Canadian dyslipidemia guidelines for family doctors

This month’s issue of Canadian Family Physician (CFP) includes the long-awaited, updated simplified lipid guidelines (page 675).¹ Our internal data show that the previous dyslipidemia guidelines,² published in 2015, have been accessed online almost a quarter of a million times—one of our most accessed articles ever.

Despite being released 8 years ago, those guidelines continue to be well read. I expect the updated guidelines will be equally relevant to family medicine practice. In fact, clinical practice guidelines (CPGs) published by the PEER (Patients, Experience, Evidence, Research) group from the Department of Family Medicine at the University of Alberta in Edmonton are often among our most frequently accessed articles. The PEER guidelines on low back pain,³ released in March 2022, were the most highly accessed article in August 2023. The fact that guidelines published in CFP are so well received is a concept worth exploring.

One reason for their broad appeal may be the lack of industry-related conflicts of interest among the guideline authors. For the development of the 2023 simplified lipid guidelines, a pan-Canadian panel was established. To be a panel member, an author could not have had conflicts of interest involving pharmaceutical companies within the past 3 years. This is clearly stated in the article’s methods. Expenses and honoraria tied to not-for-profit organizations are declared in the appendices.

This lack of pharmaceutical company involvement stands in contrast to many other CPGs. For example, in the Canadian Cardiovascular Society’s 2021 dyslipidemia guidelines,⁴ authors were required to recuse themselves from voting on specific recommendations for which they had conflicts, yet the presence of conflicts of interest alone did not wholly preclude their authorship. A 2021 analysis in the Canadian Medical Association Journal draws attention to the extent of this problem in Canada and beyond.⁵

Another reason the PEER guidelines may resonate with readers is that their authorship—mainly primary care clinicians—mimics the readership. Specifically, the voting members included 5 FPs, 2 internal medicine specialists, 1 nurse practitioner, 1 pharmacist, and 1 patient. By the nature of their clinical practices, the authors have a clear idea of what FPs experience and what would be most helpful to them to support patient care.

These insights of the authorship team were fundamental to shaping the approach to the updated CPGs. For example, the guidelines introduce the concept of time to treat. In family medicine we are constantly being asked to do more in the same, or even in less, time with patients. A 2023 review found that to carry out all preventive care and chronic disease management as recommended, it would take 21 hours per day.⁶

These guidelines aim to reduce time needed to treat in several ways. To start, they offer clear, evidence-based direction on screening and management. Who needs a statin? Who does not? What tests are needed? Guidelines are reference tools that can be used to make quick decisions. But the time and cost savings of guidelines may be more indirect.

For example, these guidelines recommend against targeting a specific low-density lipoprotein level when treating with statins. They also recommend against routine testing for lipoprotein a, apolipoprotein B, and coronary artery calcium levels. If a patient with no cardiac risk factors presents for standard preventive screening at age 40 and the findings are normal, repeat testing can be considered at a 5- or, better yet, 10-year interval. One can see how time and costs could be saved at the levels of the patient, the provider, and the system. What does this mean practically? Likely, it means that only the most relevant information is collected, which is more efficient for physicians, patients, and an already-strained health care system.

Guidelines render only one small part of what FPs do for patients a little easier. We are not cogs in a wheel, playing out a time-versus-money trade-off. But the minutes we get back from worrying about lipid levels allow us to spend time on the complexities of practice no guidelines could ever make simpler. The guidelines CFP publishes, by authors who are free from pharmaceutical conflicts of interest and who understand primary care, are guidelines FPs can trust. When will this be the new normal?

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