Before starting

Required

• Baseline
  • ALT or AST
  • Blood pressure
  • Body mass index
  • HDL cholesterol (non-fasting)
  • non-HDL cholesterol (non-fasting)
  • Serum creatinine (for creatinine clearance) or Estimated glomerular filtration rate
  • Total cholesterol (non-fasting)
  • Triglycerides (non-fasting)
  • HbA1c

Consider

• Baseline
  • Creatine kinase · If persistent muscle symptoms (pain, tenderness, weakness). Do not measure after strenuous exercise or after possible cause of increase.
  • Thyroid stimulating hormone · In people with symptoms of underactive or overactive thyroid

Continued until stable

Required

• Between months 2 and 3
  • ALT or AST
  • HDL cholesterol (non-fasting)
  • non-HDL cholesterol (non-fasting)
  • Total cholesterol (non-fasting)
  • Triglycerides (non-fasting)

Consider

• At 3 months
  • HbA1c or Blood glucose · if high risk of diabetes mellitus
  • Creatine kinase · If persistent muscle symptoms (pain, tenderness, weakness) but do not measure after strenuous exercise or after possible cause of increase (e.g. fall)

Ongoing once stable

Consider

• Annually
  • ALT or AST · repeat after first year only if indicated
  • non-HDL cholesterol (non-fasting) · to inform annual review
  • HDL cholesterol (non-fasting) · to inform annual review
  • Total cholesterol (non-fasting) · to inform annual review
  • Triglycerides (non-fasting) · to inform annual review

About annual review of statin therapy

Cholesterol and triglyceride values should be used to inform annual review as discussed in the NHS England summary of national guidance for lipid management.

Abnormal results

Transaminases

Stop existing statin or do not initiate new statin if ALT or AST are greater than 3 times upper limit of normal (ULN). Repeat ALT or AST in one month, and if they are still greater than 3 times upper limit of normal, do not prescribe a statin.

Further information on the management of raised transaminases less than 3 times ULN can be found in the NHS England National Guidance for Lipid Management.

Creatine kinase

Stop existing statin or do not initiate statin if creatine kinase (CK) greater than 5 times ULN.
Consider specialist advice if baseline CK level extremely elevated (e.g. because of physical occupation or rigorous exercise).
Re-measure after 7 days: if CK still greater than 5 times ULN do not re-start statin; if CK less than 5 times ULN, re-start statin at lower dose.

Renal impairment

If eGFR less than 30mL/min/1.73m² check dose with renal specialist.

Rosuvastatin in renal impairment

Rosuvastatin contra-indicated if eGFR less than 30mL/min/1.73m²; 40mg dose contraindicated if eGFR less than 60ml/min/1.73m².

Hypothyroidism

Manage hypothyroidism adequately before starting a statin.

Rosuvastatin in hypothyroidism

Rosuvastatin 40mg is contraindicated in hypothyroidism.

Notes

Advice to patients

Advise patients to report any unexplained muscle pain.

Bibliography

• National Institute for Health and Care Excellence (NICE). Cardiovascular disease: risk assessment and reduction, including lipid modification [NG238]. December 2023 [Cited 4/11/2024]
• Joint Formulary Committee. British National Formulary (online) London: BMJ Group and Pharmaceutical Press [cited 4/11/2024]
• NICE Clinical Knowledge Summaries (CKS). Lipid modification – CVD prevention. Updated September 2024 [cited 4/11/2024]
• AstraZeneca UK Ltd. Summary of Product Characteristics – Crestor 40mg film-coated tablets. Last revised 10/2024 [cited 4/11/2024]
• Upjohn UK Limited. Summary of Product Characteristics – Lipitor 20mg film coated tablets. Last revised 07/2024 [cited 4/11/2024]
• NHS England. Summary of national guidance for lipid management. Updated September 2024. [cited 4/11/2024]

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