When are moderate intensity statins (3-hydroxy-3-methylglutaryl-coenzyme A reductase inhibitors) prescribed?

When to Prescribe Moderate Intensity Statins

Moderate intensity statins should be prescribed as first-line therapy for adults aged 40-75 years with diabetes mellitus without established atherosclerotic cardiovascular disease (ASCVD), and for adults with intermediate ASCVD risk (7.5-19.9% 10-year risk) without diabetes. 1

Moderate Intensity Statin Definition

Moderate intensity statins lower LDL cholesterol by 30-49% from baseline and include:

• Atorvastatin 10-20 mg
• Rosuvastatin 5-10 mg
• Simvastatin 20-40 mg
• Pravastatin 40-80 mg
• Lovastatin 40 mg
• Fluvastatin XL 80 mg
• Pitavastatin 1-4 mg

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Primary Prevention Indications for Moderate Intensity Statins

1. Adults with Diabetes Mellitus

• Age 40-75 years with diabetes: Moderate intensity statin therapy is indicated regardless of estimated 10-year ASCVD risk 1
• Exception: Consider high-intensity statin if patient has multiple ASCVD risk factors 1

2. Adults without Diabetes Mellitus

• Intermediate risk (7.5-19.9% 10-year ASCVD risk): Moderate intensity statin recommended after clinician-patient risk discussion 1
• Borderline risk (5-7.5% 10-year ASCVD risk): Consider moderate intensity statin if risk-enhancing factors are present 1
• Age <40 years: Consider moderate intensity statin if additional ASCVD risk factors present 1

3. Special Populations

• Age >75 years: Consider moderate intensity statin after evaluating potential benefits, adverse effects, drug interactions, frailty, and patient preferences 1
• Coronary artery calcium score 1-99 in patients ≥55 years: Reasonable to initiate moderate intensity statin 1

Secondary Prevention Considerations

While high-intensity statins are generally preferred for secondary prevention (established ASCVD), moderate intensity statins may be appropriate in:

• Elderly patients (>75 years) with established ASCVD 1
• Patients with statin intolerance who cannot tolerate high-intensity statins 2
• Recent evidence suggests moderate-intensity statin plus ezetimibe may be preferable to high-intensity statin monotherapy in elderly patients with ASCVD due to lower incidence of statin-associated muscle symptoms (0.7% vs 5.7%) 2

Risk Assessment and Treatment Decision Algorithm

1. Determine patient's age and presence of diabetes
2. If age 40-75 with diabetes: Start moderate intensity statin
3. If age 40-75 without diabetes: Calculate 10-year ASCVD risk
   • If ≥7.5%: Recommend moderate intensity statin
   • If 5-7.5%: Consider moderate intensity statin if risk-enhancing factors present
4. If age <40 years: Consider moderate intensity statin only if additional ASCVD risk factors present
5. If age >75 years: Individualized decision based on risk/benefit assessment

Common Pitfalls and Caveats

• Undertreatment: Failing to prescribe statins to patients with diabetes aged 40-75 years, who benefit regardless of baseline LDL-C 1
• Overtreatment: Starting with high-intensity statins in lower-risk patients, increasing adverse effect risk 3
• Inadequate follow-up: Not checking LDL-C response (aim for 30-49% reduction with moderate intensity statins) 1
• Discontinuation due to perceived side effects: Many side effects may be nocebo effect; consider rechallenge at lower dose when intolerance occurs 3
• Missing combination therapy opportunities: For elderly patients with ASCVD, moderate-intensity statin plus ezetimibe may provide similar LDL-C reduction with fewer side effects compared to high-intensity statin monotherapy 2

Moderate intensity statins remain a cornerstone of primary prevention, providing significant cardiovascular risk reduction while minimizing adverse effects in appropriate patient populations.