From the FDA Drug Label
In the atorvastatin calcium placebo-controlled clinical trial database of 16,066 patients (8,755 atorvastatin calcium vs 7,311 placebo; age range 10 to 93 years, 39% female, 91% White, 3% Black or African American, 2% Asian, 4% other) with a median treatment duration of 53 weeks, the most common adverse reactions in patients treated with atorvastatin calcium that led to treatment discontinuation and occurred at a rate greater than placebo were: myalgia (0.7%), diarrhea (0.5%), nausea (0. 4%), alanine aminotransferase increase (0.4%), and hepatic enzyme increase (0. 4%).
Table 1 summarizes adverse reactions reported in ≥ 2% and at a rate greater than placebo in patients treated with atorvastatin calcium (n=8,755), from seventeen placebo-controlled trials
Adverse Reaction% Placebo N=7,311 % 10 mg N=3,908 % 20 mg N=188 % 40 mg N=604 % 80 mg N=4,055 % Any dose N=8,755 Nasopharyngitis8.212.95.37.04.28.3 Arthralgia6.58.911.710.64.36.9 Diarrhea6.37.36.414.15.26.8 Pain in extremity5.98.53.79.33.16.0 Urinary tract infection5.66.96. 48.04.15.7 Dyspepsia4.35.93.26.03.34.7 Nausea3.53.73.77.13.84.0 Musculoskeletal pain3.65.23.25.12.33.8 Muscle spasms3.04.64.85.12.43.6 Myalgia3.13.65.98.42.73.5 Insomnia2.92.81.15.32.83.0 Pharyngolaryngeal pain2.13.91.62.80.72.2
The FDA drug label does not answer the question.
From the Research
Pitavastatin is generally the best tolerated statin for elderly patients and Asians, as it has been associated with a lower risk of safety events compared to other statins, such as atorvastatin and rosuvastatin, in this population. This is based on a recent study published in 2022, which found that pitavastatin was associated with a lower risk of composite safety events, including hepatitis, myopathy, and new-onset diabetes mellitus, compared to usual-dose and high-dose statins 1.
When prescribing statins to elderly patients and Asians, it's essential to consider the potential for statin-related muscle symptoms and adverse effects, which can be more common in these populations due to genetic differences in drug metabolism and age-related changes in pharmacokinetics. Specifically, many Asians have polymorphisms in the SLCO1B1 gene that affect statin transport into the liver, leading to higher blood levels and increased risk of side effects. Elderly patients have reduced drug clearance, altered body composition, and are often on multiple medications that can interact with statins.
Some key points to consider when prescribing statins to these populations include:
- Starting with a lower dose and gradually titrating up while monitoring for muscle pain, weakness, and liver function
- Regular follow-up within 4-12 weeks of initiation to check lipid response and assess for adverse effects
- Considering alternate-day dosing or twice-weekly dosing regimens if intolerance occurs, to improve adherence while maintaining reasonable lipid-lowering effects
- Being aware of the potential benefits of statins for primary prevention of cardiovascular disease in the elderly Asian population, as suggested by a recent study published in 2023 2.
Overall, the choice of statin and dosing strategy should be individualized based on the patient's specific needs and risk factors, with a focus on minimizing the risk of adverse effects while maximizing the benefits of lipid-lowering therapy.