What statin (HMG-CoA reductase inhibitor) is suitable for use in a patient with Impaired renal function undergoing hemodialysis (HD)?

From the Guidelines

Statin therapy should not be initiated in most prevalent hemodialysis patients, but may be considered in those with recent myocardial infarction or greater life expectancy. When prescribing statins to hemodialysis patients, it's essential to monitor for side effects like myopathy, which may be more common in this population due to altered drug metabolism and polypharmacy. Regular monitoring of liver function tests and creatine kinase is recommended, especially during the initial treatment period. The decision to use statins should consider the patient's overall cardiovascular risk, life expectancy, and potential for drug interactions with other medications commonly used in dialysis patients 1.

Some key points to consider when using statins in hemodialysis patients include:

• Atorvastatin and fluvastatin are preferred options as they have minimal renal clearance and don't require dose adjustments in kidney failure.
• Typical starting doses are atorvastatin 10-20mg daily or fluvastatin 20-40mg daily.
• Rosuvastatin should be used cautiously at reduced doses (5-10mg daily maximum) in dialysis patients.
• Simvastatin and pravastatin may also be used without specific dose adjustments but require monitoring.
• The benefit of statins in hemodialysis patients is somewhat controversial, with stronger evidence for those with known atherosclerotic disease or diabetes rather than for primary prevention 1.

In patients already receiving statins or statin/ezetimibe combination at the time of dialysis initiation, it is suggested that these agents be continued 1. However, the lack of data regarding statin therapy in incident dialysis patients makes it challenging to provide a definitive recommendation. Ultimately, the decision to use statins in hemodialysis patients should be individualized, taking into account the patient's unique characteristics and preferences.

From the FDA Drug Label

Due to extensive drug binding to plasma proteins, hemodialysis is not expected to significantly enhance atorvastatin clearance. Renal impairment is a risk factor for myopathy and rhabdomyolysis. Monitor all patients with renal impairment for development of myopathy. Renal impairment does not affect the plasma concentrations of atorvastatin, therefore there is no dosage adjustment in patients with renal impairment

The use of atorvastatin in patients undergoing hemodialysis is not expected to be significantly affected by the dialysis process itself, as atorvastatin is extensively bound to plasma proteins and therefore not readily cleared by hemodialysis. However, renal impairment is a risk factor for myopathy and rhabdomyolysis, and patients with renal impairment should be monitored for the development of myopathy. No dosage adjustment is necessary in patients with renal impairment 2.

From the Research

Statin Use in Hemodialysis Patients

• The use of statins in hemodialysis patients has been studied to evaluate their effects on blood lipid levels, inflammation, and nutrition [(3,4,5)].
• A study comparing atorvastatin and rosuvastatin in maintenance hemodialysis patients found that both statins reduced blood lipid levels and inhibited microinflammation, but rosuvastatin was more effective in decreasing LDL-C levels and improving nutrition 3.
• Another study reviewed the literature on drug treatments for patients on hemodialysis with multiple chronic pathologies, including cardiovascular disease, and found that statins are commonly prescribed for these patients 4.
• A randomized trial evaluating the effects of atorvastatin and simvastatin in patients on hemodialysis found that both statins significantly lowered total plasma cholesterol and LDL-cholesterol concentrations, and reduced markers of in vivo LDL oxidation 5.

Effects of Statins on Lipid Profiles and Inflammation

• Statins have been shown to improve lipid profiles in hemodialysis patients by reducing total plasma cholesterol and LDL-cholesterol concentrations [(3,5)].
• Statins also have anti-inflammatory effects, as evidenced by reduced levels of high-sensitivity CRP and interleukin-6 in hemodialysis patients 3.
• However, not all studies have found significant reductions in inflammatory markers, such as hs-CRP, with statin therapy 5.

Choice of Statin for Hemodialysis Patients

• The choice of statin for hemodialysis patients may depend on various factors, including the patient's individual needs and the pharmacokinetic profile of the statin 4.
• Rosuvastatin may be a better option than atorvastatin for some hemodialysis patients, due to its more significant effects on LDL-C levels and nutrition 3.
• However, more research is needed to determine the optimal statin regimen for hemodialysis patients and to define the pharmacokinetics of statins in patients undergoing different dialysis techniques 4.