The impetus of national initiatives highlighting the importance of lipid modification, the sheer number of people involved, and the continuous nature of therapy, mean that lipid management has become an everyday primary care discipline.1 Most patients with dyslipidaemia can be investigated and treated effectively in primary care without referral to a specialist but, paradoxically, the increasing patient burden means an enhanced role for the specialist lipidologist as well.
Patients who should be referred to a specialist lipid clinic include:
Those with extreme values (primary care practitioners often feel less secure with mixed hyperlipidaemia and hypertriglyceridaemia than with pure hypercholesterolaemia). Generally, these can be defined as total cholesterol (TC) >7.5 mmol/L and/or fasting triglycerides (TG) >7.5 mmol/L. All patients with TG >20 mmol/L need to be referred given the risk of pancreatitis.
Those who fail to show an effective response to treatment (whether by virtue of the type and severity of their dyslipidaemia or their intolerance of first-line agents).
Those with familial dyslipidaemia (e.g. familial hypercholesterolaemia, familial combined hypercholesterolaemia and Fredrickson Types I or V [TG >20 mmol/L], or type III [TG=TC and >7 mmol/L]) should be managed by specialists as family tracking may be easier to co-ordinate, drug doses used are higher and combination therapies are more common.
Special cases (such as those requiring the help of joint paediatric, nephrology, neurology, vascular surgery and HIV clinics) or those requiring special investigations such as apolipoproteins, enzyme testing, DNA genotyping, or more detailed vascular assessment.