Endocrinology: Lipids and obesity (Complete)

• Lipids: Lipid Basics | CV Risk and Statins (NICE NG238) | Lipid Targets and Add-on Drugs | Statin Side Effects and Intolerance | Familial Hypercholesterolaemia | Hypertriglyceridaemia | Secondary and Other Dyslipidaemias
• Obesity: Obesity | Assessing Obesity | Weight-loss Drugs | Bariatric Surgery | After Bariatric Surgery
• Revision: Drug Reference Table | Spot the Diagnosis | Exam-style Scenarios | Key Points | Guidelines and Further Reading

🫀 Lipids and obesity are the two great modifiable drivers of cardiovascular and metabolic disease. This chapter covers statins and the NICE NG238 lipid targets, familial hypercholesterolaemia, high triglycerides, and the modern management of obesity - from lifestyle to GLP-1-based drugs and bariatric surgery.
Your four questions for every patient: What is the cardiovascular risk? Is there a genetic or secondary cause? Which treatment, and what target? What are the safety issues (muscle, liver, pregnancy, contraception, nutrition)?

Lipid Basics

• LDL cholesterol ("bad"): Carries cholesterol to tissues and into artery walls. It is the main causal driver of atherosclerosis - the lower and the longer, the better.
• HDL cholesterol: Removes cholesterol from tissues. Low HDL is a risk marker, but raising it with drugs has not reduced events.
• Triglycerides: Carried in chylomicrons (from the diet) and VLDL (from the liver).
  • Very high levels (above 10 mmol/L) cause pancreatitis.
  • Moderate rises add to cardiovascular risk.
• Non-HDL cholesterol: Total cholesterol minus HDL. It includes all atherogenic particles, does not need fasting, and is used by NICE for monitoring.
• Lipoprotein(a) [Lp(a)]: A genetically determined, LDL-like particle that raises cardiovascular risk and is largely unaffected by lifestyle. HEART UK recommends measuring it once in adults, particularly with premature CVD or familial hypercholesterolaemia.
• Lipid profile: A non-fasting sample is fine for most purposes (NICE). Repeat fasting if triglycerides are high.

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CV Risk and Statins (NICE NG238)

Before starting a statin:

• Full lipid profile.
• HbA1c.
• U&E and eGFR.
• LFTs (ALT).
• TSH if dyslipidaemia is present.
• Consider urine ACR.
• Look for and treat secondary causes (see Secondary Dyslipidaemias).
• Consider familial hypercholesterolaemia if levels are very high.

Primary prevention:

• Estimate 10-year risk with QRISK3, for people aged 25–84 without CVD.
• Do not use QRISK3 in people who are automatically high risk:
  • Type 1 diabetes.
  • eGFR below 60 or albuminuria.
  • Familial hypercholesterolaemia.
  • Age 85 or over - consider a statin.
• QRISK3 of 10% or more: Offer atorvastatin 20 mg after discussing lifestyle.
• QRISK3 below 10%: Do not rule out a statin if the person prefers one - QRISK3 can underestimate lifetime risk, especially in younger people.
• Type 1 diabetes: Offer atorvastatin 20 mg if any of:
  • Age over 40.
  • Diabetes for over 10 years.
  • Nephropathy.
  • Other CV risk factors.
• CKD: Offer atorvastatin 20 mg. Increase it if non-HDL falls by less than 40% and eGFR is 30 or above. Seek renal advice for higher doses below an eGFR of 30.

Secondary prevention (established CVD - MI, angina, stroke, TIA, peripheral arterial disease):

• Offer atorvastatin 80 mg.
• Use a lower dose if there are interactions, a high risk of side effects, or patient preference.

Lifestyle for everyone:

• Cardioprotective diet - Mediterranean-style, less saturated fat.
• Exercise.
• Weight loss.
• Stop smoking.
• Limit alcohol.

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Lipid Targets and Add-on Drugs

Targets (NICE NG238):

• Primary prevention: Aim for a reduction of more than 40% in non-HDL cholesterol.
• Secondary prevention: Aim for LDL cholesterol of 2.0 mmol/L or less, or non-HDL cholesterol of 2.6 mmol/L or less.
• When to check: Lipids at 2–3 months after starting or changing treatment. Then yearly, to check adherence and response.

