What statin should I start a patient on?

Statin Selection for Patients Requiring Lipid-Lowering Therapy

For most patients requiring statin therapy, start with atorvastatin 10-20 mg or rosuvastatin 5-10 mg once daily, with dose selection based on the required LDL-C reduction needed to reach target goals. 1, 2, 3

Initial Statin Selection Algorithm

Step 1: Determine Required LDL-C Reduction

• <30% reduction needed: Low-intensity statin (e.g., atorvastatin 10 mg)
• 30-49% reduction needed: Moderate-intensity statin (e.g., atorvastatin 10-20 mg, rosuvastatin 5-10 mg)
• ≥50% reduction needed: High-intensity statin (e.g., atorvastatin 40-80 mg, rosuvastatin 20-40 mg)

Step 2: Consider Patient Risk Category

• Secondary prevention (established ASCVD): Use high-intensity statin to achieve LDL-C <70 mg/dL 1
• Primary prevention with diabetes: Use moderate to high-intensity statin based on age and risk factors 1
• Primary prevention without diabetes: Select intensity based on calculated 10-year ASCVD risk and LDL-C levels 1

Specific Statin Recommendations

Atorvastatin

• Starting dose: 10-20 mg once daily 2
• Patients requiring >45% LDL-C reduction: Start with 40 mg once daily 2, 4
• Maximum dose: 80 mg once daily
• Can be taken any time of day with or without food 2

Rosuvastatin

• Starting dose: 5-10 mg once daily 3
• Maximum dose: 40 mg once daily
• Can be taken any time of day with or without food 3
• For Asian patients: Start at 5 mg once daily 3

Monitoring Protocol

1. Baseline measurements: Obtain lipid profile, liver function tests (ALT/AST) before starting therapy 5

2. Initial follow-up: Check lipid levels 4-12 weeks after starting therapy or changing dose 1, 5

3. Dose adjustment: If target LDL-C not achieved:

   • Assess medication adherence
   • Double the dose and recheck in 4-12 weeks
   • Continue stepped titration until target achieved or maximum tolerated dose reached 1, 5

4. Safety monitoring:

   • Ask about muscle symptoms at each visit
   • Check liver enzymes if clinically indicated
   • No need for routine CK measurement unless muscle symptoms develop 5, 6

Special Considerations

• Elderly patients (>75 years): Start with lower doses and titrate more cautiously 1
• Renal impairment: For severe renal impairment, start rosuvastatin at 5 mg and don't exceed 10 mg 3
• Drug interactions: Be cautious with medications that may increase statin levels (e.g., cyclosporine, certain antifungals, protease inhibitors) 5, 2
• Statin intolerance: If muscle symptoms occur without significant CK elevation, consider a lower dose or alternate-day dosing 6

Common Pitfalls to Avoid

• Starting with inadequate doses: Many patients fail to reach LDL-C targets because initial doses are too low for their required LDL-C reduction 7, 8
• Insufficient follow-up: Failing to check lipid levels 4-12 weeks after initiation misses opportunities for timely dose adjustment 5
• Premature discontinuation: Stopping therapy due to minor side effects or laboratory abnormalities that may be unrelated to the statin 6
• Not individualizing starting dose: Using a one-size-fits-all approach rather than selecting dose based on baseline LDL-C and target goals 8

Remember that the goal of statin therapy is to reduce cardiovascular morbidity and mortality through adequate LDL-C reduction. The evidence strongly supports using an adequate statin dose that reduces LDL-C to <100 mg/dL AND achieves at least a 30% lowering of LDL-C, with even lower targets (<70 mg/dL) for very high-risk patients 1.