Acronyms
- P - Drugs with approved pediatric dosing
Atorvastatin
Lipitor®, Atorvaliq®
Lipitor®, Atorvaliq®
Dosage forms
Tablet
- 10 mg
- 20 mg
- 40 mg
- 80 mg
Suspension (Atorvaliq®)
- 20 mg/5 ml
- Comes in 150 ml bottle
- Store at room temp
Dosing
High cholesterol (adults)
- Starting: 10 - 20 mg once daily
- Maintenance: 10 - 80 mg once daily
- Max: 80 mg once daily
- Patients who require LDL reductions ≥ 45% may start with 40 mg once daily
- Assess lipids as early as 4 weeks after initiation and adjust dose as necessary
- Tablets may be taken without regard to food. Atorvaliq should be taken on an empty stomach (1 hour before or 2 hours after a meal).
Heterozygous familial hypercholesterolemia (10 - 17 years old)
- Starting: 10 mg once daily
- Maintenance: 10 - 20 mg once daily
- Tablets may be taken without regard to food. Atorvaliq should be taken on an empty stomach (1 hour before or 2 hours after a meal).
Homozygous familial hypercholesterolemia (10 - 17 years old)
- Starting: 10 - 20 mg once daily
- Maintenance: 10 - 80 mg once daily
- Max: 80 mg once daily
- Assess lipids as early as 4 weeks after initiation and adjust dose as necessary
- Tablets may be taken without regard to food. Atorvaliq should be taken on an empty stomach (1 hour before or 2 hours after a meal).
Kidney disease
- No dose adjustment necessary
Liver disease
Studies
Generic / Price
- Tablets: YES/$
- Suspension (150 ml): NO/$$$$
Fluvastatin
Lescol®, Lescol XL®
Lescol®, Lescol XL®
Dosage forms
Capsule (Lescol®)
- 20 mg
- 40 mg
Tablet, extended-release (Lescol XL®)
- 80 mg
Dosing
High cholesterol (adults)
- Lescol
- Starting: 40 mg once daily in evening
- Maintenance: 20 - 80 mg/day
- Max: 80 mg/day
- For 80 mg/day dosing, give 40 mg twice a day
- For patients requiring LDL reduction of < 25%, a 20 mg starting dose may be used
- Do not open capsules
- May take without regard to food
- Lescol XL
- Dosing: 80 mg once daily
- Max: 80 mg once daily
- May take without regard to food
- Do not crush, cut, or chew tablet
Heterozygous familial hypercholesterolemia (pediatric patients 10 - 16 years old)
- Starting: 20 mg once daily in evening
- Maintenance: 20 - 80 mg/day
- Max: 80 mg/day
- For 80 mg dosing, give 40 mg capsule twice a day or one Lescol XL 80 mg tablet once daily
- Do not open capsules
- May take without regard to food
Kidney disease
- CrCl ≥ 30 ml/min: no dose adjustment necessary
- CrCl < 30 ml/min: has not been studied at doses greater than 40 mg; use caution
Liver disease
Generic / Price
- Lescol capsule - YES/$-$$
- Lescol XL tablet - YES/$$
Lovastatin
Mevacor®, Altoprev®
Mevacor®, Altoprev®
Dosage forms
Tablet (Mevacor®)
- 10 mg
- 20 mg
- 40 mg
Tablet, extended-release (Altoprev®)
- 20 mg
- 40 mg
- 60 mg
Dosing
High cholesterol (adults)
- Mevacor
- Starting: 20 mg once daily with evening meal
- Maintenance: 10 - 80 mg/day
- Max: 80 mg/day
- May be given once daily or in two divided doses
- Take with meals
- Altoprev
- Dosing: 20 - 60 mg once daily at bedtime
- Elderly: starting dose should be 20 mg
- Max: 60 mg once daily
- Take on an empty stomach. Food decreases absorption.
- Do not crush, cut, or chew tablet
Heterozygous Familial Hypercholesterolemia (pediatric patients 10 - 17 years old)
- Dosing: 10 - 40 mg/day
- Max: 40 mg/day
- For reductions in LDL of ≥ 20%, starting dose should be 20 mg/day. A starting dose of 10 mg/day may be considered for patients requiring smaller reductions.
