Advances in the Management of Hypercholesterolemia - Episode 7
Howard Weintraub, MD: Now we’re going a step further. You’re now with a patient who has either acquiesced or has demonstrated to both of your satisfactions that a stain is important. How do you make your choices? Which statins do you reflex to? Do you go for the high-intensity statins first? If you know someone needs 40% or 50% LDL [low-density lipoprotein] reduction, do you start with moderate- to high-dose statins, or do you titrate? What is the ground scheme?
Alan S. Brown, MD, FACC, FAHA, FNLA: That’s a good question. We know from the clinical trials that you can start with high-dose statin, and most patients do just fine. If you remember, almost all the atorvastatin trials started with 80 mg, and people did just fine with that. There’s a slightly higher risk of adverse effects in trials in the higher doses. This starts with listening, as you pointed out. There’s an old Italian saying that there’s a reason God gave you 2 ears and only 1 mouth. You listen to your patient. If they are apprehensive about starting a statin, you might use a statin that is actually more potent, but at a lower dose, such as rosuvastatin 10 or 20 mg. That may sound less concerning to a patient than 80 mg of atorvastatin and you’re going to get fairly similar LDL reductions. You make that judgment based on how the patient feels. You always have the option of choosing a lower-dose statin if it makes them more comfortable, giving them ezetimibe, and telling them it is a drug that has no difference in adverse effects vs placebo. That combination can give you quite potent LDL lowering. It is a judgment. You feel your patients out.
As you well know, years ago most of our referrals were for severe dyslipidemias, and now we still get those rare genetic disorders and then the more common FH [familial hypercholesterolemia] patients. The majority of my referrals are statin-intolerance patients, so we have to deal with patients who have already had problems. There are a lot of different ways to deal with that. No. 1 is to talk about the lower-dose drugs, as I mentioned. No. 2 is to offer patients who’ve had intolerance to statins an opportunity to take a longer-acting statin once, twice, or 3 times a week. Rosuvastatin and atorvastatin get pretty good LDL lowering even if you take it a couple of times a week.
A lot of people forget the only comparative study that was done many years ago and published in a clinical pharmacology journal. In terms of myalgias, it showed that fluvastatin—that was before rosuvastatin came out—had fewer muscle aches. There are some older, generic medicines that one can try—fluvastatin, lovastatin, pravastatin. In my 35 years, I’ve never been able to figure out if there’s any biochemical reason why a patient does well with 1 and not another. Whether they’re synthetic or not synthetic and water soluble or fat soluble has never helped me, in terms of picking a drug that a patient can tolerate. You really have to try multiple statins.
One thing you do have to pay attention to, and we’re now learning the physiology behind it, is the family history. If mom can’t take atorvastatin and neither can the patient, we used to think the patient was nutty. But the reality is, there clearly are genetic snips that affect statin intolerance with certain statins. I do pay attention to it when everyone in the family has intolerance to a certain statin. I try to avoid those things.
Those are my approaches. I think sometimes the psychological effect of using pitavastatin, with only have a 2 or 4 mg dose, is helpful. In my hands, a lot of patients who can’t tolerate other statins seem to be able to tolerate the pitavastatin. Those are some of the approaches we use.
Finally, in terms of statin intolerance, don’t miss other superimposed disorders like hypothyroidism, for example, where the patient is going to be more prone to muscle symptoms if they’re not well replaced on their thyroid.
Transcript Edited for Clarity