Should atorvastatin (Lipitor) be increased to 80 mg in a patient with elevated Low-Density Lipoprotein (LDL) levels, currently taking atorvastatin 40 mg and ezetimibe (Zetia) 10 mg?

From the Guidelines

Increasing atorvastatin from 40 mg to 80 mg is a reasonable next step for this patient with elevated LDL levels despite combination therapy with atorvastatin 40 mg and ezetimibe 10 mg, as high-intensity statin therapy is recommended for patients with clinical atherosclerotic cardiovascular disease (ASCVD) to reduce LDL-C levels by 50% 1.

Considerations for Dose Increase

When considering increasing the atorvastatin dose, several factors should be taken into account:

• The patient's current LDL level and overall cardiovascular risk
• The potential for additional LDL reduction with high-dose statin therapy, which can provide an additional 6-7% reduction in LDL cholesterol
• The patient's adherence to the current medication regimen and lifestyle modifications
• The potential for side effects with high-dose statin therapy, including muscle symptoms and elevated liver enzymes

Monitoring and Follow-up

After increasing the atorvastatin dose to 80 mg, the patient should be monitored for:

• Potential side effects of high-dose statin therapy
• Efficacy of the dose increase, with a follow-up lipid panel obtained 4-12 weeks after the change

Alternative Therapies

If the patient still doesn't achieve their LDL goal with atorvastatin 80 mg plus ezetimibe, alternative therapies such as adding a PCSK9 inhibitor may be considered, especially if they have established ASCVD or familial hypercholesterolemia, as recommended by the 2018 AHA/ACC/AACVPR/AAPA/ABC/ACPM/ADA/AGS/APhA/ASPC/NLA/PCNA guideline on the management of blood cholesterol 1.

Key Points

• High-intensity statin therapy is recommended for patients with clinical ASCVD to reduce LDL-C levels by 50%
• Increasing atorvastatin from 40 mg to 80 mg can provide an additional 6-7% reduction in LDL cholesterol
• The decision to intensify therapy should be based on the patient's overall cardiovascular risk, target LDL goal, and tolerance of statin therapy 1

From the FDA Drug Label

The FDA drug label does not answer the question.

From the Research

Patient Considerations

• The patient is currently taking atorvastatin 40 mg and ezetimibe 10 mg, and has elevated Low-Density Lipoprotein (LDL) levels.
• The goal is to determine whether increasing the atorvastatin dose to 80 mg is necessary, or if the current combination therapy is sufficient.

Study Findings

• A study published in 2008 2 compared the efficacy and safety of adding ezetimibe to atorvastatin 40 mg versus uptitrating atorvastatin to 80 mg in hypercholesterolemic patients at high risk of coronary heart disease.
• The results showed that adding ezetimibe to atorvastatin 40 mg was significantly more effective than uptitrating to atorvastatin 80 mg at lowering LDL cholesterol and other lipid parameters.
• Another study published in 2004 3 found that the addition of ezetimibe to atorvastatin followed by response-based atorvastatin dose titration provided a more effective means for reducing LDL-C levels in patients at high risk for coronary heart disease than continued doubling of atorvastatin alone.
• A 2013 study 4 also found that treatment with ezetimibe added to atorvastatin 10 or 20 mg produced significantly greater improvements in key lipid parameters and significantly greater attainment of LDL-C treatment targets than doubling atorvastatin or switching to (or doubling) rosuvastatin.

Treatment Options

• Based on the study findings, adding ezetimibe to atorvastatin 40 mg may be a more effective treatment option than increasing the atorvastatin dose to 80 mg.
• The current combination therapy of atorvastatin 40 mg and ezetimibe 10 mg may be sufficient to achieve the desired LDL-C levels, and increasing the atorvastatin dose to 80 mg may not provide additional benefits.
• However, the decision to increase the atorvastatin dose or continue with the current combination therapy should be made on a case-by-case basis, taking into account the individual patient's response to treatment and other factors, as suggested by studies 5, 6.