If not at target: Check adherence, increase the statin dose, then add another drug:

• Ezetimibe 10 mg daily: Blocks gut cholesterol absorption and lowers LDL by about 20% more. The first add-on (NICE TA385).
• Inclisiran (a siRNA that blocks PCSK9 production):
  • Dose: SC injection at day 0, 3 months, then every 6 months.
  • NICE TA733: For people with established CVD and LDL of 2.6 mmol/L or more despite maximum tolerated lipid-lowering treatment.
  • Can be given in primary care.
• PCSK9 monoclonal antibodies (evolocumab, alirocumab):
  • SC every 2–4 weeks. Lower LDL by about 50–60%.
  • NICE TA393 and TA394, for specified LDL thresholds in high-risk CVD and familial hypercholesterolaemia (specialist).
• Bempedoic acid with ezetimibe (NICE TA694): When statins are contraindicated or not tolerated, and ezetimibe alone is not enough.
• Icosapent ethyl (purified EPA, NICE TA805): For people with CVD on a statin with raised triglycerides (1.7–10 mmol/L) and LDL between 1.04 and 2.6 mmol/L.
• Not recommended for CV prevention: Routine fibrates, nicotinic acid, bile acid binders or standard omega-3 supplements.

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Statin Side Effects and Intolerance

• Muscle symptoms:
  • Aches are common, but most are not caused by the statin - in blinded trials, rates were similar to placebo.
  • Check CK if there are muscle symptoms.
  • Stop the statin if CK is more than 10 times the upper limit, or if symptoms are severe.
  • Rhabdomyolysis is rare - risk increases with high doses, interacting drugs, hypothyroidism, CKD and older age.
• Liver:
  • Check ALT at baseline, at 3 months and at 12 months.
  • Stop if ALT is more than 3 times the upper limit.
  • A modest rise, or stable fatty liver disease, is not a reason to withhold a statin.
• New diabetes: A small increase in risk, far outweighed by cardiovascular benefit.
• Rare: Immune-mediated necrotising myopathy (anti-HMGCR antibodies) - ongoing weakness and high CK after stopping.
• Interactions:
  • Clarithromycin and erythromycin - pause simvastatin and atorvastatin during the course.
  • Some azole antifungals and HIV protease inhibitors.
  • Amlodipine, diltiazem, verapamil - maximum simvastatin dose 20 mg.
  • Ciclosporin.
  • Fibrates (especially gemfibrozil).
  • Grapefruit juice - simvastatin and atorvastatin.
• "Statin intolerance" (NICE):
  • Stop the statin until symptoms resolve, then rechallenge.
  • Try a lower dose, a different statin (e.g. rosuvastatin), or alternate-day dosing.
  • True intolerance of all statins is uncommon. If it occurs, use ezetimibe, bempedoic acid or inclisiran.
• Pregnancy: Stop statins about 3 months before planned conception, and as soon as pregnancy is confirmed.

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Familial Hypercholesterolaemia

Mechanism: An inherited (autosomal dominant) inability to clear LDL from the blood. The usual cause is mutations in the LDL receptor gene (LDLR), less often APOB or PCSK9.

• Heterozygous FH: About 1 in 250 people. Lifelong high LDL means untreated men have about a 50% chance of coronary disease by 50.
• Homozygous FH: About 1 in 300,000. Extreme LDL, with coronary disease in childhood.
• Most people with FH in the UK are undiagnosed.

Clinical pattern:

• Very high LDL - adults often have total cholesterol above 7.5 mmol/L.
• Family history of premature coronary disease - under 60 in a first-degree relative.
• Tendon xanthomata - Achilles tendon, extensor tendons of the hands. These are specific for FH.
• Xanthelasma and corneal arcus under 45 - suggestive but less specific.

Diagnosis:

• Clinical criteria: Simon Broome or Dutch Lipid Clinic Network criteria.
• Genetic testing confirms it.
• Suspect FH when total cholesterol is above 7.5 mmol/L, or LDL above about 4.9 mmol/L, in an adult - especially with a family history of premature CHD.
• Refer to a specialist lipid clinic if total cholesterol is above 9.0 mmol/L, or non-HDL above 7.5 mmol/L, even without a family history (NICE NG238).
• Exclude secondary causes - hypothyroidism, nephrotic syndrome, cholestasis.

