Resident Editor: Lulu Tsao, MD
Faculty Editor: Soraya Azari, MD
Doses of Statins (mg) Required to Achieve Various Reductions in LDL-C From Baseline
|
Percent Reduction in LDL Cholesterol§ |
|||||||
|---|---|---|---|---|---|---|---|
|
|
20-25% |
26-30% |
31-35% |
36-40% |
41-50% |
51-55% |
56-60% |
|
Statin Intensity* |
Low |
Low |
Mod |
Mod |
Mod |
High |
High |
|
Lovastatin, Pravastatin |
10 |
20 |
40 |
80 |
|
|
|
|
Fluvastatin |
20 |
40 |
80 |
|
|
|
|
|
Pitavastatin |
|
1 |
2 |
4 |
|
|
|
|
Simvastatinx |
-- |
10 |
20 |
40 |
80 |
|
|
|
Atorvastatin |
-- |
-- |
10 |
20 |
40+ |
80 |
|
|
Rosuvastatin |
-- |
-- |
-- |
5 |
10 |
20 |
40 |
|
Vytorin** |
-- |
-- |
-- |
10/10 |
10/20 |
10/40 |
10/80 |
* 2013 ACC/AHA guidelines: high-intensity statin lowers cholesterol by >50%, moderate-intensity statin lowers cholesterol by 30-50%, low-intensity statin lowers cholesterol by <30%. All patients age 21-75 with any form of CVD, or LDL-C ≥ 190, should be given high-intensity statin unless they have clinical features that might predispose them to statin toxicity (i.e., serious co-morbidities such as renal or liver dz, hx statin intolerance, ALT >3xULN, drug interactions). Patients with CVD over 75 years old or unable to tolerate high-intensity statin should be on moderate-intensity statin. All patients with DM (age 40-75) with LDL-C 70-189, without known CVD, should receive moderate-intensity statin, or if 10-year risk by ASCVD risk calculator is > 7.5%, high-intensity statin. Patients age 40-75 without diabetes or CVD, but with LDL-C 70-189 and 10-year risk >7.5%, should consider a moderate-to-high intensity statin.
+ Atorvastatin 40-80mg considered high intensity. Avoid atorvastatin with glecaprevir/pibrentasvir (Mavyret) for HCV.
** 10 mg ezetimibe§ plus 10, 20, 40 or 80mg simvastatin. Vytorin not included in statin intensity charts
§ 2017 guidelines from ACC recommend considering non-statin therapies to achieve ≥50% LDL-C reduction (or LDL <70) for patients with clinical ASCVD who are already on maximally tolerated statin. First review adherence given estimates that ~50% of patients poorly adhere. Following that, combining ezetimibe, 10 mg/day, adds up to 25% additional LDL-C lowering. In patients who require more lowering, a PCSK9 inhibitor may be considered.
x FDA recommends that healthcare professionals should maintain patients on simvastatin 80mg only if they have been taking this dose for >12 months without evidence of muscle toxicity; do not start new patients on simvastatin 80mg or escalate to this dose.
x Do not exceed 10 mg simvastatin daily with diltiazem, verapamil.
x Do not exceed 20 mg simvastatin daily with amiodarone, amlodipine, ranolazine
x Avoid simvastatin with glecaprevir/pibrentasvir (Mavyret) for HCV.
References:
Adapted from Goodman & Gilman’s The Pharmacologic Basis of Therapeutics, Chapter 31, McGraw Hill, 2010
FDA Drug Safety Communication (updated December 15, 2017), from http://www.fda.gov/drugs/drugsafety/ucm256581.htm
Stone NJ, Robinson JG, Lichtenstein AH, et al. 2013 ACC/AHA guideline on the treatment of blood cholesterol to reduce atherosclerotic cardiovascular risk in adults: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines. Circulation 2014;129:S1-45.
Lloyd-Jones DM, Morris PB, Ballantyn CM, et. al. 2017 Focused Update of the 2016 ACC Expert Consensus Decision Pathway on the Role of Non-Statin Therapies for LDL-Cholesterol Lowering in the Management of Atherosclerotic Cardiovascular Disease Risk: A Report of the American College of Cardiology Task Force on Expert Consensus Decision Pathways. J Am Coll Cardiol 2017;70(14):1785-1822.