Statin for Hipirlepid

8/11/2019 Statin for Hipirlepid

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Prescribing Focus:

Statins for the Management of Hyperlipidemia

Introduction

It is estimated that 102.2 million adults in the US have total blood cholesterol values of 200 mg/dL,

with about 35.7 million having levels 240 mg/dL, significantly increasing the risk for cardiovascular

events (CV) in these patients.1Statinsor HMG-CoA reductase inhibitorshave demonstrated the ability

to reduce the risk of adverse CV events in diverse patient populations. This Prescribing Focusoffers

recommendations for the management of hyperlipidemia with statin therapy to decrease morbidity and

mortality in your patients with CV risk.

Lipoprotein Profile Testing in Adults2

The National Cholesterol Education Program Adult Treatment Panel III (NCEP ATP III) recommends a

fasting lipoprotein profile test, including LDL-C screening every 5 years in all low-risk adults age 20 and

over. For those with diabetes or coronary heart disease, annual testing is recommended with an LDL-Cgoal of


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Selecting a Statin for Your Patient4

There are different factors to consider when selecting the appropriate statin for your patient, including:

The extent of each statins ability to lower LDL-C levels and raise HDL-C levels (Table 1)

Drug interactions between statins and your patients concurrent drug therapy (Table 2). With the

exception of pravastatin, all other statins undergo microsomal metabolism by the cytochrome

P450 isoenzyme systems. About half of all medications currently available in clinical practice are

metabolized by CYP3A4.4

Your patients prescription drug coverage. Some statins may be subject to prior authorizations

or step therapy edits.

Table 1. Relative Lipid-Lowering Efficacy of Statins Mean Changes from Baseline (%)4

The results in the table are derived from various clinical trials. Therefore, any direct comparisons of

the lipid-lowering effects of each medication should take into account the differences in trial design,

endpoints and patient demographics.

Drug Name and Dosage LDL-C HDL-C TG

Altoprev (lovastatin, extended-release)

20 mg QD -30 +12 -13

40 mg (QD or divided BID) -35 +13 -10

60 mg (QD or divided BID) -40 +12 -25

Crestor (rosuvastatin)

5 mg QD -28 to 45 +3 to 13 -21 to 35

10 mg QD -45 to 52 +8 to 14 -10 to 37

20 mg QD -31 to 55 +8 to 22 -23 to 37

40 mg QD -43 to 63 +10 to 17 -28 to 43

Lescol (fluvastatin)

20 mg QPM -22 to 25 +2 to 6 -12 to 17

40 mg QPM -24 to 31 +4 to 8 -14 to 20

40 mg BID (80 mg) -34 to 36 +4 to 9 -18 to 23

Lescol XL (fluvastatin, extended-release)

80 mg QPM -33 to 38 +7 to 11 -19 to 25

Lipitor (atorvastatin)

10 mg QD -27 to 39 +6 to 14 -17 to 41

20 mg QD -30 to 43 +9 to 11 -26 to 39

40 mg QD -50 +6 -29

80 mg QD -41 to 60 +5 to 7.5 -37 to 53

*Generic available


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Livalo (pitavastatin)

1 mg QD -32 +8 -15

2 mg QD -36 +7 -19

4 mg QD -43 +5 -18

Mevacor (lovastatin)*

10 mg QD -21 +5 -10

20 mg (QD or divided BID) -24 to 28 +6 to 8 -7 to 10

40 mg (QD or divided BID) -30 to 34 +2 to 9 -6 to 21

80 mg (QD or divided BID) - 40 to 42 +8 to 10 -19 to 27

Niaspan (niacin, extended release)

1000 mg QPM -5 +18 -21

1500 mg QPM -12 +20 -13

2000 mg QPM -14 +22 -28

Pravachol (pravastatin)*

10 mg QD -22 +7 -15

20 mg QD -26 to 32 +1 to 2 -10 to 11

40 mg QD -21 to 41 +5 to 14 -12 to 24

80 mg QD -37 +3 -19

Zocor (simvastatin)*

5 mg QD -26 +10 -12

10 mg QD -30 +12 -15

20 mg QD -38 +8 -19

40 mg QD -28 to 50 +7 to 13 -8 to 41

80 mg QD -36 to 51 +7 to 16 -24 to 38

*Generic available


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Combination Products

Advicor (niacin ER/lovastatin)

2000 mg/40 mg QHS -47 (women)-34 (men)

+ 33 (women)+24 (men)

-48 (women)-35 (men)

Caduet (amlodipine/atorvastatin )

2.5 mg/10 mg N/A N/A N/A

2.5 mg/20mg N/A N/A N/A

2.5 mg/40mg N/A N/A N/A

5 mg/10 mg -39 N/A N/A

5 mg/20mg -42 N/A N/A

5 mg/40mg -45 N/A N/A

5 mg/80mg -48 N/A N/A

10mg/10 mg -37 N/A N/A

10mg/20mg -39 N/A N/A

10mg/40mg -43 N/A N/A

10mg/80mg -49 N/A N/A

Simcor (niacin ER/simvastatin)

1000mg/20mg QPM -12 21 -27

2000mg/20mg QPM -14 29 -38

1000mg/40mg QPM -7 15 -23

2000mg/40mg QPM -5 24 -32

Vytorin (ezetimibe/simvastatin)

10 mg/10 mg QD -45 +8 -23

10 mg/20 mg QD -52 +10 -24

10 mg/40 mg QD -55 +6 -23

10 mg/80 mg QD -60 +6 -31

N/A = Not available *Generic available

Note: The information above is provided for your reference only. Not all products listed may be included

in the health plan's formulary. Please call your patient's health plan to inquire about the formulary status

of the desired statin medication or for more benefit information.


