How do I approach the management of hyperlipidaemia in patients with comorbid conditions such as diabetes or cardiovascular disease?

Management of hyperlipidaemia in patients with diabetes mellitus or cardiovascular disease (CVD) involves a comprehensive approach:

• Initial assessment: Measure a non-fasting full lipid profile if not already done as part of cardiovascular risk assessment. Assess and treat comorbidities and secondary causes of dyslipidaemia such as uncontrolled diabetes, liver disease, and nephrotic syndrome before initiating lipid-lowering treatment ¹,².
• Statin therapy: Do not withhold statin treatment in people with diabetes due to increased HbA1c or blood glucose levels. For primary prevention in type 1 diabetes, offer statins to adults over 40 years, or with diabetes duration over 10 years, nephropathy, or other CVD risk factors, starting with atorvastatin 20 mg ¹,⁵.
• Targets and intensity: For secondary prevention of CVD, aim for LDL cholesterol ≤2.0 mmol/L or non-HDL cholesterol ≤2.6 mmol/L. Offer high-intensity statins such as atorvastatin 80 mg unless contraindicated or patient prefers lower doses ⁵. In type 2 diabetes, aim for >40% reduction in non-HDL cholesterol, considering dose up-titration of atorvastatin as appropriate ³,⁴.
• Monitoring: Repeat liver transaminases and full lipid profile 2–3 months after starting or changing treatment, then liver function at 12 months unless clinically indicated. Monitor for muscle symptoms and measure creatine kinase if symptoms develop ¹,⁵.
• Additional considerations: Chronic kidney disease does not preclude statin use but requires dose adjustments based on CKD stage. Optimize management of other CVD risk factors including blood pressure and lifestyle factors ¹,³,⁵.
• Referral: Refer for specialist assessment if total cholesterol >9.0 mmol/L or non-HDL cholesterol >7.5 mmol/L, or if triglycerides are very high (>10 mmol/L) despite addressing secondary causes ¹,².