Lipid Disorders
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​Last updated on 7 August 2024


Raised blood lipid levels are important risk factors for coronary artery disease (CAD). 

The relationship between CAD and total cholesterol levels is continuous and curvilinear. LDL cholesterol (LDL-cholesterol) is a well-established risk for CAD.1

​

  • Please refer to the Cardiovascular Risk Assessment Care Protocol and Cardiovascular Disease (CVD) Risk Calculator where needed.

  • Screening for lipids should be performed as part of a global cardiovascular/cardiometabolic risk assessment. Clinicians should also consider screening for other risk factors such as high blood pressure (BP) and high blood glucose.

  • ​ In the prevention of CAD, the intensity of risk reduction therapy should be adjusted to a person's risk of developing future coronary events. As such, the first step should be to assess the individual's risk status.

    • ​ ​Risk Stratification and Treatment Goals (adapted from 2023 Lipids ACE Clinical Guidelines)  may be calculated with the Healthier SG ​ Cardiovascular Disease Risk Calculator​​

    • Estimation of 10-Year Coronary Artery Disease Risk for Men without significant medical conditions .

    • Estimation of 10-Year Coronary Artery Disease Risk for Women without significant medical conditions .

    • Secondary dyslipidaemia should be excluded in selected patients diagnosed with lipid disorders .

  • Hypertriglyceridaemia

    • Elevated blood triglyceride (TG) levels (>1.7 mmol/L) are associated with CAD. However, this association is significantly attenuated after adjustment for other blood lipid levels.

    • Individuals with very high levels of fasting TG, i.e. >4.5 mmol/L (400 mg/dL) or especially >10 mmol/L (>900mg/dL), have an increased risk of acute pancreatitis.

  • Familial Hypercholesterolaemia (FH)​2

    • Screening of all first degree relatives of diagnosed FH patients is recommended.

    • Clinical diagnosis may be made by the Dutch Lipid Clinic Network criteria or Simon Broome Trust diagnostic criteria .

    • Offer patients with possible or definite FH a referral to a specialist to make a recommendation on the need for therapy.

    • Coronary artery disease risk estimation tools for the general population should not be used because patients with FH are already at a high risk of premature coronary artery disease. 

    • Early screening provides the opportunity to teach good eating habits from a young age, if a child is identified to have FH. Children who have a first degree relative diagnosed with FH can be screened within specialist centres starting from the age of 2 years.

​
Treatment Goals

  • Please refer to the Risk Stratification and Treatment Goals for the target LDL-c to treat.


Lifestyle Management

Care teams may use the relevant Lifestyle Prescription to help patients understand practical steps they can take to manage lipid disorders. A copy may be printed​ for the patient's use.

Pharmacological Management

  • Drug classes: 
    ​a. Statins, alone or with ezetimibe if needed, are the first line option for most patients. 

    i. ​​​Where maximally tolerated statin is recommended, most of such patients would benefit from >50% reduction in LDL-cholesterol. If high-intensity statins therapy is not tolerated, addition of non-statin medication like ezetimibe may be helpful. 

    • ​​b. Fibrates may be added on for patients with TG >4.5 mmol/L despite being on statin therapy to reduce risk of acute pancreatitis. Fenofibrate is preferred over gemfibrozil as add-on therapy to statins for its lower risk of myopathy. Monitor liver function for hepatotoxicity. 

  • Initiating therapy
    a. Check for pregnancy, intention to conceive, breastfeeding; hepatic impairment; renal function (to guide dose adjustment). 

    • b. Also consider predisposition to adverse events and concurrent treatments that may limit dosage or use. 

  • Monitoring side effects of therapy.

  • Refer to the 2023 Lipids ACE Clinical Guidelines for more details.​

Refer to the Note on Patient Education  for more information.


Special Considerations1

  • Elderly

    • In the elderly (age >75 years), the decision to start treatment should consider the potential risk-reduction associated with treatment, risk of adverse effects, drug-drug interactions, and patient preferences.1

    • While older age alone may confer significant CV risk, direct evidence of intensive lipid lowering is currently lacking for patients older than 75 years with no ASCVD. Treatment for such patients should be individualised.1

    • When used, lipid-lowering medications in the elderly should be started at the lowest dose and then titrated to achieve optimal LDL-cholesterol levels, in order to reduce possible statin-associated side effects. For patients on treatment with a statin and LDL-cholesterol​ <2.1 mmol/L or 80 mg/dL when they turn >75 years of age, there is no need to reduce therapy if the treatment is well-tolerated without any adverse effects.1

    • For patients on treatment with a statin and LDL-cholesterol <2.1 mmol/L or 80 mg/dL when they turn >75 years of age, there is no need to reduce therapy if the treatment is well-tolerated without any adverse effects.

  • Women

    • Statins are contraindicated in women who are pregnant, likely to be pregnant, or breastfeeding.

  • Renal Disease

    • The starting dose of statins in chronic kidney disease (CKD) should be low (e.g. 10 mg simvastatin or equivalent ). During therapy, serum creatine kinase (CK) and renal function should both be carefully monitored.

