nhs forth valley formulary 11 - Community Pharmacy

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Forth Valley Formulary Eleventh Edition 2012/13Appendix 5SECONDARY PREVENTION OF CARDIOVASCULAR DISEASEEstablished occlusive arterial disease- Coronary heart disease- Cerebrovascular disease- Peripheral vascular diseaseTreat all patients with statins regardless of baseline cholesterolconcentration.See treatment flowchartAll patients should have LFTs performed prior to statin treatmentATHEROSCLEROTIC ARTERIAL DISEASE IS OF MULTIFACTORIAL ORIGIN.NO SINGLE RISK FACTOR, INCLUDING CHOLESTEROL CONCENTRATION,SHOULD BE VIEWED IN ISOLATION.• Encourage smoking cessation (consider nicotine replacement therapy)• All other risk factors hypertension, diabetic control, should be addressed (see separate guidelines)• An antiplatelet agent (see separate guideline) should be taken by all those with occlusive arterialdisease in the absence of contraindications (active peptic ulceration, a bleeding disorder, or truehypersensitivity)• Treat with ACE-inhibitors unless contraindicated• Consider β-blockers, and ensure attendance at a rehabilitation programme, for patients after MI• Dietary and other lifestyle advice e.g. alcohol, obesity, physical activity, should be given.Goals of TreatmentFor secondary prevention, the ideal target is total cholesterol concentration of < 4 mmol/L.NICE recommends an audit target of total cholesterol of
Forth Valley Formulary Eleventh Edition 2012/13Appendix 5TREATMENT FLOWCHARTTreatment necessaryLifestyle advice + Simvastatin 40mg dailySee BNF for cautions and contra-indications. Note potentialinteractions (Box 1, page 7)Check LFTs before starting simvastatin.Re-test at 2 monthsRandom non-fasting total cholesterol +LFT'sCholesterol goals not achievedDiscuss concordance.Change to Atorvastatin 40mg daily.See BNF for cautions and contra-indicationsCholesterol GoalsAchievedAnnual review to ensurecontinued controlCholesterol goals not achievedDiscuss concordance.Change to Atorvastatin 80mg daily.See BNF for cautions andcontra-indicationsIf total cholesterol remains >5mmol/L* Consider addition of ezetimibe 10mg* Consider referral for specialist advicePage 59
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