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Table 2. Myopathy and Rhabdomyolysis Drug-Drug Interactions4,5

The risk of myopathy with statins is increased when used in combination with drugs listed in Table 2

below. These interactions range from moderate to severe in nature. Please refer to the package inserts

for the full range of drug interactions associated with each statin.

Interacting

Drug

Advicor(niacinER/lovastatin)

Cre

stor(rosuvastatin)

Les

col(fluvastatin)

Les

colXL(fluvastatin,extended-release)

Lipitor(atorvastatin)

Cad

uet(amlodipine/atorvastatin)

Mevacor(lovastatin)

Altoprev(lovastatin,extended-release

)

Pravachol(pravastatin)

Vyt

orin(ezetimibe/simvastatin)

Zoc

or(simvastatin)

Sim

cor(niacinER/simvastatin)

Livalo(pitavastatin)

Amiodarone x xc xe xe

Itraconazole x x x x xf xf

Ketoconazole x x x x xf xf

Posaconazole x x x x xf xf

Cyclosporine xa x x xd x xf xf x

Macrolides

(clarithromycin

erythromycin)

x x x xf xf xh

Fenofibrate x xb x x xd x x x x

aCrestor dose should not exceed 5 mg/day

bCrestor dose should not exceed 10 mg/daycLovastatin dose should not exceed 40 mg/daydLovastatin dose should not exceed 20 mg/dayeSimvastatin dose should not exceed 10 mg/day

fUse with simvastatin is contraindicated

gSimvastatin dose should not exceed 20 mg/dayhPitavastatin dose should not exceed 1 mg/dayiPitavastatin dose should not exceed 2 mg/day


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Interacting

Drug

Advicor(niacinER/lovas

tatin)

Crestor(rosuvastatin)

Lescol(fluvastatin)

LescolXL(fluvastatin,ex

tended-release)

Lipitor(atorvastatin)

Caduet(amlodipine/atorvastatin)

Mevacor(lovastatin)

Altoprev(lovastatin,extended-release)

Pravachol(pravastatin)

Vytorin(ezetimibe/simvastatin)

Zocor(simvastatin)

Simcor(niacinER/simvastatin)

Livalo(pitavastatin)

Gemfibrozil x xb x x xd x xf xf x

HIV Protease Inhibitors xb x x xf xf x

Niacin (1g/day) x x x x xd x x x x

Amlodipine xg xg

Diltiazem x x x xe xe

Verapamil x x xc xe xe

Grapefruit Juice

(> 1 quart/day)x x x x

Rifampin xi

aCrestor dose should not exceed 5 mg/daybCrestor dose should not exceed 10 mg/daycLovastatin dose should not exceed 40 mg/daydLovastatin dose should not exceed 20 mg/daye

Simvastatin dose should not exceed 10 mg/day

fUse with simvastatin is contraindicatedgSimvastatin dose should not exceed 20 mg/dayhPitavastatin dose should not exceed 1 mg/dayiPitavastatin dose should not exceed 2 mg/day

Some of the common adverse effects associated with statins include headache, constipation and

abdominal pain. Statins are contraindicated in patients with acute liver disease or unexplained persistent

elevations of serum transaminases. They are also contraindicated during pregnancy (Category X). All

statins have the potential to cause persistent elevations in serum transaminases. Liver function tests

should be performed prior to initiation of statin therapy, particularly in patients with a history of liver

disease, and when otherwise clinically indicated.


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Summary of Recommendations

Proper disease management will help reduce the risk and burden of coronary heart disease and

maximize your patients overall well-being. Please consider a lipoprotein profile test or statin therapy

in your patient as clinically appropriate for the management of hyperlipidemia.

References:

1. Cholesterol Statistics. American Heart Association Web site. http://www.americanheart.org/presenter.jhtml?identier=4506.

Accessed February 19, 2010.

2. Third report of the National Cholesterol Education Program (NCEP) expert panel on detection, evaluation, and treatment of high

blood cholesterol in adults (ATP III Final Report). National Heart, Lung, and Blood Institute, National Institutes of Health Web site.

http://www.nhlbi.nih.gov/guidelines/cholesterol/atp3_rpt.htm. Accessed November 29, 2010.

3. American Diabetes Association. Standards of medical care in diabetes 2010. Diabetes Care.2010;33(suppl 1):S11-S61.

4. Micromedex Web site. http://www.thomsonhc.com/ Accessed November 29, 2010.

5. FDA News Release. FDA announces new safety recommendations for high-dose simvastatin. United States Food and Drug

Administration web site. http://www.fda.gov/NewsEvents/Newsroom/PressAnnouncements/ucm258338.htm. Accessed June 8, 2011.


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Statin for Hipirlepid