What other statins could we try?

Alternative Statin Options for Patients

When selecting an alternative statin, rosuvastatin, pravastatin, pitavastatin, or fluvastatin are the preferred options due to their favorable drug interaction profiles and efficacy in reducing cardiovascular risk. 1

Non-CYP3A4 Metabolized Statins (Preferred Options)

• Rosuvastatin (5-40 mg daily) is a highly effective statin with minimal CYP3A4 metabolism, making it less susceptible to drug interactions. It provides ≥50% LDL-C reduction at doses of 20-40 mg and 30-49% reduction at doses of 5-10 mg 1, 2
• Pravastatin (10-80 mg daily) is hydrophilic and not significantly metabolized by CYP3A4, offering a safer option for patients on multiple medications 1, 3
• Pitavastatin (1-4 mg daily) undergoes limited metabolism via CYP450 pathways despite being lipophilic, making it suitable for patients with drug interaction concerns 1, 3
• Fluvastatin (20-80 mg daily) has different metabolic pathways than statins that caused previous issues 1

CYP3A4 Metabolized Statins (Use with Caution)

• Atorvastatin (10-80 mg daily) is metabolized by CYP3A4 but has a longer half-life allowing for once-daily dosing. It should be used with caution if the patient is taking medications that inhibit CYP3A4 1, 4
• Lovastatin (10-80 mg daily) requires dose limitations when used with certain medications (e.g., limit to 40 mg with amiodarone, 20 mg with ranolazine) 1, 5
• Simvastatin (5-40 mg daily) has significant drug interaction concerns and requires strict dose limitations with many common medications (e.g., limit to 20 mg with amiodarone, 10 mg with dronedarone) 1, 5

Special Considerations for Drug Interactions

• When combining with calcium channel blockers like diltiazem or verapamil, a non-CYP3A4 metabolized statin (rosuvastatin, pravastatin, pitavastatin, fluvastatin) is preferred 1
• For patients on amiodarone, combination therapy with rosuvastatin, atorvastatin, pitavastatin, fluvastatin, or pravastatin is reasonable 1
• With ranolazine, rosuvastatin, atorvastatin, pitavastatin, fluvastatin, or pravastatin may be considered without dose limitations 1

Alternative Dosing Strategies for Statin-Intolerant Patients

• Once-weekly rosuvastatin may be effective for patients who experienced intolerance to daily statin dosing 6
• Starting with the lowest effective dose of any statin and gradually titrating upward can improve tolerance 1
• Combination therapy with lower statin doses plus non-statin lipid-lowering agents (like ezetimibe) may achieve lipid goals with fewer side effects 7

Common Pitfalls to Avoid

• Failing to consider drug interactions when selecting an alternative statin 1
• Not adjusting statin doses when used with medications that affect their metabolism 1
• Overlooking ethnic differences in statin metabolism, particularly in patients of Asian descent who may require lower starting doses 1
• Assuming all statins have similar efficacy and safety profiles at equivalent doses 1, 3

Monitoring Recommendations

• Check lipid levels 4-12 weeks after initiating a new statin to assess efficacy 1
• Monitor for muscle symptoms and consider checking creatine kinase if symptoms develop 8
• For patients on warfarin and statins, monitor INR more closely after initiating a statin or changing statin dose 1