Why is pitavastatin (Pitavastatin) not prescribed as frequently as other statins, such as atorvastatin (Atorvastatin) or simvastatin (Simvastatin), despite its benefits?

From the Guidelines

Pitavastatin is prescribed less frequently than older statins primarily due to its higher cost, limited marketing, and relatively recent entry to the market, as well as restrictions in availability and reimbursement in some countries, as noted in the 2024 recommendations on the optimal use of lipid-lowering therapy 1. As a newer statin (FDA approved in 2009), pitavastatin lacks the decades of clinical experience and extensive research data that support older statins like atorvastatin and simvastatin. Despite offering benefits such as minimal drug interactions, less metabolism through the cytochrome P450 system, and potentially fewer side effects, pitavastatin remains less familiar to many clinicians. Some of the key benefits of pitavastatin include its ability to reduce LDL-C effectively, with a mean reduction of 43-47% 1, and its potential to reduce the risk of new-onset diabetes (NOD) compared to other statins, as suggested by the Cholesterol Treatment Trialists’ Collaboration meta-analysis 1. Additionally, many older statins are available as inexpensive generics and have established prescribing patterns among physicians. Insurance coverage also plays a significant role, as many formularies prefer older, less expensive statins as first-line options. While pitavastatin may be particularly beneficial for patients with drug interaction concerns or those who have experienced side effects with other statins, these advantages haven't yet overcome the practical barriers of cost, familiarity, and established prescribing habits that favor older statins in routine clinical practice. The recent results of the REPRIVE trial, which demonstrated the efficacy and safety of pitavastatin in patients with HIV infection, further support the potential benefits of pitavastatin in specific patient populations 1. However, the availability and reimbursement of pitavastatin vary widely between countries, which can limit its use in some regions, as noted in the 2024 recommendations on the optimal use of lipid-lowering therapy 1. In light of these factors, pitavastatin should be considered as a valuable option for patients who require lipid-lowering therapy, particularly those with metabolic disturbances, diabetes, or statin intolerance, as recommended by the International Lipid Expert Panel (ILEP) and the Polish Expert Group on the use of pitavastatin 1. Some key points to consider when prescribing pitavastatin include:

• Its efficacy in reducing LDL-C and cardiovascular risk
• Its potential benefits in reducing the risk of NOD
• Its safety profile, including minimal drug interactions and fewer side effects
• Its availability and reimbursement in different countries and regions
• Its potential use in specific patient populations, such as those with HIV infection or statin intolerance. Overall, while pitavastatin may not be prescribed as frequently as older statins, it remains a valuable option for patients who require lipid-lowering therapy, and its benefits and potential uses should be carefully considered by clinicians.

From the Research

Reasons for Less Frequent Prescription of Pitavastatin

• Pitavastatin is not prescribed as frequently as other statins, such as atorvastatin or simvastatin, despite its benefits, due to several factors:
  • Higher acquisition cost compared to other statins 2
  • Lack of evidence showing improvement in clinical outcomes in high-risk patient populations, making it less preferred over cheaper, clinically proven alternatives 2
  • Although pitavastatin has a favorable pharmacokinetic profile and is well tolerated, its efficacy in lowering LDL-C is similar to other statins, which may not justify its higher cost 3, 4, 5, 6
• The choice of statin depends on the characteristics and needs of the individual patient, and pitavastatin's distinct pharmacological features may make it a better option for certain patients, such as those with metabolic syndrome or type 2 diabetes 4
• Pitavastatin's benefits, including its ability to increase HDL-C levels and improve lipid parameters, may not be fully recognized or appreciated, leading to less frequent prescription 3, 4, 6

Clinical Evidence and Studies

• Studies have shown that pitavastatin is effective in reducing LDL-C and triglyceride levels, and increasing HDL-C levels, with a similar or greater efficacy compared to other statins 3, 4, 5, 6
• Pitavastatin has a favorable safety profile, with a low incidence of adverse events, including musculoskeletal and gastrointestinal events 3, 5, 6
• The JAPAN-ACS study demonstrated that pitavastatin was non-inferior to atorvastatin in reducing plaque volume in patients with acute coronary syndrome 3