Statin therapy: indication and monitoring

What it is

Statin therapy is high-, moderate- or low-intensity, and it is the intensity, not the drug name, that the guidelines ask for.

• High-intensity lowers LDL-C by 50% or more: atorvastatin 40-80 mg, rosuvastatin 20-40 mg
• Moderate-intensity lowers LDL-C by 30-49%: atorvastatin 10-20 mg, rosuvastatin 5-10 mg, simvastatin 20-40 mg, pravastatin 40-80 mg, lovastatin 40-80 mg, fluvastatin XL 80 mg, fluvastatin 40 mg bid, pitavastatin 1-4 mg
• Low-intensity lowers LDL-C by less than 30%: simvastatin 10 mg, pravastatin 10-20 mg, lovastatin 20 mg, fluvastatin 20-40 mg

Causes and risk

Elevated cholesterol is a risk factor for IHD, and LDL cholesterol is the single most important subgroup that carries that risk. The other risk factors are smoking, hypertension, physical inactivity, obesity and diabetes mellitus, with age, sex and genetics as the major uncontrollable ones. So the decision to treat is a risk decision. In the nondiabetic with an abnormal lipid profile, start lifestyle modification (weight loss, increased physical activity, and medical nutrition therapy: Mediterranean style or Dietary Approaches to Stop Hypertension) and then look at the ASCVD risk: if 40 or older use the 10 year risk, if younger use the LIFETIME RISK. The bands are:

• Low risk, under 5%: lifestyle and follow up
• Borderline, 5-7.4%: lifestyle and consider a statin
• Intermediate, 7.5-19.9%: lifestyle and consider a statin
• High risk, over 20%: lifestyle and start a statin

Primary prevention means no history of CV events, and that is where the risk assessment is needed. Secondary prevention means the patient already has a cardiovascular event and has been seen by a specialist, and there no risk assessment is done. Any patient with HTN needs a risk assessment, and any patient with DM should be on moderate intensity. The non-drug therapy has numbers of its own: decrease intake of fats to under 30% of total energy intake with saturated fats under 10%, decrease cholesterol intake to under 300 mg/d, replace saturated fats with monounsaturated or polyunsaturated fats, decrease alcohol intake to under 3-4 u/d in males and under 2-3 u/d in females, reduce weight, increase physical activity, and stop smoking.