From the Guidelines
Statin therapy should be considered for individuals with LDL-C levels above 190 mg/dL or those with a 10-year risk of ASCVD of 7.5% or higher, with the decision to start therapy based on overall cardiovascular risk assessment rather than a single LDL threshold. When initiating statin therapy, the guidelines recommend moderate-intensity statin therapy if a discussion of treatment options favors statins 1. The 2018 American Heart Association/American College of Cardiology/Multisociety Cholesterol Guideline provides a framework for risk assessment and stratification, categorizing patients into four categories of 10-year risk for ASCVD: low (<5%), borderline (5% to 7.4%), intermediate (7.5% to 19.9%), and high (≥20%) 1.
Key Considerations
- Patients without ASCVD are categorized and stratified for risk by age, coexisting conditions, and risk factors 1.
- Evidence from RCTs supports the efficacy of statin therapy for patients whose 10-year risk is 5% or higher 1.
- In those with borderline or intermediate risk, clinical judgment is required to initiate statin treatment on the basis of risk–benefit considerations and patient preferences 1.
Treatment Approach
- Treatment usually begins with a moderate-intensity statin, with dose adjustments based on follow-up lipid panels after 4-12 weeks.
- High-risk patients may start with high-intensity therapy, such as atorvastatin 40-80 mg or rosuvastatin 20-40 mg daily.
- Patients should be monitored for side effects like muscle pain and liver function abnormalities, and medication should be taken consistently at the same time each day for optimal effectiveness.
From the FDA Drug Label
Adults( 2. 2): Recommended starting dosage is 10 or 20 mg once daily; dosage range is 10 mg to 80 mg once daily. Patients requiring LDL-C reduction >45% may start at 40 mg once daily. The starting LDL-C level for initiating atorvastatin therapy is not explicitly stated in the drug label. However, the label does provide information on the recommended starting dosage of atorvastatin, which is 10 or 20 mg once daily for adults.
- The dosage may be adjusted based on the patient's response to treatment and their individual risk factors.
- Patients requiring a greater than 45% reduction in LDL-C may start at a higher dose of 40 mg once daily 2. It is essential to assess LDL-C levels when clinically appropriate, as early as 4 weeks after initiating atorvastatin, and adjust the dosage if necessary 2.
From the Research
LDL Starting Levels for Statin Therapy
The decision to start statin therapy and the target LDL levels are based on an individual's cardiovascular risk factors. According to 3, statin therapies are warranted as a first-line agent in all secondary prevention patients, as well as those in primary prevention at high or very high risk for ASCVD events.
Key Considerations
- The potency and dose of statins should be tailored to the individual's cardiovascular risk and the tolerance to their potential adverse effects in order to achieve the guidelines-directed LDL goals 3.
- There is no specific LDL level mentioned in the studies provided as the starting point for statin therapy. However, the studies suggest that statins are effective in reducing LDL levels and preventing ASCVD events in patients with elevated LDL cholesterol 4, 3.
- The use of more potent statins such as atorvastatin and simvastatin affords greater lowering of LDL-C and triglyceride levels, allowing more patients to achieve target goals 4.
Alternative Treatment Options
- For patients who cannot tolerate statins, alternative treatment options such as ezetimibe and PCSK9 inhibitors are available 5.
- PCSK9 inhibitors have been shown to be effective in reducing LDL-C levels in patients not receiving statins, including those who are statin intolerant 5.
- The combination of ezetimibe and rosuvastatin has also been shown to be effective in reducing serum cholesterol and triglyceride levels 6.
Ongoing Research
- Ongoing clinical trials, such as the PURSUIT trial, are evaluating the efficacy and safety of new treatments for hypercholesterolemia, including oral PCSK9 inhibitors 7.
- The results of these trials may provide further guidance on the optimal LDL starting levels for statin therapy and the use of alternative treatment options.