Management:

• High-intensity statin, aiming for a reduction in LDL of more than 50%.
• Add ezetimibe, then PCSK9 inhibitors if needed.
• Do not use QRISK3 - it underestimates risk in FH.
• Cascade testing of first-degree relatives (genetic or lipid testing). Children are tested by age 10, and statins can be considered from about age 10.
• Homozygous FH: Specialist treatment - LDL apheresis, lomitapide, evinacumab.
• Pregnancy planning: Stop statins beforehand.

💡 Clinical Pearl: A young person with an MI, a strong family history and a cholesterol of 9 - think FH. Diagnosing one patient can protect a whole family through cascade testing.

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Hypertriglyceridaemia

Why it matters: Triglycerides above about 10 mmol/L carry a risk of acute pancreatitis (highest above 20 mmol/L). Moderate rises add to cardiovascular risk.

Causes:

• Secondary (most common):
  • Poorly controlled diabetes.
  • Alcohol.
  • Obesity.
  • Hypothyroidism.
  • CKD.
  • Pregnancy.
  • Drugs - oral oestrogens, retinoids, thiazides, beta-blockers, steroids, antipsychotics, antiretrovirals, tamoxifen.
• Primary (genetic):
  • Polygenic - often combined with a secondary cause.
  • Familial chylomicronaemia syndrome (lipoprotein lipase deficiency, rare): Triglycerides above 10 mmol/L from childhood, recurrent pancreatitis, eruptive xanthomas, lipaemia retinalis, hepatosplenomegaly.

NICE NG238 action:

• Triglycerides above 20 mmol/L not due to alcohol or poor diabetic control: Refer urgently to a lipid specialist.
• Triglycerides 10–20 mmol/L: Repeat a fasting sample in 5–14 days and treat secondary causes. Refer if still above 10.
• Triglycerides 4.5–9.9 mmol/L: CV risk may be underestimated. Optimise risk factors and consider referral if non-HDL is above 7.5.

Treatment:

• Stop alcohol.
• Control glucose.
• Reduce weight.
• Low-fat diet - very strict (below about 15–20 g a day) in familial chylomicronaemia.
• Fibrates (e.g. fenofibrate) and omega-3 for very high triglycerides to prevent pancreatitis.
• Volanesorsen for genetically confirmed familial chylomicronaemia (specialist, NICE HST13).
• In acute pancreatitis from triglycerides: IV insulin (with glucose) to lower levels; specialist plasmapheresis in some.

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Secondary and Other Dyslipidaemias

Secondary causes - always check before labelling a dyslipidaemia as primary:

• Hypothyroidism - high LDL. Treat the thyroid first.
• Diabetes and insulin resistance - high triglycerides, low HDL.
• Nephrotic syndrome - very high cholesterol.
• CKD.
• Cholestatic liver disease (e.g. PBC) - high cholesterol, sometimes xanthomas.
• Obesity and alcohol.
• Pregnancy.
• Drugs - thiazides, beta-blockers, glucocorticoids, ciclosporin, retinoids, atypical antipsychotics, antiretrovirals.
• Anorexia nervosa.

Other primary dyslipidaemias:

• Familial combined hyperlipidaemia:
  • The commonest inherited dyslipidaemia.
  • High cholesterol and/or triglycerides that vary over time, across family members.
  • High apoB.
  • Premature CVD.
• Familial dysbetalipoproteinaemia (remnant hyperlipidaemia):
  • APOE2/E2 genotype plus a second factor (obesity, diabetes, hypothyroidism).
  • Cholesterol and triglycerides raised to similar levels.
  • Palmar crease xanthomas and tuberous xanthomas.
  • Responds well to fibrates and statins.
• Raised Lp(a):
  • Genetic.
  • Manage by lowering LDL aggressively and controlling other risk factors.
  • Specific Lp(a)-lowering drugs are in trials.

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Obesity

Mechanism: Obesity is a chronic, relapsing disease of excess body fat that harms health. Body weight is defended by brain circuits (hypothalamic leptin and gut hormone signalling). This is why dieting alone often fails: after weight loss, hunger rises and energy use falls.

Drivers:

• Genetics - strongly heritable.
• Environment - calorie-dense food, inactivity.
• Sleep, stress.
• Drugs - antipsychotics, insulin, sulfonylureas, steroids, some antidepressants and antiepileptics.
• Rare monogenic causes (e.g. MC4R mutations, leptin deficiency) - consider in severe early-onset obesity.
• Syndromes - Prader–Willi.
• Endocrine causes - rare (hypothyroidism, Cushing's), but check if suggested.

