Stopping Atorvastatin in Patients with Normalized Cholesterol
No, you should not stop atorvastatin in a patient with a history of hypercholesterolemia or cardiovascular disease simply because their cholesterol levels are now normal—the benefit of statin therapy in these patients is based on cardiovascular risk reduction, not on achieving or maintaining specific cholesterol targets. 1
Why Statins Should Be Continued
The Evidence Does Not Support Cholesterol Targets
The 2013 ACC/AHA guidelines explicitly state that no recommendations are made for or against specific LDL-C or non-HDL-C goals for primary or secondary prevention of atherosclerotic cardiovascular disease (ASCVD). 1
Randomized controlled trials did not titrate statin therapy to achieve specific LDL-C goals; instead, they used fixed-dose statin therapy and demonstrated cardiovascular benefit based on the intensity of therapy, not the cholesterol level achieved. 1
The guideline emphasizes that "given the absence of data on titration of drug therapy to specific goals," treatment decisions should be based on cardiovascular risk category and statin intensity, not on whether cholesterol has normalized. 1
Cardiovascular Risk Persists Despite Normal Cholesterol
For patients with established cardiovascular disease (secondary prevention):
High-intensity statin therapy (atorvastatin 80 mg) reduces cardiovascular events by 16% compared to moderate-intensity therapy, regardless of achieved cholesterol levels. 1, 2
Adults with clinical ASCVD (history of acute coronary syndromes, MI, stable/unstable angina, revascularization, stroke, TIA, or peripheral arterial disease) remain at increased risk for recurrent ASCVD and death even with normal cholesterol. 1
The ACC/AHA recommends that high-intensity statin therapy should be initiated or continued in adults ≤75 years with clinical ASCVD, and moderate-intensity therapy for those >75 years. 1
For patients with hypercholesterolemia without cardiovascular disease (primary prevention):
- If the patient has other cardiovascular risk factors, statin therapy provides benefit through pleiotropic effects beyond cholesterol lowering, including anti-inflammatory and plaque-stabilizing properties. 3, 4
The Mechanism of Benefit
Each 38.7 mg/dL (1 mmol/L) reduction in LDL-C reduces cardiovascular events by approximately 28%, but this benefit accrues from continuous statin therapy, not from achieving a specific target. 1
Clinical trials demonstrated that patients maintained on fixed-dose statins experienced sustained cardiovascular risk reduction throughout the study period, with no evidence supporting discontinuation once cholesterol normalizes. 1
Common Pitfall to Avoid
The critical error is treating cholesterol levels as the therapeutic endpoint rather than treating cardiovascular risk. The patient's cholesterol is normal because they are taking atorvastatin—stopping the medication will likely result in cholesterol rising again and, more importantly, loss of cardiovascular protection. 1
When Discontinuation Might Be Considered
The only scenarios where stopping atorvastatin is appropriate include:
Documented statin intolerance with myopathy (CK >5 times upper limit of normal with symptoms) or severe adverse effects. 1, 5
Contraindications develop, such as active liver disease with persistent transaminase elevations >3 times upper limit of normal. 1
In these cases, consider switching to a different statin (fluvastatin or pravastatin at lower doses), alternate-day dosing, or combination therapy with ezetimibe rather than complete discontinuation. 5
Recommended Approach
Continue the current atorvastatin dose and explain to the patient that:
The medication is preventing cardiovascular events, not just lowering cholesterol. 1, 3
Their normal cholesterol is a result of the medication working effectively. 1
Discontinuation would eliminate cardiovascular protection and likely result in cholesterol elevation. 1
If cost or side effects are concerns, discuss these specifically rather than stopping therapy entirely. 5