What statin (HMG-CoA reductase inhibitor) should be started with for initial therapy?

Initial Statin Selection for Therapy

For initial statin therapy, moderate-intensity statin therapy should be started for most patients, with high-intensity statin therapy reserved for those with atherosclerotic cardiovascular disease (ASCVD) or at high risk. 1

Recommended Initial Statin Selection

Primary Prevention (without ASCVD):

• For adults aged 40-75 years without ASCVD, moderate-intensity statin therapy should be initiated 1
• For patients with diabetes aged 40-75 years, moderate-intensity statin therapy should be initiated or continued 1
• For patients with diabetes and a 10-year ASCVD risk ≥7.5%, high-intensity statin therapy is reasonable 1
• For adults with LDL-C ≥190 mg/dL, high-intensity statin therapy should be used 1

Secondary Prevention (with ASCVD):

• For adults ≤75 years with clinical ASCVD, high-intensity statin therapy should be initiated 1
• For adults >75 years with ASCVD, moderate-intensity statin therapy is recommended, with consideration of high-intensity therapy based on risk-benefit assessment 1

Specific Statin Selection

Moderate-Intensity Statins (First-Line Options):

• Pravastatin 40 mg daily - well-tolerated with minimal drug interactions due to different metabolic pathway 1, 2
• Atorvastatin 10-20 mg daily - effective and available as generic 3
• Simvastatin 20-40 mg daily - effective moderate-intensity option 1

High-Intensity Statins (When Indicated):

• Atorvastatin 40-80 mg daily - achieves approximately 50% LDL-C reduction 1, 3
• Rosuvastatin 20-40 mg daily - potent LDL-C reduction 1

Special Considerations

• Renal impairment: For patients with severe renal impairment, pravastatin is recommended at a starting dose of 10 mg daily with maximum 40 mg daily 1, 2
• Drug interactions: Pravastatin has fewer drug interactions compared to other statins and is preferred when patients are on multiple medications 1, 2
• Elderly patients: Start with lower doses, particularly in women over 80 years of age 1
• Diabetes: Moderate-intensity statin therapy is recommended for all adults 40-75 years with diabetes 1

Monitoring After Initiation

• Obtain lipid profile 4-12 weeks after initiation of statin therapy, after any dose change, and annually thereafter 1
• Monitor for side effects, particularly muscle symptoms 1
• If LDL-C levels are not responding despite medication adherence, clinical judgment is recommended to determine the need for and timing of lipid panels 1

Potential Pitfalls and Caveats

• Myopathy risk: Higher with increased age (>65 years), renal impairment, hypothyroidism, and drug interactions 1, 2, 3
• Perioperative periods: Consider temporarily withholding statins during hospitalization for major surgery 1
• Pregnancy: Statins are contraindicated in pregnancy 1
• Statin intolerance: For patients experiencing myalgia, consider lower doses, alternate-day dosing, or switching to a different statin (particularly pravastatin or fluvastatin) 4

Conclusion

When initiating statin therapy, the choice should be guided by patient risk factors, comorbidities, and potential for drug interactions. For most patients without established ASCVD, moderate-intensity statin therapy with pravastatin 40 mg or atorvastatin 10-20 mg is appropriate for initial therapy. For high-risk patients with established ASCVD, high-intensity statin therapy with atorvastatin 40-80 mg should be considered as initial therapy. 1