Classification (NICE NG246):

• BMI bands:
  • Healthy weight: 18.5–24.9.
  • Overweight: 25–29.9.
  • Obesity class 1: 30–34.9.
  • Obesity class 2: 35–39.9.
  • Obesity class 3: 40 or more.
• Lower thresholds (overweight 23, obesity 27.5) for people of South Asian, Chinese, other Asian, Middle Eastern, Black African or African-Caribbean family background, who have higher metabolic risk at a given BMI.
• Waist-to-height ratio: Measure it in people with a BMI below 35.
  • 0.5 or above means increased health risk.
  • 0.6 or above means high risk.
  The patient message is "keep your waist to less than half your height".

Complications:

• Metabolic: Type 2 diabetes, dyslipidaemia, MASLD (fatty liver).
• Cardiovascular: Hypertension, CVD, heart failure, atrial fibrillation, VTE.
• Respiratory: Obstructive sleep apnoea, obesity hypoventilation.
• Musculoskeletal: Osteoarthritis.
• Cancer: Breast, endometrial, colorectal, oesophageal, kidney and others.
• Reproductive: PCOS, subfertility, male hypogonadism, pregnancy complications.
• Mental health: Depression and stigma.
• Idiopathic intracranial hypertension.

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Assessing Obesity

• Ask permission to discuss weight, and use non-stigmatising language ("living with obesity").
• History:
  • Weight history.
  • Eating pattern, including binge eating.
  • Activity, sleep, mood.
  • Drugs that cause weight gain.
  • Family history.
  • Previous attempts.
  • Readiness to change.
• Measure: BMI, waist-to-height ratio, BP.
• Tests:
  • HbA1c.
  • Lipids.
  • LFTs (MASLD), with a fibrosis score (FIB-4) if abnormal.
  • U&E.
  • TSH if symptomatic.
  • Screening for obstructive sleep apnoea (STOP-BANG, Epworth score).
  • Cushing's tests only if there are specific features.
• The weight management tiers:
  • Tier 1: Universal public health measures.
  • Tier 2: Lifestyle weight management programmes.
  • Tier 3: Specialist multidisciplinary weight management - doctor, dietitian, psychologist and physiotherapist; prescribing of weight-loss drugs.
  • Tier 4: Bariatric surgery.
• Lifestyle foundation:
  • An energy deficit of about 600 kcal a day.
  • Low-energy (800–1,200 kcal) or total diet replacement programmes - e.g. NHS type 2 diabetes remission.
  • Activity - 150 minutes or more a week, plus strength training.
  • Behavioural support.
  A 5–10% weight loss brings meaningful health gains.

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Weight-loss Drugs

How incretin drugs work: GLP-1 is a gut hormone released after eating. GLP-1 receptor agonists act on the brain to reduce appetite and increase fullness, slow gastric emptying, and boost insulin when glucose is high. Tirzepatide also activates the GIP receptor (a "twincretin"), which gives greater weight loss.

• Semaglutide 2.4 mg SC weekly (Wegovy):
  • Start at 0.25 mg and increase every 4 weeks.
  • Average weight loss is about 15% in trials.
  • Reduced major cardiovascular events in people with CVD and overweight (SELECT trial).
  • NICE TA875: BMI of 35 or more with at least one weight-related comorbidity - or BMI 30–34.9 meeting the criteria for specialist weight management. Used within a specialist weight management service, for a maximum of 2 years. Lower BMI thresholds apply for higher-risk ethnic groups.
• Tirzepatide SC weekly (Mounjaro):
  • Start at 2.5 mg and increase by 2.5 mg every 4 weeks, up to a maximum of 15 mg.
  • Average weight loss is about 20% in trials.
  • NICE TA1026: BMI of 35 or more with at least one weight-related comorbidity (thresholds 2.5 lower for higher-risk ethnic groups).
  • NHS rollout: Being phased in through primary care over several years. It started with people at the highest need - BMI 40 or more with four or more qualifying comorbidities (hypertension, dyslipidaemia, obstructive sleep apnoea, CVD, type 2 diabetes) - and is widening year by year.
  • No fixed stopping rule. Reassess if less than 5% weight loss after 6 months at the highest tolerated dose.
• Liraglutide 3 mg SC daily (Saxenda):
  • NICE TA664: BMI 35 or more with non-diabetic hyperglycaemia and high CV risk, in specialist services.
  • Stop if less than 5% weight loss at 12 weeks on the full dose.
  • Largely superseded.
• Orlistat 120 mg up to three times daily with fat-containing meals:
  • A lipase inhibitor that blocks about 30% of fat absorption.
  • Modest effect.
  • Side effects: Oily stools, urgency, fat-soluble vitamin deficiency.
  • Continue beyond 12 weeks only if 5% or more weight has been lost.

