What are the guidelines for statin (HMG-CoA reductase inhibitor) drug use?

From the Guidelines

High-intensity statin therapy should be initiated or continued as first-line therapy in patients ≤75 years of age who have clinical atherosclerotic cardiovascular disease (ASCVD), unless contraindicated, as it has been shown to reduce major vascular events by 15% compared to less intensive therapy 1.

Key Points

• The 2013 ACC/AHA Guideline on the Treatment of Blood Cholesterol to Reduce Atherosclerotic Cardiovascular Risk in Adults recommends high-intensity statin therapy for patients ≤75 years of age with clinical ASCVD 1.
• Moderate-intensity statin therapy is recommended for patients >75 years of age with clinical ASCVD, or for those who have contraindications or intolerance to high-intensity regimens 1.
• Statin therapy should be individualized in patients >75 years of age, taking into account the potential for ASCVD risk-reduction benefits, adverse effects, drug-drug interactions, and patient preferences 1.

Statin Therapy

• First-line statins include atorvastatin (10-80mg daily) and rosuvastatin (5-40mg daily) 1.
• High-intensity statin therapy reduces LDL cholesterol by >50%, while moderate-intensity therapy reduces LDL by 30-50% 1.
• Treatment should be initiated after lifestyle modifications and continued indefinitely, with regular monitoring of lipid levels and liver function tests 1.

Monitoring and Adverse Effects

• Muscle symptoms should be monitored, with CK levels checked if significant symptoms develop 1.
• Statins work by inhibiting HMG-CoA reductase, reducing cholesterol synthesis in the liver and upregulating LDL receptors, which increases clearance of LDL from the bloodstream 1.
• The goal is typically to reduce LDL cholesterol by at least 30-50% from baseline, with more aggressive targets (<70 mg/dL or even <55 mg/dL) for very high-risk patients with established cardiovascular disease 1.

From the Research

Guidelines for Statin Drug Use

• The use of statins is recommended for patients at high risk for atherosclerotic cardiovascular disease (ASCVD) 2.
• High-intensity statins are recommended for patients with ASCVD (secondary prevention) and high-risk patients without clinical ASCVD, with a goal of reducing low-density lipoprotein cholesterol by 50% or greater 2.
• Patients with ASCVD who are at very high risk may benefit from the addition of non-statin drugs, such as ezetimibe, bile acid sequestrant, or proprotein convertase subtilisin/kexin type 9 (PCSK9) inhibitors 2, 3.
• For primary prevention, statins are recommended for adults aged 40 to 75 years with one or more cardiovascular disease (CVD) risk factors and an estimated 10-year CVD event risk of 10% or greater 4.

Patient Selection

• High-risk primary prevention patients include those with severe hypercholesterolemia, diabetes with associated risk factors, and patients aged 40 to 75 years with a 10-year risk for ASCVD of 20% or greater 2.
• Coronary artery calcium scoring is an option for patients with a 10-year risk of 7.5% to less than 20%, and if the score is 300 or more Agatston units, the patient can be up-classified to high risk 2.

Treatment Strategies

• If high-intensity statin treatment is not tolerated in high-risk patients, a reasonable approach is to combine a moderate-intensity statin with ezetimibe 2.
• PCSK9 inhibitors can be used in combination with statins to reduce low-density lipoprotein cholesterol levels and cardiovascular events in very high-risk patients 3, 5.
• The use of ezetimibe and PCSK9 inhibitors can provide additional low-density lipoprotein cholesterol reduction and decrease ASCVD risk when added to statin therapy 5, 6.