NICE vs RCOG: Management of Hyperlipidaemia (2025)

This guideline provides a comparative analysis of the National Institute for Health and Care Excellence (NICE) and the Royal College of Physicians (RCP) guidelines for the management of hyperlipidaemia in adults. It is designed to help UK clinicians navigate the similarities and differences between these two key resources to inform evidence-based practice.

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Diagnosis and Initial Assessment

NICE CG181 (Updated 2023/24)

NICE recommends using a formal risk estimation tool as the cornerstone of assessment.

• Primary Tool: QRISK3 is the recommended risk assessment tool for the primary prevention of cardiovascular disease (CVD) in people aged up to 84 years.
• Lipid Measurement: A full fasting lipid profile (total cholesterol, LDL-C, HDL-C, and non-HDL-C) is advised. Non-HDL-C is highlighted as a primary treatment target.
• Risk Threshold: A 10-year CVD risk score of 10% or more is the threshold for considering lipid-lowering therapy.
• Secondary Prevention: All patients with established CVD are considered at high risk and require lipid-lowering therapy, irrespective of their lipid levels.

RCP National Clinical Guideline for Lipid Management (2023)

The RCP guideline also emphasises risk assessment but provides a broader, more pragmatic framework.

• Primary Tool: QRISK2 or QRISK3 are considered acceptable. The guideline acknowledges that many electronic health record systems still use QRISK2.
• Lipid Measurement: Similar to NICE, a full lipid profile is recommended. It places strong emphasis on calculating non-HDL-C and, where available, apolipoprotein B (ApoB) as more accurate measures of atherogenic particle number.
• Risk Threshold: The RCP guideline uses a 20% or more 10-year CVD risk threshold as a key intervention point, aligning with some older national recommendations. It also introduces the concept of "risk enhancers" (e.g., family history, chronic kidney disease) which may lower the threshold for treatment.

Key Difference: The most significant difference lies in the primary prevention risk threshold (NICE: ≥10% vs RCP: ≥20%). This has major implications for the number of patients eligible for treatment.

Treatment Recommendations

Pharmacological Therapy: Primary Prevention

• NICE: For primary prevention in adults with a 10-year risk ≥10%, offer atorvastatin 20 mg. The aim is a >40% reduction in non-HDL-C.
• RCP: For primary prevention in adults with a 10-year risk ≥20%, consider atorvastatin 20 mg. The guideline is slightly more cautious, emphasising shared decision-making, especially near the risk threshold.

Pharmacological Therapy: Secondary Prevention

Both guidelines are aligned for secondary prevention, advocating high-intensity statin therapy.

• First-line: Atorvastatin 80 mg is recommended for all patients with established CVD, unless contraindicated or not tolerated.
• Targets: Both guidelines focus on percentage reductions. NICE targets a >40% reduction in non-HDL-C. The RCP provides more explicit targets: non-HDL-C reduction >50% and LDL-C < 1.8 mmol/L (or < 1.4 mmol/L for very high-risk patients).

Management of Statin Intolerance

• NICE: Recommends trying a different statin, a lower dose, or alternate-day dosing. If no statin is tolerated, consider ezetimibe.
• RCP: Provides a more detailed stepwise approach, including re-challenge and, if necessary, ezetimibe. It gives stronger consideration to bempedoic acid as a second-line agent after ezetimibe in statin-intolerant patients requiring secondary prevention.

Use of Non-Statin Agents (Ezetimibe, PCSK9 Inhibitors)

• NICE: Ezetimibe is recommended in combination with a statin if a >40% non-HDL-C reduction is not achieved, or if a statin is not tolerated. PCSK9 inhibitors (alirocumab, evolocumab) are reserved for patients with familial hypercholesterolaemia (FH) or established CVD who have persistently high LDL-C despite maximum tolerated statin and ezetimibe, following NICE Technology Appraisals.
• RCP: More readily advocates for combination therapy. Suggests adding ezetimibe if LDL-C targets are not met with a statin alone. For PCSK9 inhibitors, the RCP guideline suggests a broader application in very high-risk patients not at goal, reflecting evolving evidence post-NICE appraisal.

Practical Takeaway: NICE provides a stricter, cost-effectiveness-led pathway. The RCP guideline offers a more intensive, target-driven approach, particularly for very high-risk patients, reflecting a clinician-focused perspective.

