From the Guidelines
If you cannot tolerate atorvastatin, rosuvastatin is often the best alternative statin medication, as it is a high-intensity statin that can lower LDL-C levels by ≥50%. According to the 2018 AHA/ACC/AACVPR/AAPA/ABC/ACPM/ADA/AGS/APhA/ASPC/NLA/PCNA guideline on the management of blood cholesterol 1, rosuvastatin is a suitable alternative to atorvastatin, with a recommended starting dose of 5-10 mg daily, and potential dose adjustments up to 40 mg daily based on response and tolerance.
When considering alternative statins, it's essential to evaluate the intensity of statin therapy, which is divided into three categories: high-intensity, moderate-intensity, and low-intensity 1. The choice of statin should be based on the patient's individual response and tolerance, as well as the specific intolerance symptoms experienced with atorvastatin. Other options, such as pravastatin or fluvastatin, may be considered due to their fewer drug interactions and lower risk of muscle-related side effects. Pitavastatin is another alternative with minimal liver metabolism and low risk of drug interactions.
Key factors to consider when switching statins include:
- Starting at a lower dose and gradually increasing while monitoring for side effects
- Evaluating the specific intolerance symptoms experienced with atorvastatin, such as muscle pain, liver enzyme elevations, or gastrointestinal issues
- Considering alternate-day or twice-weekly dosing schedules for patients who cannot tolerate daily dosing
- Adding CoQ10 supplements to prevent muscle-related side effects, if necessary
- Discussing these options with a healthcare provider to determine the most appropriate choice based on individual medical history and cholesterol-lowering needs.
From the FDA Drug Label
The FDA drug label does not answer the question.
From the Research
Statin Intolerance and Alternative Options
When a patient cannot tolerate atorvastatin, there are several alternative statin options to consider.
- Pravastatin or fluvastatin are recommended as alternative statins, although they are less effective in reducing LDL cholesterol 2.
- Pitavastatin has been shown to be a viable alternative to atorvastatin, with similar efficacy in lowering LDL-C and a favorable safety profile 3, 4.
- Rosuvastatin is another option, with studies demonstrating its effectiveness and tolerability in patients who cannot tolerate other statins 5.
Non-Statin Alternatives
If a patient is unable to tolerate any statins, there are non-statin alternatives available.
- Ezetimibe and/or bile acid sequestrants can be used as alternative drugs for patients who cannot tolerate any of the statins 2.
- PCSK9 inhibitors may be used if LDL cholesterol targets are not reached 2.
- Lipoprotein apheresis may be considered for high-risk patients with multiple cardiovascular events and sub-optimal LDL cholesterol despite lipid-lowering drug therapy 2.
Considerations for Statin Selection
When selecting a statin, it is essential to consider the patient's individual needs and medical history.