- How should patients new to a statin be managed?
- How should patients already on a statin be managed?
- How should patients over age 75 be managed?
- How should patients on non-statins (ezetimibe, etc) be managed?
How should patients new to a statin be managed?
Recommend a statin for those with CV disease, LDL ≥ 190 mg/dL or diabetes ages 40 to 75. For others, use the new CV risk estimator to help determine if a statin may be beneficial and take into account individual preferences. Suggest starting at the appropriate dose for most patients because there's no proof that titrating up prevents side effects. For a high-intensity statin that lowers LDL by ≥ 50%, suggest atorvastatin (Lipitor) 40 to 80 mg/day for most patients. It has the most evidence for preventing CV events in high-risk patients and available as a generic. For a moderate-intensity statin that lowers LDL by 30% to 49%, suggest atorvastatin 10 to 20 mg, simvastatin (Zocor) 20 to 40 mg, etc.
How should patients already on a statin be managed?
Check if patients are on a high-intensity statin if they have CV disease or LDL ≥ 190 mg/dL. If not, suggest a dose increase. For others, consider requesting pretreatment lipid values, so you can use the CV risk estimator to see if a dose change is needed. If baseline levels aren't available, suggest aiming for an LDL < 100 mg/dL especially in high-risk patients.
How should patients over age 75 be managed?
For patients with CV disease, suggest a moderate-intensity statin to limit side effects. But don't back off if patients are doing well on a high-intensity statin. For others over 75, suggest discussing benefits and risks before starting a statin. There is less evidence of benefit in these patients.
How should patients on non-statins (ezetimibe, etc) be managed?
Help re-evaluate whether non-statins are needed. So far, there's no proof they improve CV outcomes when added to a statin. In general, suggest saving non-statins for patients who can't take a statin or have triglycerides ≥ 500 mg/dL or high-risk patients who don't get the expected percent LDL-lowering from a statin. See additional note on, "Pharmacology of HMG-CoA inhibitors (Statins)".
REFERENCES
- Bakhai, S., Bhardwaj, A., Sandhu, P. and Reynolds, J.L. (2018). Optimisation of lipids for prevention of cardiovascular disease in a primary care. BMJ Open Quality, [online] 7(3). Available at: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6109820