Original Title: Protocoles médicaux nationaux et ordonnances associées (mise à jour octobre 2019): ajustement des hypolipémiants (statines et ézétimibe) dans la prise en charge du risque cardiovasculaire

Authors' objectives: Given the extent of the current problem posed by the incidence of cardiovascular disease (CVD), evidence-based clinical practice guidelines recommend the use of lipid-lowering pharmacologic agents from the class of statins according to the patient’s CVD risk. Statin use must also be accompanied by adherence to and persistence with healthy life habits (diet, physical activity and weight loss). These pharmacological and nonpharmacological modalities reduce serum LDL (low-density lipoprotein) levels and the CVD risk in both the primary and secondary prevention context. Reducing the CVD risk therefore requires global management by a multidisciplinary team, this in collaboration with the patient. Such management is facilitated by the use of a collective or individual prescription by authorized health professionals who have the necessary qualifications to execute it. Considering that the current versions of the national medical protocol (NMP) and the individual adjustment prescription (IAP) template for lipid-lowering agents will cease to be in effect in September 2019, and in the interest of consistency with work INESSS did previously in 2017, the Direction nationale des soins et services infirmiers (DNSSI) of the Ministère de la Santé et des Services sociaux (MSSS), following a prioritization exercise, asked INESSS to update the above-mentioned protocol and template.

Authors' results and conclusions: RESULTS: The information search identified 1,784 items, of which two CPGs were selected. These CPGs are from the United States, specifically, the US Preventive Services Task Force and the American Heart Association and American College of Cardiology. The Canadian Cardiovascular Society's CPG was selected as well for contextual and comparative purposes, even though it predates the search period [Anderson et al., 2016]. In addition, two consensus statements were selected to address the issue of adverse effect management [Newman et al., 2019; Mancini et al., 2016], and a reference manual was selected for the purpose of updating the signs and symptoms of hepatotoxicity. Lastly, the report entitled Statines, hypolipémiants et diminution du risque cardiovasculaire and clinical tools published by INESSS in 2017 served to harmonize all the information. Like the report entitled Statines, hypolipémiants et diminution du risque cardiovasculaire, published by INESSS in 2017, the CPGs examined incorporate the adjustment of lipid-lowering agents (statins and ezetimibe) into the broader concept of cardiovascular risk management, which gives due importance to promoting healthy life habits. Other changes to the NMP and IAP include the option of adjusting statins downward if necessary and the addition of possible options in the IAP for modifying the treatment in the event of failure to achieve the targets or of muscle intolerance to a statin. The American and Canadian consensus statements on adverse effect management has finally made it possible to define the decision algorithm for managing statin intolerance and to specifically include in it hepatotoxicity. CONCLUSION: This updating of the national medical protocol and the individual adjustment prescription template for lipid-lowering agents (statins and ezetimibe) is based on clinical data and clinical practice recommendations from the literature, which have been enhanced with experiential knowledge from different experts and clinicians and with contextual information. Following an analysis involving the triangulation of data from these different sources, the update enabled us to determine the appropriateness of maintaining, removing or modifying the information in the previous version or adding new information, when this proved necessary. The changes made as part of the update will help improve the joint follow-up and, ultimately, the care experience of the person taking one or more lipid-lowering agents to reduce their cardiovascular risk.

Authors' methods: A systematic review of clinical practice guidelines (CPGs), expert consensus statements, consensus conference reports, guidance documents and other publications containing clinical recommendations was conducted in accordance with INESSS’s standards to update the literature from its previous work. The literature search was limited to items published between September 2016 (last update) and March 2019. A manual literature search was carried out by consulting the websites of North American regulatory agencies and health technology assessment agencies, as well as those of government agencies and professional orders and associations associated with the topic of this work. Clinical reference works were consulted as well. The bibliographies of the selected publications were examined for other relevant items.

Project Status: Completed

URL for protocol: https://www.inesss.qc.ca/thematiques/medicaments/protocoles-medicaux-nationaux-et-ordonnances-associees/hypolipemiants.html

Year Published: 2019

URL for published report: https://www.inesss.qc.ca/thematiques/medicaments/protocoles-medicaux-nationaux-et-ordonnances-associees/hypolipemiants.html

Requestor: Minister of Health

English language abstract: An English language summary is available

Publication Type: Other

Country: Canada

Province: Quebec

Organisation Name: Institut national d'excellence en sante et en services sociaux

Contact Address: L'Institut national d'excellence en sante et en services sociaux (INESSS) , 2021, avenue Union, bureau 10.083, Montreal, Quebec, Canada, H3A 2S9;Tel: 1+514-873-2563, Fax: 1+514-873-1369

Contact Name: demande@inesss.qc.ca

Contact Email: demande@inesss.qc.ca

Copyright: L'Institut national d'excellence en santé et en services sociaux (INESSS)