What is the recommended dose of pravastatin (HMG-CoA reductase inhibitor) for a 70-year-old female with elevated low-density lipoprotein (LDL) cholesterol?

Pravastatin Dosing for 70-Year-Old Female with LDL 4.88 mmol/L

For a 70-year-old female with an LDL-C of 4.88 mmol/L (approximately 189 mg/dL), moderate-intensity pravastatin at a dose of 40 mg daily is recommended as the initial therapy. 1, 2

Risk Assessment and Treatment Rationale

• This patient's LDL-C level of 4.88 mmol/L (189 mg/dL) is very close to the severe hypercholesterolemia threshold of 4.9 mmol/L (190 mg/dL), warranting statin therapy 1
• At age 70, the patient falls into the older adult category (≥75 years) where moderate-intensity statin therapy is reasonable for primary prevention 1
• Pravastatin is an appropriate choice as it has demonstrated efficacy and safety in older patients 2, 3

Dosing Recommendations

• Initial dose: Pravastatin 40 mg once daily 2
• This dose can reduce LDL-C by approximately 25-34% 4
• The medication can be taken at any time of day, with or without food 2
• For patients over 75 years of age with LDL-C 70-189 mg/dL, initiating a moderate-intensity statin is reasonable (Class IIb recommendation) 1

Monitoring and Follow-up

• Assess LDL-C levels 4-12 weeks after initiating therapy to evaluate response 1
• Monitor adherence to medication and lifestyle modifications 1
• Follow up every 3-12 months thereafter based on need to assess adherence and safety 1

Special Considerations for Older Adults

• Benefits of statin therapy should be weighed against potential risks in older adults 1
• Consider functional status, multimorbidity, frailty, and life expectancy 1
• If functional decline (physical or cognitive), multimorbidity, frailty, or reduced life expectancy develops, it may be reasonable to discontinue statin therapy 1

Potential Adjustments to Therapy

• If the patient does not achieve at least a 30-49% reduction in LDL-C with pravastatin 40 mg, consider:
  • Adding ezetimibe if LDL-C remains elevated despite maximally tolerated statin therapy 1
  • For patients with severe hypercholesterolemia who achieve less than 50% reduction in LDL-C while on maximally tolerated statin therapy, ezetimibe therapy is reasonable 1

Cautions and Contraindications

• Assess for potential drug interactions, particularly with cyclosporine, clarithromycin, or erythromycin which would require dose adjustments 2
• Monitor for myopathy and rhabdomyolysis, which are rare but serious side effects 2
• Pravastatin is contraindicated in patients with acute liver failure or decompensated cirrhosis 2

Additional Considerations

• Emphasize therapeutic lifestyle changes alongside medication therapy 1
• Consider the patient's overall cardiovascular risk profile, not just LDL-C levels 1
• If the patient has renal impairment, dose adjustments may be necessary 2