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# Atorvastatin ## Overview Atorvastatin is a statin (HMG-CoA reductase inhibitor) used to lower cholesterol and triglyceride levels in the blood. It reduces the synthesis of cholesterol in the liver. ## Primary Indications * **Hyperlipidemia:** Adjunct to diet to reduce elevated total-C, LDL-C, and triglyceride levels and to increase HDL-C in patients with primary hypercholesterolemia (heterozygous familial and nonfamilial) and mixed dyslipidemia. * **Hypertriglyceridemia:** Treatment of isolated hypertriglyceridemia. * **Dysbetalipoproteinemia:** Treatment of homozygous familial dysbetalipoproteinemia. * **Homozygous Familial Hypercholesterolemia (HoFH):** Reduction of elevated total-C and LDL-C in patients with HoFH. * **Cardiovascular Risk Reduction:** Primary prevention of cardiovascular disease in patients with multiple risk factors for coronary heart disease (CHD) or with existing clinical atherosclerotic cardiovascular disease. ## Adult Dosing * **Hyperlipidemia/Cardiovascular Risk Reduction:** * **Initiation:** 10 mg to 80 mg once daily. * **Titration:** Doses may be titrated up as needed at intervals of 4 weeks or more. * **Maximum:** 80 mg once daily. ## Pediatric Dosing * **Pediatric patients 10 to 17 years of age with heterozygous familial hypercholesterolemia (HeFH):** * **Initial:** 10 mg once daily. * **Titration:** Doses may be adjusted as needed, not to exceed 40 mg once daily (maximum dose for this age group is 40 mg daily). * *Note: Dosing for younger children or those with other lipid disorders is not well established.* ## Dose Adjustments * **Renal Impairment:** No dose adjustment necessary. * **Hepatic Impairment:** Use with caution. Refer to contraindications and adverse effects. Starting at a lower dose may be appropriate. * **Concomitant Medications:** Dose adjustments may be needed for interactions (see Key Drug Interactions). ## Contraindications * Active liver disease or unexplained persistent elevations of serum transaminases greater than 3 times the upper limit of normal (ULN). * Hypersensitivity to any component of this medication. * Pregnancy and breastfeeding. ## Adverse Effects * **Common:** Myalgia, arthralgia, diarrhea, nausea, nasopharyngitis, pain in extremity, urinary tract infection. * **Serious:** Rhabdomyolysis with myoglobinuria and acute renal failure, hepatotoxicity, immune-mediated necrotizing myopathy, new-onset diabetes mellitus. ## Key Drug Interactions * **CYP3A4 Inhibitors (e.g., itraconazole, ketoconazole, posaconazole, voriconazole, erythromycin, clarithromycin, telithromycin, protease inhibitors, boceprevir, telaprevir, nefazodone, cobicistat-containing products):** Increased risk of myopathy and rhabdomyolysis. Limit atorvastatin dose to 20 mg daily if coadministered with these agents. * **CYP3A4 Inducers (e.g., efavirenz, rifampin):** May decrease atorvastatin plasma concentrations. Consider coadministration of atorvastatin and rifampin at the same time, as later dosing of rifampin has been associated with a significant reduction in atorvastatin plasma concentrations. * **Cyclosporine:** Increased atorvastatin exposure. Limit atorvastatin dose to 10 mg once daily. * **Gemfibrozil:** Increased risk of myopathy. Avoid concomitant use. If used together, limit atorvastatin to 20 mg once daily. * **Fenofibrate and other fibrates:** Increased risk of myopathy. Monitor for signs of myopathy. * **Colchicine:** Increased risk of myopathy and rhabdomyolysis. Use with caution and monitor for signs of myopathy. * **Grapefruit Juice:** May increase atorvastatin plasma concentrations. Avoid excessive consumption. ## Monitoring * **Liver Function Tests (LFTs):** Baseline LFTs before initiating therapy and periodically thereafter. If signs and symptoms of liver disease develop, obtain LFTs immediately. * **Creatine Kinase (CK):** Monitor for muscle pain or weakness. If CK levels are significantly elevated (>10x ULN) or myopathy is diagnosed or suspected, discontinue statin therapy. * **Lipid Panel:** Assess efficacy at baseline and typically within 4-12 weeks of initiating or titrating therapy, then at least annually thereafter. * **HbA1c and Fasting Blood Glucose:** Monitor for development of new-onset diabetes. ## Clinical Pearls * Instruct patients to report any unexplained muscle pain, tenderness, or weakness, especially if accompanied by fever or malaise. * Advise patients to avoid excessive alcohol consumption while taking atorvastatin. * Atorvastatin is a potent LDL-lowering agent and should be used with caution in patients with risk factors for myopathy. * Dose selection should be individualized based on baseline lipid levels and cardiovascular risk. *** *Disclaimer: This information is intended for healthcare professionals. Always consult the most current prescribing information and relevant guidelines for complete details, as drug information can change.*