Statin Therapy: Indications and Adverse Effects
Primary Indications for Statin Initiation
All patients with established atherosclerotic cardiovascular disease (ASCVD) aged ≤75 years should receive high-intensity statin therapy immediately, regardless of baseline LDL-C levels. 1, 2, 3
The 2018 ACC/AHA guidelines define four primary categories where statin therapy is indicated 1:
1. Clinical ASCVD (Secondary Prevention)
- High-intensity statin therapy (atorvastatin 40-80 mg or rosuvastatin 20-40 mg daily) is required for patients ≤75 years with established ASCVD, including acute coronary syndrome, myocardial infarction, stable/unstable angina, stroke, TIA, or peripheral arterial disease 1, 3
- For patients >75 years with ASCVD, moderate-intensity statin therapy is recommended, though high-intensity may be considered based on tolerability and patient preference 1
2. Severe Primary Hypercholesterolemia
- Maximally tolerated statin therapy (preferably high-intensity) is required for patients with LDL-C ≥190 mg/dL (≥4.9 mmol/L), regardless of calculated ASCVD risk 1, 3
- Risk calculation is unnecessary in this population; treatment should begin immediately 1
3. Diabetes Mellitus
- All adults aged 40-75 years with diabetes and LDL-C ≥70 mg/dL (≥1.8 mmol/L) should receive at least moderate-intensity statin therapy without needing to calculate 10-year ASCVD risk 1
- High-intensity statin therapy is reasonable for diabetic patients aged 50-75 years or those with multiple risk factors to achieve ≥50% LDL-C reduction 1
4. Primary Prevention Based on 10-Year ASCVD Risk
- Adults aged 40-75 years without diabetes, with LDL-C 70-189 mg/dL, and 10-year ASCVD risk ≥7.5% should receive moderate-intensity statin therapy after clinician-patient risk discussion 1, 3
- Those with 10-year ASCVD risk ≥20% should receive high-intensity statin therapy 1, 3
- For borderline risk (5-7.4%) or intermediate risk (7.5-19.9%), consider coronary artery calcium (CAC) scoring; CAC ≥300 Agatston units or >75th percentile for age/sex/ethnicity favors statin initiation 1, 3
Statin Intensity Definitions
High-intensity statins reduce LDL-C by ≥50% 1, 3:
Moderate-intensity statins reduce LDL-C by 30-49% 1, 3:
- Atorvastatin 10-20 mg daily 1
- Rosuvastatin 5-10 mg daily 1
- Simvastatin 20-40 mg daily 1
- Pravastatin 40-80 mg daily 1
Special Population Considerations
Asian Patients (Including Filipinos)
- Initiate therapy at 5 mg rosuvastatin daily due to increased sensitivity to statin dosing 2, 4
- Consider risks versus benefits if adequate control is not achieved at doses up to 20 mg daily 1
Severe Renal Impairment
- Initiate at 5 mg rosuvastatin daily; do not exceed 10 mg daily in patients not on hemodialysis 4
Adverse Effects and Safety Profile
Myopathy and Rhabdomyolysis
The most clinically significant adverse effect is myopathy, occurring in <1.33% of patients, with rhabdomyolysis being rare. 4, 5
Risk factors for myopathy include 4:
- Age ≥65 years 4
- Uncontrolled hypothyroidism 4
- Renal impairment 4
- Higher statin doses 4
- Asian ethnicity 4
- Concomitant use of certain medications (see below) 4
Instruct all patients to report unexplained muscle pain, tenderness, or weakness, particularly if accompanied by malaise or fever. 4
- Discontinue statin immediately if markedly elevated creatine kinase (CK) levels occur or myopathy is diagnosed 4
- Temporarily discontinue in patients with acute conditions at high risk of developing renal failure secondary to rhabdomyolysis 4
- Routine CK monitoring in asymptomatic patients is not recommended 6
Immune-Mediated Necrotizing Myopathy (IMNM)
- Rare autoimmune myopathy reported with statin use 4
- Presents with persistent proximal muscle weakness and elevated CK levels even after statin discontinuation 4
- Discontinue statin if IMNM is suspected 4
Hepatic Dysfunction
- Increases in serum transaminases occur but are usually transient 4
- Rare reports of fatal and non-fatal hepatic failure have occurred 4
- Consider testing liver enzymes before initiating therapy and as clinically indicated thereafter 4
- Promptly discontinue statin if serious hepatic injury with clinical symptoms and/or hyperbilirubinemia or jaundice occurs 4
- Routine liver enzyme monitoring in asymptomatic patients is not required 6
Diabetes Risk
- Statins may modestly increase risk of new-onset diabetes, but cardiovascular benefits far outweigh this risk 5
Cognitive Effects
- No consistent evidence of clinically significant cognitive impairment with statin therapy 5
Critical Drug-Drug Interactions
Gemfibrozil is contraindicated with simvastatin and should be avoided with lovastatin and pravastatin; use fenofibrate instead if fibrate therapy is needed 6
Other significant interactions requiring dose adjustment or avoidance 6:
- Cyclosporine and HIV protease inhibitors significantly increase statin levels 6
- Limit simvastatin to 10-20 mg daily with diltiazem or verapamil 6
- Macrolide antibiotics (erythromycin, clarithromycin) may temporarily increase myopathy risk 6
- Azole antifungals may require statin dose reduction or temporary discontinuation 6
Quantitative Risk-Benefit Analysis
The number needed to treat (NNT) to prevent one ASCVD event ranges from 3-61 depending on baseline risk and LDL-C level, while the number needed to harm (NNH) for adverse events of severity equivalent to ASCVD is >750. 5
- At least 75 patients must be treated for one to experience any side effect attributable to statin therapy 5
- This favorable risk-benefit ratio strongly supports statin use in appropriate populations 5
Monitoring Requirements
Check lipid profile before starting therapy, at 4-12 weeks after initiation or dose change, and annually thereafter. 1, 3
- Assess adherence to lifestyle modifications and medication effect at each visit 3
- No routine CK or liver enzyme monitoring is required in asymptomatic patients 6
Management of Statin Intolerance
When statin intolerance occurs, the most effective strategy is to rechallenge with low-dose potent statin, then up-titrate until cholesterol target is achieved, adding ezetimibe 10 mg daily if necessary. 5
- The most severe complication of statin intolerance is discontinuation of effective cholesterol-lowering treatment in patients who would otherwise benefit 5
- Most patients reporting statin intolerance can tolerate therapy with dose adjustment or alternative statin selection 5
Contraindications
Statins are absolutely contraindicated in: 4