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Table 13 Summary of recommendations for monitoring lipids and enzymes in patients, before and on lipid-lowering therapy

Testing lipids How often should lipids be tested? • Before starting lipid-lowering drug treatment, at least two measurements should be made, with an interval of 112 weeks, with the exception of condi-

tions where prompt drug treatment is suggested, such as ACS and very high-risk patients. How often should a patient’s lipids be tested after starting lipid-lowering treatment? • After starting treatment: 8 (±4) weeks. • After adjustment of treatment: 8 (±4) weeks until the goal is achieved. How often should lipids be tested once a patient has achieved the target or optimal lipid level? • Annually (unless there are adherence problems or other specific reasons for more frequent reviews). Monitoring liver and muscle enzymes How often should liver enzymes (ALT) be routinely measured in patients on lipid-lowering drugs? • Before treatment. • Once, 812 weeks after starting a drug treatment or after dose increase. • Routine control of ALT thereafter is not recommended during statin treatment, unless symptoms suggesting liver disease evolve. During treatment with

fibrates, control of ALT is still recommended. What if liver enzymes become elevated in a person taking lipid-lowering drugs? If ALT <3 ULN: • Continue therapy. • Recheck liver enzymes in 46 weeks. If ALT rises to >_3 ULN • Stop lipid-lowering therapy or reduce dose and recheck liver enzymes within 46 weeks. • Cautious reintroduction of therapy may be considered after ALT has returned to normal. • If ALT remains elevated check for the other reasons. How often should CK be measured in patients taking lipid-lowering drugs? Pre-treatment • Before starting therapy. • If baseline CK is >4 ULN, do not start drug therapy; recheck. Monitoring: • Routine monitoring of CK is not necessary. • Check CK if patient develops myalgia. Be alert regarding myopathy and CK elevation in patients at risk, such as: elderly patients, those on concomitant interfering therapy, multiple medications, liver or renal disease, or athletes. What if CK becomes elevated in a person taking lipid-lowering drugs? Re-evaluate indication for statin treatment. If >_4 ULN: • If CK >10 ULN: stop treatment, check renal function, and monitor CK every 2 weeks. • If CK <10 ULN: if no symptoms, continue lipid-lowering therapy while monitoring CK between 2 and 6 weeks. • If CK <10 ULN: if symptoms present, stop statin and monitor normalization of CK, before rechallenge with a lower statin dose. • Consider the possibility of transient CK elevation for other reasons such as exertion. • Consider myopathy if CK remains elevated. • Consider combination therapy or an alternative drug. If <4 ULN: • If no muscle symptoms, continue statin (patient should be alerted to report symptoms; check CK). • If muscle symptoms, monitor symptoms and CK regularly. • If symptoms persist, stop statin and re-evaluate symptoms after 6 weeks; re-evaluate indication for statin treatment. • Consider rechallenge with the same or another statin. • Consider low-dose statin, alternate day or once/twice weekly dosing regimen, or combination therapy. For details on CK elevation and treatment of muscular symptoms during statin treatment see algorithm in Supplementary Figure 4. In which patients should HbA1c or blood glucose be checked? • Regular checks of HbA1c or glucose should be considered in patients at high-risk of developing diabetes, and on high-dose statin treatment. • Groups to be considered for glucose control are the elderly and patients with metabolic syndrome, obesity, or other signs of insulin resistance.

ACS = acute coronary syndrome; ALT = alanine aminotransferase; CK = creatine kinase; ULN = upper limit of normal. Downloaded from academic.oup.com/eurheartj/article/41/1/111/5556353 by guest on 07 October 2026