Side effects and safety of GLP-1 drugs:

• Common: Nausea, vomiting, diarrhoea, constipation - worst on dose increases.
• Dehydration and AKI.
• Gallstones.
• Pancreatitis - stop if suspected.
• Loss of muscle as well as fat - encourage protein intake and resistance exercise.
• Aspiration risk under anaesthesia or sedation - delayed gastric emptying. Follow local peri-procedural guidance.
• Worsening of diabetic retinopathy with rapid glucose lowering (semaglutide).
• Hypoglycaemia if combined with insulin or sulfonylureas - reduce those doses.
• Pregnancy:
  • Not to be used in pregnancy.
  • Use effective contraception; stop semaglutide at least 2 months before trying to conceive.
  • Tirzepatide may reduce the effectiveness of oral contraceptives in people with obesity. Use a non-oral method, or add a barrier method for 4 weeks after starting and after each dose increase (MHRA).
• Avoid with a personal or family history of medullary thyroid cancer or MEN2 (a thyroid C-cell signal in rodents).
• Weight regain is usual after stopping. Obesity drugs work like antihypertensives - the effect lasts only while they are taken.
• Illegal and unregulated products: MHRA warnings about counterfeit "weight-loss pens" bought online.

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Bariatric Surgery

Why it works: Surgery reduces stomach capacity and, especially with bypass, changes gut hormones (GLP-1, PYY, ghrelin) and bile acids. It produces the largest and most lasting weight loss (typically 25–30% of body weight). It can put type 2 diabetes into remission and reduces mortality.

Eligibility (NICE NG246):

• BMI of 40 or more, or 35–39.9 with a significant weight-related condition - e.g. type 2 diabetes, hypertension, sleep apnoea.
• Has engaged with specialist weight management without enough benefit.
• Fit for anaesthesia and surgery.
• Committed to lifelong follow-up and supplements.
• Expedited assessment: BMI 35 or more with recent-onset type 2 diabetes (within 10 years). Consider it at BMI 30–34.9 with recent-onset type 2 diabetes.
• Lower thresholds (by 2.5 BMI units) for higher-risk ethnic groups.

Procedures:

• Sleeve gastrectomy: About 75–80% of the stomach is removed, leaving a tube. Now the commonest operation. It can worsen reflux.
• Roux-en-Y gastric bypass: A small stomach pouch is joined to the jejunum, bypassing the duodenum. Very effective for diabetes and reflux, but has more nutritional effects.
• One-anastomosis gastric bypass: A single join; increasingly used.
• Gastric band: Now rarely performed - high failure and removal rates.

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After Bariatric Surgery

Lifelong supplements and monitoring (BOMSS guidance):

• Complete multivitamin and mineral daily.
• Calcium and vitamin D.
• Iron, and folic acid as needed.
• Vitamin B12 injections every 3 months after bypass (and often after sleeve).
• Annual bloods:
  • FBC, ferritin, folate, B12.
  • Vitamin D, calcium, PTH.
  • LFTs, U&E.
  • Zinc, copper and vitamin A as indicated.
  • HbA1c if previously diabetic.

Complications to recognise:

• Nutritional deficiencies:
  • Iron deficiency anaemia.
  • B12 deficiency.
  • Thiamine deficiency - Wernicke's encephalopathy with persistent vomiting. Give IV Pabrinex urgently.
  • Secondary hyperparathyroidism, osteomalacia, osteoporosis.
  • Copper deficiency - myelopathy, anaemia.
• Dumping syndrome:
  • Early (within 30 minutes of sugary food): Rapid fluid shift into the gut - palpitations, flushing, diarrhoea, abdominal pain.
  • Late (1–3 hours after eating): An exaggerated insulin response causes hypoglycaemia - see the Neuroendocrine Tumours and Hypoglycaemia chapter.
  • Treatment: Small, low-sugar meals, with protein, fibre and complex carbohydrate.
• Surgical:
  • Internal hernia after bypass - intermittent or severe abdominal pain, sometimes with normal bloods. Needs urgent CT and surgical review, because the bowel can become ischaemic.
  • Marginal (anastomotic) ulcers - avoid NSAIDs and smoking.
  • Strictures, leaks.
  • Gallstones.
  • Reflux after sleeve gastrectomy.
• Drugs:
  • Absorption is altered - avoid modified-release preparations where possible.
  • Oral contraceptives are less reliable after bypass - use non-oral methods.
  • Review and reduce antihypertensive and diabetes drugs as weight falls.
• Pregnancy: Avoid for 12–18 months after surgery. Needs specialist antenatal care and supplements. Do not use the glucose tolerance test - it can provoke dumping.
• Mental health: Increased alcohol sensitivity and alcohol problems, depression and self-harm risk. Weight regain.

