is being addressed. I'm glad to say Thinking about all things cardiology aim and um one of the the newer um Aspects of of of lipid management that I hear from time to time revolve around um lipoprotein a Both from colleagues and from people on the street wondering why I'm not measuring their lipoprotein a very frequent intervals could you maybe Haras that's one out for me a little bit So yes, I think it's definitely something we'll be hearing more about in the future um It's a very interesting thing it seems to be um Something that increases your risk of cardiovascular disease It seems to be quite independent of the other lipids so it's independent of LDL um Interestingly, it stays stable throughout your life So it's not something that you will need when when when it does become available to us on a regular basis It's not something that you that that that does any point in repeating And throughout your life once once in your lifetime will give you your your LP little a uh result and you don't need to repeat it again I think there's some debate as to maybe perhaps women after the menopause might need to get a second one if they had one done before then so it also isn't isn't modified by by lifestyle um And what we know is that it it independently increases your risk of cardiovascular disease So as I said labs at the moment do not have the facility to provide it on a regular basis um Some labs are starting to offer it in limited um cases The kind of person you might be thinking about Too particularly would come to mind one is a person who has a family history of premature heart disease um And particularly in that case if the person has high lipid levels Um because if you think about it We use QRISQ or we use the score and very often a young person even if they're quite high lipid levels [BLANK_AUDIO] their overall risk will be in the case of QRISK would be under 10%, so we probably won't be advising a statin. But where LPA little A comes in is that in that situation, they let's say, it's got somebody with a high DLDL, but the overall QRISK is low because of their age, the relatively young age. If they happen to have an LPA little A checked and it was high, that might re-stratify their risk and that might push them into statin territory. Earlier then would otherwise be the case. So I think it's something that we're going to hear a little bit more about it. At the moment, there isn't any proven therapy out there for lowering lipoproposaline A, but those of us that are keeping an eye on the journals will see that there's research coming out. I think those kind of drugs are in the pipeline. So at the moment, its value really is in perhaps re-stratifying risk in a person that might not necessarily be a case for a statin on the information we have at the moment. Occasionally, a micr-de-patient too comes from a private clinic or a clinic overseas and they have their printout of their results and there's a lipopropotine A or some of those tests where they're jabbing at the page saying, "Do something about this." You're trying to catch up with this. But that's useful. So there is an independent risk factor there. So at the bare minimum, it opens up the discussion around lifestyle modifications. If there's nothing to treat as it were in terms of blood pressure being normal, BMI being normal, and cholesterol being normal. If this is an elevated marker, then you can have that conversation. Yeah, to advise that person, if somebody had gone to a private lab and got an LLP little A that was raised, their latest European society cardiology guidelines gives you a little graph that you can add the LLP little A test result to their overall risk and see how that changes. So that's one thing you could do if you're interested. And the bottom line is what that person needs to do is have a healthy lifestyle, keep the blood pressure normal, keep the LDL to normal levels. And so the overall management is very similar to what we would already do for people with raised risk of cardiovascular disease. Okay, thanks for that, Damon. And David, I suppose what we're talking about there is oftentimes a younger cohort of patients. And another obvious category in that younger cohort would be women of reproductive age. And you wanted to send a note of caution around women who would like to conceive. That's right. Increasingly we are picking up cases of familial dyslipidemia. And these patients will be established on proxistatin plus zetamib. None of the lipid lowering agents are safe in pregnancy or breastfeeding. So I think if if if you had a woman was familial dyslipidemia on a lipid lowering agent, I think it would be very important to flag this often that it's not safe in pregnancy. That pregnancy would be planned. That you would allow a three months period for the lipid agent to wash out before you had abandoned contraception, get through the pregnancy and then restart the lipid lowering agent as soon as possible after delivery. But I accept that many listeners would might find this a daunting and challenging case. So I wouldn't see any problem either of enlisting the help of a lipid clinic or a teleology colleague in the management of structure case. But have inside that said that David, as you said, you know, we did a separate podcast on familial hypercholestralemia as I said. And a really important one to remember if possible when commencing a woman of childbearing age on the statin. At that stage, like a number of other medications that it is contraindicated. So I suppose four warrants, four armed is netted. Correct indeed. And again, it goes for a woman also on various anti-hypertensive agents as well, which are not recommended in pregnancy. Okay, thanks for that. And even before we wrap up, I think you've got some of the numbers in front of you, but actually the value of embarking on these strategies to our patients, and that might be a good place to end. Would you mind just going through some of the numbers? Yeah, so I suppose at the end of the day, we're about preventing atherosclerotic disease. And, you know, LDL cholesterol is, you know, a very, very significant risk factor in the development of atherosclerotic plaques. And people like sometimes to keep numbers needed to treat in their heads. So if you think of it, even on the kind of low-grade statins that were the first trials, like the 4S study, there was a numbers needed to treat a 15 to prevent another event in somebody who already had an event. So that's the secondary prevention value. And that's even less with the higher potency statins. And we're looking at in terms of, you know, we're often wondering about trying to convince somebody who is at risk of an event but hasn't had one yet. And sometimes it's a difficult job to persuade them to take a statin. But, you know, the numbers needed to treat in primary prevention is in around 40 or less. And, you know, so that's a quite a significant benefit in terms of reducing the chances of something that could cause death or significant morbidity in the future. So I think there's no doubt about it that our current obsession with managing LDL and getting it to target coms with significant benefits. Many thanks to Dr. Amel O'Shea and Dr. David McConehey for speaking to me today. And don't forget to check the show notes for chapter markers, links to resources and a full transcript of today's episode. If you have any comments, feedback or indeed suggestions for a future episode, please let us know. You can drop us a line at [email protected]. And that's it for today. Many thanks again for listening and until next time, take care. We hope you enjoy this new podcast for general practitioners from the Irish College of GPs. If you do, please subscribe so you never miss an episode. And if you have a minute, please consider leaving a review in the podcast app of your choice to help us reach more people. And if you have any questions or comments, or indeed suggestions for future episodes, we'd love to hear from you. You can reach us at [email protected].