What is the recommended starting dose of Pravastatin (pravastatin) for an elderly male patient with Barrett's esophagus, taking multiple cardiovascular medications and anticoagulants (blood thinners), who has recently consumed cabbage?

Recommended Starting Dose for Pravastatin

The recommended starting dose of pravastatin for this elderly male patient is 40 mg once daily, which can be taken at any time of day with or without food. 1

Rationale for Standard Dosing

• The FDA-approved starting dose for adults is 40-80 mg once daily, with no specific dose reduction required based solely on age 1
• Pravastatin has minimal drug-drug interactions compared to other statins because it is not metabolized through the CYP3A4 pathway, making it particularly suitable for patients on multiple cardiovascular medications 2
• Barrett's esophagus is not a contraindication to statin therapy and does not require dose modification 3, 4
• Recent cabbage consumption is irrelevant to pravastatin dosing, as there are no known clinically significant food-drug interactions with pravastatin that would necessitate dose adjustment 1

Drug Interaction Considerations

Pravastatin demonstrates favorable safety with common cardiovascular medications:

• Warfarin and other anticoagulants: Combination therapy is safe and useful when clinically indicated, though INR should be monitored more closely after statin initiation 2
• Digoxin: Coadministration with pravastatin is reasonable if clinically indicated, unlike atorvastatin which can increase digoxin levels 2
• Amiodarone: Pravastatin can be used without dose limitation, unlike simvastatin (≤20 mg) or lovastatin (≤40 mg) 2
• Calcium channel blockers: No dose adjustment needed with pravastatin, unlike simvastatin or lovastatin which require dose restrictions 2

Elderly Patient Considerations

Age alone does not mandate starting at a lower dose:

• Clinical trials demonstrate pravastatin 40 mg daily is effective and well-tolerated in elderly patients (≥60-65 years) with excellent safety profiles 5
• The PROSPER trial used pravastatin 40 mg daily in elderly patients and demonstrated significant reduction in coronary events with minimal adverse effects 5
• Compliance rates are high (91-95%) with pravastatin in elderly populations, supporting standard dosing 6

Renal Function Exception

The only scenario requiring dose reduction is severe renal impairment:

• If creatinine clearance is severely reduced, start with 10 mg once daily (using another pravastatin formulation) with a maximum of 40 mg daily 1
• Mild to moderate renal impairment requires no dose adjustment 1

Monitoring Recommendations

• Assess LDL-C as early as 4 weeks after initiation and adjust dosage if necessary 1
• Monitor for myopathy symptoms: Instruct the patient to report unexplained muscle pain, tenderness, or weakness, particularly if accompanied by malaise or fever 1
• Consider baseline and periodic liver enzyme testing as clinically indicated 1

Important Caveats

If the patient is taking specific interacting medications, dose adjustments are required:

• Cyclosporine: Start at 10 mg daily, maximum 20 mg daily 1
• Clarithromycin or erythromycin: Maximum dose 40 mg daily 1
• Bile acid sequestrants: Administer pravastatin at least 1 hour before or 4 hours after the sequestrant 1

The 40 mg starting dose represents moderate-intensity statin therapy, which achieved a median LDL-C of 95 mg/dL in the PROVE-IT TIMI 22 trial 2. If higher intensity lipid lowering is required and the patient cannot achieve LDL-C goals on pravastatin 80 mg daily, consider alternative statin therapy 1.