⚠️ Safety Pearl: Abdominal pain in a patient who has had a gastric bypass is an internal hernia until proven otherwise. A normal examination and normal bloods do not exclude it - discuss urgently with the bariatric or surgical team.

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Drug Reference Table

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Spot the Diagnosis

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Exam-style Scenarios

1. A 52-year-old man has had an MI. On atorvastatin 80 mg and ezetimibe, his LDL is 2.9 mmol/L.
Answer: Above the NICE target (LDL 2.0 or less).

• Check adherence.
• He meets NICE TA733 for inclisiran (CVD with LDL 2.6 or more on maximum tolerated treatment). A PCSK9 antibody is an alternative.
• Consider FH if there is a family history.

2. A 34-year-old woman has total cholesterol 9.4 mmol/L. Her brother had an MI at 41.
Answer: Probable familial hypercholesterolaemia.

• Exclude secondary causes (TSH, LFTs, urine protein).
• Refer to a lipid clinic for genetic testing.
• High-intensity statin aiming for more than 50% LDL reduction - after discussing pregnancy plans.
• Cascade testing of relatives, including her children.

3. A 45-year-old woman with BMI 42, type 2 diabetes, hypertension, sleep apnoea and dyslipidaemia asks about weight-loss treatment.
Answer: She meets NICE criteria for tirzepatide (TA1026), and falls within the highest-priority primary care cohort. She is also eligible for bariatric surgery assessment.

• Advise on contraception - tirzepatide reduces oral contraceptive reliability.
• Reduce sulfonylurea or insulin doses to avoid hypoglycaemia.

4. A woman 3 years after Roux-en-Y gastric bypass has fatigue and paraesthesia. She stopped her supplements.
Answer: Likely B12 deficiency (and possibly iron, copper or folate).

• FBC, B12, folate, ferritin, copper.
• Restart IM B12 and complete supplements.
• Lifelong annual monitoring.

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Key Points

• LDL is causal in atherosclerosis - lower for longer is better. Use non-HDL for monitoring.
• NICE NG238: Atorvastatin 20 mg for primary prevention (QRISK3 10% or more), 80 mg for secondary prevention.
• Secondary prevention target: LDL 2.0 or less, or non-HDL 2.6 or less. Add ezetimibe, then inclisiran or a PCSK9 inhibitor.
• Most statin muscle symptoms are not caused by the statin - rechallenge or switch.
• Suspect FH with very high cholesterol, tendon xanthomata or premature family CHD. Do cascade testing.
• Triglycerides above 10 mmol/L risk pancreatitis. Refer urgently if above 20.
• Obesity is a chronic disease. Use lower BMI thresholds for higher-risk ethnic groups.
• GLP-1 and GIP drugs produce 15–20% weight loss. Watch for GI effects, pancreatitis, pregnancy and contraception issues, and weight regain on stopping.
• After gastric bypass: lifelong supplements, B12 injections, and urgent review for abdominal pain.

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Guidelines and Further Reading

• NICE NG238: Cardiovascular disease - risk assessment and reduction, including lipid modification
• NICE TA733: Inclisiran
• HEART UK: Familial hypercholesterolaemia and Lp(a) consensus statements
• NICE NG246: Overweight and obesity management
• NICE TA875: Semaglutide for managing overweight and obesity
• NICE TA1026: Tirzepatide for managing overweight and obesity
• NHS England: Interim commissioning guidance for tirzepatide
• BOMSS: Guidelines on biochemical monitoring and micronutrient replacement after bariatric surgery
• MHRA Drug Safety Updates: GLP-1 and GIP drugs (contraception, aspiration), counterfeit weight-loss pens
• BNF / BNFc - for current doses

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