HEART
November 22, 2016

Statins: New Dosing Guidelines

Higher doses statins can significantly prolong life, even for those over 75.

Monitoring and managing cholesterol levels is a primary focus in preventing heart attacks and strokes. High cholesterol builds up in arteries causing plaques that narrow the passageways available for blood to flow freely to muscles and organs throughout the body.

Pieces of plaques can break off and be transported to other locations where they cause a decrease or total stoppage of blood flow. When this happens in brain tissue and heart muscle, it can lead to long-term disability and death.

Guidelines for statin prescribing, particularly regarding the best dosing strategies, have been unclear.

Many of these serious outcomes can be prevented with appropriate medical guidance and treatment. That's why your doctor will check your cholesterol levels — LDL, HDL and triglycerides — with blood tests, so elevated levels can be addressed with diet, exercise and medication.

Perhaps the most common pharmacological treatment is a class of drugs called statins — atorvastatin (Lipitor), fluvastatin (Lescol), lovastatin (Altoprev), pitavastatin (Livalo), pravastatin (Pravachol), rosuvastatin (Crestor) and simvastatin (Zocor) are among the well known brands.

Statins are not without risk. They can cause side effects like muscle pain, liver damage, increased blood sugar and neurologic symptoms such as memory loss and confusion. These side effects may be dose-related, with risks increasing at higher doses. But statins also interact with certain foods (such as grapefruit juice) and with certain medications, which can change the expected level of the statin or other medications in one's blood stream. This can raise the risk of side effects, or it can reduce the effectiveness of the medication.

What's The Right Dose?

Guidelines for statin prescribing, particularly regarding the best dosing strategies, have been unclear. There has been much conflicting and incomplete research data. The impact of higher vs. moderate dose of statins has been debated, and physicians and patients have often resisted starting treatment with higher doses, hoping to avoid side effects leading to discontinuation of the medication altogether.

A recent study, published in JAMA Cardiology, helped clarify the value of high dose statins.

Patients treated with higher doses had lower mortality and this was also true in the patients over 75 years of age.

The researchers, from Baylor and Stanford, reviewed the records of about 500,000 patients who were taking no, low, moderate or high dose statin therapy. Unlike many previous studies, this study included patients who were 75 years or older. All the patients had been diagnosed with some form of atherosclerotic cardiovascular disease, including coronary artery disease, peripheral vascular disease or stroke.

The team looked at the impact of the statin therapy and the dose of medication on the incidence of death in the study population over one year. The study defined low-intensity statin therapy as treatment with fluvastatin, 20 to 40 mg, lovastatin, 20 mg, simvastatin, 10 mg, pitavastatin, 1 mg, and pravastatin, 10 to 20 mg.

Moderate-intensity statin therapy was defined as atorvastatin, 10 to 20 mg, fluvastatin, 40 mg twice a day or 80 mg once a day (extended-release formulation), lovastatin, 40 mg, pitavastatin, 2 to 4 mg, pravastatin, 40 to 80 mg, rosuvastatin, 5 to 10 mg, and simvastatin, 20 to 40 mg.

High-intensity statin therapy was defined as atorvastatin, 40 to 80 mg, or rosuvastatin, 20 to 40 mg.

Nearly 30% of patients used high-intensity statin therapy. Moderate-intensity therapy was used by 46% of the people in the study, low-intensity by 7% and no statin therapy by 18%.

High-intensity treatment had significant benefits, the researchers found. No matter what their age, people treated with higher doses had lower mortality. The results showed a 9% increased chance of survival for people taking high-intensity statins compared to those receiving moderate-intensity treatment, and these findings held true for older patients — those between the ages of 75 and 85 — taking high-intensity statins.

The researchers hope that their study will inform current practice and help reduce the incidence of cardiovascular disease caused by elevated cholesterol. They conclude there is a “graded association between intensity of statin therapy and mortality, with the greatest reductions for patients receiving high-intensity statins. We also found that the maximal doses of high-intensity statins (atorvastatin, 80 mg, and rosuvastatin, 40 mg) conferred the greatest survival advantage compared with submaximal doses of high-intensity statins. The benefits of high-intensity statins were consistent for those older than 75 years compared with younger patients.”

The study suggests health care providers should reassess their statin prescribing practices for patients who have atherosclerotic cardiovascular disease (ASCVD). This would include more aggressive use of the drug, starting patients on higher doses, treating patients over 75 and encouraging compliance with their medication recommendations in their patients with ASCVD. Higher intensity treatment can offer improved survival, as well as individual and public health benefits, the authors believe.

You should never increase your dose of a medication without medical supervision. If you have some form of atherosclerotic cardiovascular disease, including coronary artery disease, peripheral vascular disease or stroke, you may want to review your current medication treatment with your doctor to decide if you might benefit from a change. If you have been experiencing some undesirable side effects, don't simply stop your medication, instead discuss your concerns about side effects or other barriers to the use of statins with your doctor. It may take a few tries to find the right drug and the right dose.

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