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# Atorvastatin ## Overview Atorvastatin is a statin medication used to lower cholesterol levels in the blood, thereby reducing the risk of cardiovascular events. It works by inhibiting HMG-CoA reductase, a key enzyme in cholesterol synthesis. ## Primary Indications * **Hyperlipidemia:** To lower elevated total cholesterol, LDL cholesterol, triglycerides, and VLDL cholesterol, and to increase HDL cholesterol in patients with primary hypercholesterolemia and mixed dyslipidemia. * **Prevention of Cardiovascular Disease:** To reduce the risk of myocardial infarction, stroke, and revascularization procedures in patients with multiple risk factors for coronary heart disease. * **Homozygous Familial Hypercholesterolemia:** As an adjunct therapy to other lipid-lowering treatments. ## Adult Dosing * **Hyperlipidemia:** * **Starting dose:** 10 mg to 20 mg once daily. * **Maintenance dose:** 10 mg to 80 mg once daily. * **Maximum dose:** 80 mg once daily. * **Prevention of Cardiovascular Disease:** Typically initiated at 10 mg to 20 mg once daily. Dosing may be adjusted based on individual risk assessment. * **Homozygous Familial Hypercholesterolemia:** 10 mg to 80 mg once daily. Dose titration should occur at intervals of 4 weeks or more. ## Pediatric Dosing * **Hyperlipidemia (10 to 17 years):** * **Starting dose:** 10 mg once daily. * **Maximum dose:** 20 mg once daily (for heterozygous familial hypercholesterolemia). * **Maximum dose:** 80 mg once daily (for homozygous familial hypercholesterolemia). * **Note:** Dosing in younger children is not well-established and should be based on expert opinion or specialist guidance. ## Dose Adjustments * **Renal Impairment:** No dose adjustment is generally required. * **Hepatic Impairment:** Use with caution. Patients with active liver disease or unexplained persistent elevations of serum transaminases should not take atorvastatin. Doses should be used cautiously in patients with a history of liver disease. ## Contraindications * Active liver disease or unexplained persistent elevations of serum transaminases exceeding 3 times the upper limit of normal (ULN). * Hypersensitivity to any component of the formulation. * Pregnancy and breastfeeding. ## Adverse Effects * **Common:** Myalgia, arthralgia, diarrhea, nausea, headache, nasopharyngitis. * **Serious:** Rhabdomyolysis with or without acute kidney injury, hepatotoxicity, immune-mediated necrotizing myopathy, hyperglycemia, memory impairment, cognitive dysfunction. ## Key Drug Interactions * **CYP3A4 Inhibitors:** Increased risk of myopathy and rhabdomyolysis when co-administered with strong CYP3A4 inhibitors (e.g., itraconazole, ketoconazole, posaconazole, voriconazole, erythromycin, clarithromycin, telithromycin, boceprevir, telaprevir, ritonavir, lopinavir/ritonavir, atazanavir, indinavir, darunavir, tipranavir, cyclosporine, nefazodone). * **CYP3A4 Inducers:** May decrease atorvastatin plasma concentrations. * **Gemfibrozil and Fenofibrate:** Increased risk of myopathy. * **Colchicine:** Increased risk of myopathy and rhabdomyolysis. * **Digoxin:** May increase digoxin levels. * **Oral Contraceptives:** May increase levels of ethinyl estradiol and norgestrel. ## Monitoring * **Lipid Panel:** Baseline and periodically thereafter (typically within 3-6 months) to assess efficacy. * **Liver Function Tests (LFTs):** Before initiating therapy and as clinically indicated. Elevations in transaminases >3x ULN warrant discontinuation or dose reduction. * **Creatine Kinase (CK):** If symptoms of myopathy develop. * **Renal Function:** If signs/symptoms of rhabdomyolysis or acute kidney injury. ## Clinical Pearls * Atorvastatin is generally taken once daily, with or without food. * Maximum dose of 80 mg daily is associated with increased risk of adverse events, particularly myopathy. * Counsel patients on the signs and symptoms of myopathy (muscle pain, tenderness, or weakness) and to report them immediately. * Women of childbearing potential should use effective contraception during treatment. *** *This information is intended for healthcare professionals. Please consult the most current prescribing information and local protocols for definitive guidance.*