Important Considerations When Prescribing Statin Therapy for Hypercholesterolemia

Dhiren Patel, PharmD, CDCES, BC-ADM, BCACP: Dr Busch, you alluded to this earlier. We want to start with lifestyle—people want to do things naturally. But that’s not always going to be the case. When it comes to prescribing that initial statin, we have varying intensities of it. What’s your progression of how you decide what patient goes on what statin? How are you deciding that?

Robert Busch, MD: If I have an LDL [low-density lipoprotein] target in mind—if I want to get the LDL below 70 mg/dL, or if they have heart disease and diabetes, below 55 mg/dL—you have to know how much efficacy they get from that statin as you titrate up. One thing we learned early on with statins was rule of 6. If you remember the starting dose of the statin, you titrate and double and double and double the statin, and you get another 6%. I always remember atorvastatin is 37, 43, 49, 55, but rosuvastatin was 46, 52, or whatever. If I want to get down below 70 mg/dL, I know where they’re starting at.

For most patients with type 2 [diabetes], their problem isn’t very high LDL. They have high triglycerides and low HDL [high-density lipoprotein]. Their LDL may not be that high, but you have to start the statin in that patient based on the CARD study. Back then, a normal cholesterol LDL was 160 mg/dL. They took patients for primary prevention with diabetes, and LDL was below 160 mg/dL, where normally you wouldn’t have started a statin. When they took atorvastatin 10 mg, they lowered their events 37%. As we said, we use statins in the drinking water, unless it’s a woman who’s pregnant or going to get pregnant, and you choose the right dose to start—maybe a low dose, but you know you’re going to titrate up, but you want somewhere to go. If you started with pravastatin, even the top-dose pravastatin is not going to drop 40%, whereas 10 mg of atorvastatin might drop you 37% to 40% in the beginning, and you have somewhere to go later.

Dhiren Patel, PharmD, CDCES, BC-ADM, BCACP: That makes sense. We talked a little [about how] some are still focused on the intensity of the statin therapy because that’s where some of the measures still are, especially from CMS [Centers for Medicare & Medicaid Services]. Then you have some guidelines specific to LDL goals. I have a question to all of you—Dr Busch, if you want to keep the mike, that’s fine. What percentage of your patients do you think fail to meet the cholesterol goals, despite them being on a statin? That’s going to segue into some of the add-ons that we have in our toolbox.

Robert Busch, MD: A lot of our colleagues don’t titrate the statin, so there’s clinician inertia. You see someone who comes in and is on the same dose of everything for the last 10 years; nothing has been adjusted. The key is that this is a start. I’m giving you my best guess that will work, but I may have to go higher so the patient doesn’t feel disappointed. Of course, if they don’t tolerate 1 statin, you can go to another. A lot of people don’t tolerate the statin because they read that statins cause muscle aches. So when they open the bottle of the statin, they get muscle aches before they even put the first pill in their mouth. The convincing thing is what’s real and what isn’t. If they have aches and pains before they started the statin, you know that was there beforehand.

Dhiren Patel, PharmD, CDCES, BC-ADM, BCACP: Go ahead, Jen.

Jennifer Goldman, RPh, PharmD, CDCES, BC-ADM, FCCP: I want to comment on what Bob just said. One thing we have to consider is that we have high-potency statins. Super-statin is the most potent, and atorvastatin. As a pharmacist, I’ll think about drug interactions too. There are fewer drug interactions with rosuvastatin. One thing I see that happens—Bob just alluded to this—is that if somebody says they have muscle pains from 1, that doesn’t mean they’re going to have muscle pain from another. That also doesn’t mean that they’re going to have muscle pain if we tried lowering the dose. What’s important for providers to understand is that if you have problem with 1, try another, then another, lower the dose—do whatever you can to use that statin.

Joyce Ross, MSN, RNC, CRNP, CS, FNLA, FPCNA: What’s really important is that somebody has to watch the medications that patients are taking. When people are going to various providers, others aren’t aware that somebody is giving a macrolide antibiotic for something. They’ve started a new medication, perhaps they’re taking protease inhibitors because they have something, maybe there’s a transplant—a lot of things have to be taken into consideration.

But before you do that, Jen, to get back to what you were saying, have the patient describe their perceived muscle ache and pain. Many times it’s that shoulder that hurt them for the last 20 years, which has nothing to do with the statin drug. There are certain concepts that go along with what that discomfort of statin therapy when it is there. Of course, pain is what the patient says it is. But they can describe to you. Does it go away sometimes? Does it come back? Is it worse with activity? We need to help the patient understand that what they’re having is not necessarily a reaction to their statin drugs. I don’t think we should assume that’s so.

Dhiren Patel, PharmD, CDCES, BC-ADM, BCACP: Absolutely. Those are great clinical pearls.

Transcript edited for clarity.