Table A : High , Moderate , and Low-Intensity Statin Therapy
High-Intensity Statin Therapy Moderate-Intensity Statin Therapy Low-Intensity Statin Therapy Daily dose lowers LDL-C , on average , by Daily dose lowers LDL-C , on average , by Daily dose lowers LDL-C , on average , approximately greater than or equal to 50 % approximately 30 % to less than 50 % by less than 30 % Atorvastatin ( 40 ¹) -80 mg Atorvastatin 10 ( 20 ) mg Simvastatin 10 mg Rosuvastatin 20 mg Rosuvastatin ( 5 ) 10 mg Pravastatin 10-20 mg Simvastatin 20-40 mg ² Pravastatin 40 ( 80 ) mg Lovastatin 40 mg Fluvastatin XL 80 mg Fluvastatin XL 40 mg bid Pitavastatin 2-4 mg
Lovastatin 20 mg Fluvastatin 20-40 mg Pitavastatin 1 mg
¹ Evidence from 1 RCT only : down-tiration if unable to tolerate atorvastatin 80 mg in IDEAL ( 47 ). ² Although simvastatin 80 mg was evaluated in RCTs , initiation of simvastatin 80 mg or titration to 80 mg is not recommended by the FDA due to the increased risk of myopathy , including rhabdomyolysis .
Note : Statins and doses that are approved by the U . S . FDA but were not tested in the RCTs reviewed are listed in italics .
Table B : Available Drug Therapy Options
Drug Class Drug ( Brand Name ) and Dose Effects Side Effects Contraindications
HMG CoA reductase inhibitors ( statins )
Bile acid sequestrants
Lovastatin ( 20-80 mg ) Pravastatin ( Pravachol ) ( 10-40 mg )* Simvastatin ( Zocor ) ( 10-40 mg ) Fluvastatin ( Lescol ) ( 20-80 mg )* Atorvastatin ( Lipitor ) ( 10-80 mg ) Rosuvastatin ( Crestor ) ( 5-40mg ; for initial therapy , limit dose to 20 mg ) Pitavastatin ( Livalo ) ( 1-4 mg )
Cholestyramine ( Prevalite ) ( 4-24 g ) Colestipol ( Colestid ) ( 10-30 g ) Colesevelam ( WelChol ) ( 1.5-4.5 g )
LDL decreases 18-63 % HDL increases 5-15 % TG decreases 7-30 %
LDL decreases 15-30 % HDL increases 3-5 % TG No change or increases
Myopathy , increased liver enzymes
Gastrointestinal distress , constipation , decreased absorption of other drugs
Absolute : Active or chronic liver disease
Relative : Concomitant use of certain drugs ** Amiodarone , Telithromycin , Erythromycin , Clarithromycin Itraconazole , & other azoles
Absolute : Dysbeta-lipoproteinemia TG greater than 400mg / dL
Relative : TG greater than200mg / dL
Fibric acids |
Fenofibrate ( e . g ., Tricor ) ( 48-145 mg ) |
LDL decreases 5-20 % |
|
|
HDL increases 10-20 % |
|
|
TG decreases 20-50 % |
B vitamin+ |
Niacin ( 250-2000 mg ) |
LDL decreases 5-25 % |
|
|
HDL increases 15-35 % |
|
|
TG decreases 20-35 % |
Dyspepsia , gallstones , myopathy
Flushing , puritis , nausea , hyperglycemia , hepatotoxicity
Absolute : Severe renal disease Severe hepatic disease
Relative : Hepatic impairment , active peptic ulcer disease
Cholesterol absorption inhibitor
Ezetimibe ( Zetia ) ( 10 mg ) |
LDL decreases 18 % |
Diarrhea , arthralgia , rhabdomyolysis , hepatitis , pancreatitis , thrombocytopenia , |
Potentiates warfarin
Absolute : Moderate to severe hepatic impairment
PCSK9++ inhibitors |
Evolucumab ( Repatha ) ( 140 mg Sub-Q every 2 weeks or 420 mg monthly )
Alirocumab ( Praluent ) ( 75-150 mg Sub-Q )
|
LDL decreases 31-61 % Respiratory infection , back pain , injection-site reactions , arthralgia , fatigue |
None |
* Lower myopathy risk ** Cyclosporine , macrolide antibiotics , various antifungal agents , and cytochrome P-450 inhibitors ( fibrates and niacin ) should be used with appropriate caution . +Several over-the-counter formulations exist . ++PCSK9 inhibitors ( Proprotein convertase subtilism / kexin 9 ) haven ’ t been proven to improve CV outcomes or to be safe long-term . These drugs are extremely expensive .
Hyperlipidemia - 5