From the Guidelines
The choice of statin is determined by the patient's 10-year risk of cardiovascular disease (CVD) and their individual risk factors.
Key Factors Influencing Statin Choice
- 10-year CVD risk: calculated using the ACC/AHA Pooled Cohort Equations, which take into account age, sex, race, cholesterol levels, systolic blood pressure level, antihypertension treatment, presence of diabetes, and smoking status 1
- Individual risk factors: such as dyslipidemia, diabetes, hypertension, and smoking 1
- LDL-C levels: with higher levels indicating a greater need for statin therapy 1
- Patient characteristics: such as age, sex, and presence of comorbidities, which may influence statin safety and efficacy 1
Statin Intensity and Dosage
- Low- to moderate-dose statins: recommended for primary prevention in adults with a 10-year CVD risk of 7.5% to 10% 1
- High-intensity statins: recommended for secondary prevention or primary prevention with a 10-year ASCVD risk ≥7.5% 1
- Dose adjustment: based on patient response to therapy, with a goal of reducing LDL-C levels by 30% to 50% 1
Monitoring and Safety
- Routine measurement of creatine kinase and transaminase levels: not recommended, but may be considered in patients at increased risk of adverse muscle events or hepatotoxicity 1
- Monitoring for muscle symptoms and hepatotoxicity: recommended, with patients asked about muscle symptoms at each visit and transaminase levels measured if symptoms suggestive of hepatotoxicity develop 1
From the Research
Factors Influencing Statin Choice
The choice of statin is determined by several factors, including:
- Efficacy in reducing cardiovascular risk and safety in specific clinical settings, such as the risk of new diabetes, chronic kidney disease, liver disease, human immunodeficiency virus infection, organ transplant, heart failure, and elderly people 2
- Pharmacokinetics, safety, drug metabolism, and interactions to provide the best choice in different clinical scenarios 2, 3
- Patient's clinical profile, including the presence of atherosclerotic cardiovascular disease (ASCVD), low-density lipoprotein cholesterol (LDL-C) ≥190 mg/dl, diabetes, or a 10-year ASCVD risk ≥7.5% 4
- Cost-effectiveness, with generic statins being a suitable option for dyslipidemic patients initiating statin therapy 5
Statin Alternatives
For patients who are unable to tolerate statins, alternative treatments may be required, including:
- Ezetimibe
- Proprotein convertase subtilisin/kexin type 9 (PCSK9) inhibitors, such as evolocumab, alirocumab, and inclisiran
- Bempedoic acid These alternatives have shown an excellent safety profile, with minimal side effects and no major drug interactions 6
Considerations for Clinicians
When choosing a statin, clinicians should consider the individual patient's needs and clinical profile, as well as the efficacy and safety of different statins in various clinical settings 2, 3, 4. The choice of statin alternative should be based on the patient's specific needs, including the degree of LDL-C reduction required, cost, and availability 6