Special Situations

Familial Hypercholesterolaemia (FH)

• NICE: Has a separate, comprehensive guideline (CG71) on FH identification and management, recommending cascade screening and specialist-led care.
• RCP: Integrates FH management into the main guideline, reinforcing the need for early, potent statin therapy and specialist referral, aligning with NICE CG71.

Diabetes Mellitus

• NICE: Management is primarily driven by CVD risk using QRISK3. Patients with type 2 diabetes over 40 are likely to have a QRISK3 ≥10% and are offered a statin.
• RCP: Places greater emphasis on diabetes as a major "risk enhancer." It suggests that most patients with type 2 diabetes and additional risk factors should be treated as being at "very high risk," warranting more aggressive lipid-lowering and lower treatment targets (LDL-C < 1.4 mmol/L).

Chronic Kidney Disease (CKD)

Both guidelines recommend statins for primary prevention in CKD. Atorvastatin 20 mg is standard. The RCP provides more specific guidance on the use of statins in advanced CKD and the safety of ezetimibe in this population.

Practical Clinical Flow: A Hybrid Approach

For many clinicians, a pragmatic approach that synthesises both guidelines is useful.

1. Assess Risk: Use QRISK3. A score ≥10% (NICE threshold) flags a patient for a detailed discussion about lipid-lowering.
2. Shared Decision-Making: For patients with a QRISK3 between 10-20%, use the RCP's concept of "risk enhancers" (e.g., strong family history, social deprivation, elevated lifetime risk) to guide the decision to initiate treatment.
3. Initiate Treatment: Start with atorvastatin 20mg for primary prevention and atorvastatin 80mg for secondary prevention.
4. Monitor and Titrate: Check a lipid profile at 3 months.
   • If non-HDL-C reduction is <40% (NICE) or LDL-C is >1.8/1.4 mmol/L (RCP), add ezetimibe 10mg.
   • For secondary prevention patients not at goal on maximum oral therapy, consider referral for PCSK9 inhibitor evaluation.
5. Statin Intolerance: Follow a stepwise approach: re-challenge, alternate statin/dosing, then introduce ezetimibe, and consider bempedoic acid for secondary prevention patients.

Frequently Asked Questions (FAQs)

1. Which guideline should I follow in my NHS practice?

NICE guidelines are the standard for care in the NHS in England and Wales and are the benchmark for commissioning and audit. The RCP guideline is an expert clinical consensus that often reflects more recent evidence and can be used to inform individual patient decisions, especially for complex cases or where a more aggressive target-driven approach is desired. In practice, a synthesis of both is common.

2. A patient's QRISK3 is 15%. They have no other risk factors. Do I start a statin?

According to NICE (threshold ≥10%), yes, you should offer atorvastatin 20mg. According to the RCP (threshold ≥20%), a statin would not be routinely recommended. This is a classic scenario for shared decision-making. Discuss the absolute risk reduction, benefits, and potential side effects with the patient to reach a mutual decision.

3. What is the most important lipid target to monitor?

Non-HDL-C (total cholesterol minus HDL-C) is recommended by both guidelines as it captures all atherogenic cholesterol particles and does not require a fasting sample. The RCP also strongly advocates for ApoB as a more direct measure, but its availability in routine NHS practice is currently limited.

4. How should I manage a patient with established CVD whose LDL-C is 2.0 mmol/L on atorvastatin 80mg?

Both guidelines would recommend intensifying therapy. The next step is to add ezetimibe 10mg. If the target (e.g., LDL-C < 1.8 mmol/L or < 1.4 mmol/L) is still not achieved, the patient should be referred to a lipid specialist for consideration of a PCSK9 inhibitor.

5. Are there any differences in recommendations for older adults (>85 years)?

Yes. QRISK3 calculates risk up to 84 years. For patients over 85, both guidelines emphasise clinical judgement. The RCP guideline provides more explicit commentary, suggesting that primary prevention statin initiation is rarely appropriate in this age group, but continuing statins for secondary prevention is beneficial if well-tolerated.

Source Links

• NICE Guideline CG181 (Lipid modification: cardiovascular risk assessment and the modification of blood lipids for the primary and secondary prevention of cardiovascular disease): NICE CG181
• RCP National Clinical Guideline for Lipid Management (2023): RCP London lipid management guideline
• NICE Guideline CG71 (Familial hypercholesterolaemia: identification and management): NICE CG71
• QRISK®3-2023 risk calculator: QRISK3 calculator (2023 page)