    • Fibrates can be used in patients with chronic kidney disease (CKD) in stages 1 to 3. Doses should be reviewed with appropriate monitoring for side effects, especially myopathy.​

    • When creatinine clearance is less than 30 ml/min (stage 4 or 5), most fibrates are contraindicated.

    • In patients with end stage CKD on dialysis, statins did not significantly improve cardiovascular outcomes.

  • Liver Disease

    • In patients with dyslipidaemia and chronic liver disease, if the level of the two transaminases (alanine transaminase [ALT] and/or aspartate transaminase [AST]) are elevated but <3 times the upper limit of the normal range, statins can be given but the starting dose should be low. Careful monitoring of the serum transaminases and CK after commencement is recommended.

    • Fibrates can be given in patients whose transaminase levels are elevated <3 times the upper limit of the normal range, but at a lower starting dosage. Careful monitoring of the serum transaminases and CK after commencement is recommended.


Recommended Care Components​2​

​Recommended Care Components

​Minimum Freq​uency*

​Remarks

​Lipid Profile

​Annually

​All patients should be risk stratified (as recommended in the Lipids ACE Clinical Guidelines​).

Targets of treatment should be personalised by levels of risk. 

​Smoking Assessment

​Annually for smokers;

Once-off for non-smokers, unless there is a change in smoking habit

​Assessment on smoking habits (estimated sticks/day; zero for non- or ex-smoker) and provide smoking cessation counselling.

For more details, please refer to the Smoking Cessation Care Protocol.

​Serum Transaminases (ALT/AST)

​Before starting statins and as clinically indicated (e.g. symptoms suggestive of hepatotoxicity, increase in statin dose)

​Especially when the statin dose is increased or when combination therapy is initiated​.

Stop the statin/fibrate if patient is symptomatic or if transaminases exceed 3 times the upper limit of normal range.

​Serum Creatine Kinase

​Before starting statins and as indicated (e.g. muscle symptoms)

​Look out for rapid increase in CK post-initiation or increase of statin or fibrate dose. Stop the medication if the CK is three times upper limit of normal or at about 800 IU/L (whichever is lower).

​

Consideration for Specialist Referral​1,2

​Specialist Referral Recommended​

​Referral to Gastroenterologist

  • Pre-treatment sustained transaminases 3 times above normal range.

  • Clinical presentation of acute hepatitis. 

  • If the ALT/A​ST is persistently elevated ≥3 times upper limit of normal despite stopping statins.

Patients who are clinically unwell, jaundiced or who will benefit from urgent evaluation should be referred to the A&E.

​Consider Specialist Input

​Consider Referral to Endocrinologist

  • Triglyceride level more than 4.5 mmol/L (400 mg/dL) despite dietary changes and maximum tolerated drug therapy.

  • Triglyceride level more than 10.0 mmol/L (885mg/dL).​

  • Target parameters not achieved despite maximal drug therapy.

  • Definite or possible FH on Dutch Lipid Clinic Network criteria or Simon Broome Trust diagnostic criteria (or other validated criteria​2).


​​​
GPs may use the CHAS Medical Referral Form​ to make subsidised SOC referrals. This can be found on Healthier SG compatible GP CMS and on the PCDS web-portal.​


The following data fields should be documented in GPs' case notes as part of good clinical practice for all patients enrolled to their practice.

Submission of data fields marked with asterisks* is required for subsidy claims and Healthier SG payments. 

Diagnosis

  1. ​Diagnosis*

  2. CDMP Condition(s)*

  3. Diagnosis Year


Blood Glucose

  1. HbA1c (%) OR Fasting Plasma Glucose (FPG) (mmol/L or mg/dL)

  2. Date


Blood Pressure 

  1. Systolic BP (mmHg)

  2. Diastolic BP (mmHg)

  3. Date


Lipid Profile

  1. LDL-Cholesterol (mmol/L or mg/dL)*

  2. HDL-Cholesterol​ (mmol/L or mg/dL)

  3. Triglycerides (mmol/L or mg/dL)

  4. Total Cholesterol (mmol/L or mg/dL)

  5. Date*


Weight

  1. BMI (kg/m2), calculated from height*, weight*

  2. Waist circumference (in cm; mandatory to fill if weight is not feasible. Otherwise optional field to fill)*

  3. Weight not feasible (if applicable)*

  4. Date*


Smoking History

  1. Smoking status (Never smoker, Ex-smoker, Current Smoker)*

  2. Year started smoking (if smoker)

  3. No. of sticks smoked/day (For never smoker or ex-smoker, input 0)*

  4. State of change: (i) Pre-contemplation, (ii) Contemplation, (iii) Preparation, (iv) Action, OR (v) Maintenance 

  5. Fagerstrom Test Score – For patients who are prepared to quit and are actively participating in a structured smoking cessation counselling programme, GPs can consider administering the Fagerstrom test to determine degree of nicotine dependence

  6. Date of Smoking Assessment 

CHAS/PG/MG cardholders who are Healthier SG enrollees will be eligible for the Healthier SG Chronic Tier, which provides percentage-based subsidies for a whitelist of drug products sold within the MOH price caps.  When making claims, GPs will need to submit the quantities and selling prices for each whitelisted drug product prescribed.

Details on the GP Annual Service Fee for enrollees with lipid disorders can be found in the Healthier SG Enrolment Programme Agreement.