- May be given once daily or in two divided doses
- Take with meals
Kidney disease
- CrCl ≥ 30 ml/min: no dose adjustment necessary
- CrCl < 30 ml/min: dosage increases above 20 mg /day should be carefully considered and, if deemed necessary, implemented cautiously
Liver disease
Generic / Price
- Tablet (Mevacor®): YES/$
- Tablet, extended-release (Altoprev®): NO/$$$$
Pitavastatin
Livalo®, Zypitamag®
Livalo®, Zypitamag®
Dosage forms
Tablet (Livalo®)
- 1 mg
- 2 mg
- 4 mg
Tablet (Zypitamag®)
- 2 mg
- 4 mg
Dosing
High cholesterol in adults (Livalo and Zypitamag)
- Starting: 2 mg once daily
- Maintenance: 1 - 4 mg once daily
- Max: 4 mg once daily
- May take without regard to food
Heterozygous familial hypercholesterolemia in pediatric patients ≥ 8 years old (Livalo)
- Starting: 2 mg once daily
- Maintenance: 1 - 4 mg once daily
- Max: 4 mg once daily
- May take without regard to food
Kidney disease (adults)
- CrCl < 60 ml/min: recommended starting dose is 1 mg once daily; do not exceed 2 mg/day
Liver disease
Generic / Price
- Livalo - NO/$$$$
- Zypitamag - NO/$$$$
Pravastatin
Pravachol®
Pravachol®
Dosage forms
Tablet
- 10 mg
- 20 mg
- 40 mg
- 80 mg
Dosing
High cholesterol (adults)
- Starting: 40 mg once daily
- Maintenance: 40 - 80 mg once daily
- Max: 80 mg once daily
- May take without regard to food
High cholesterol (adolescents 14 - 18 years)
- Dosing: 40 mg once daily
- Doses higher than 40 mg have not been studied in this population
- May take without regard to food
High cholesterol (children 8 - 13 years)
- Dosing: 20 mg once daily
- Doses higher than 20 mg have not been studied in this population
- May take without regard to food
Kidney disease
- CrCl < 30 ml/min: starting dose of 10 mg is recommended
Liver disease
Generic / Price
- YES/$
Rosuvastatin
Crestor®, Ezallor™ Sprinkle
Crestor®, Ezallor™ Sprinkle
Dosage forms
Tablet (Crestor®)
- 5 mg
- 10 mg
- 20 mg
- 40 mg
Capsule (Ezallor™ Sprinkle)
- 5 mg
- 10 mg
- 20 mg
- 40 mg
Dosing
High cholesterol (adults)
- Starting: 10 - 20 mg once daily
- Maintenance: 5 - 40 mg once daily
- Max: 40 mg once daily
- Asian patients: use a starting dose of 5 mg/day. Use caution if exceeding 20 mg/day. See statins in Asian patients for more.
- In patients with homozygous familial hypercholesterolemia, starting dose of 20 mg is recommended
- May take without regard to food
Heterozygous familial hypercholesterolemia (pediatric)
- 8 - 9 years: 5 - 10 mg once daily
- 10 - 17 years: 5 - 20 mg once daily
- May take without regard to food
Homozygous familial hypercholesterolemia (pediatric)
- 7 - 17 years: 20 mg once daily
- May take without regard to food
Kidney disease
- CrCl < 30 ml/min: recommended starting dose is 5 mg once daily. Do not exceed 10 mg/day.
Liver disease
Generic / Price
- Tablet - YES/$
- Capsule - NO/$$
Other
Ezallor™ Sprinkle
- Capsules should be swallowed whole. Do not crush or chew.
- Capsules may be opened and granules sprinkled on a teaspoon of soft food such as applesauce or chocolate/vanilla flavored pudding. Swallow whole without chewing within 60 minutes of combining.
- May be given via NG tube. See Ezallor PI for instructions.
Simvastatin
Zocor®, Flolipid®
Zocor®, Flolipid®
Dosage forms
Tablet (Zocor®)
- 5 mg
- 10 mg
- 20 mg
- 40 mg
- 80 mg
Suspension (Flolipid®)
- 20 mg/5 ml
- 40 mg/5 ml
- Comes in 150 ml bottle
- Store at room temperature
- Use within 30 days of opening
Dosing
High cholesterol (adults)
- Starting: 10 - 20 mg once daily in the evening
- Maintenance: 5 - 40 mg once daily
- Max: 40 mg once daily
- Asian patients: simvastatin may increase risk of myopathy. See statins in Asian patients for more.
- 80 mg dose should be limited to patients who have been taking it for ≥ 12 months without muscle toxicity
- The tablet may be taken without regard to food. The suspension should be taken in the evening on an empty stomach.
Heterozygous familial hypercholesterolemia (pediatric patients 10 - 17 years old)
- Starting: 10 mg once daily in the evening
- Maintenance: 10 - 40 mg once daily
- Max: 40 mg once daily
- The tablet may be taken without regard to food. The suspension should be taken in the evening on an empty stomach.
Kidney disease
- CrCl < 30 ml/min: recommended starting dose is 5 mg once daily
Liver disease
Generic / Price
- Zocor - YES/$
- Flolipid - NO/$$$$
Efficacy
Roszet®
Rosuvastatin + ezetimibe
Rosuvastatin + ezetimibe
Dosage forms
Tablet
- Rosuvastatin - Ezetimibe
- 5 mg - 10 mg
- 10 mg - 10 mg
- 20 mg - 10 mg
- 40 mg - 10 mg
Dosing
High cholesterol
- Dosing: 5/10 mg - 40/10 mg once daily
- Asian patients: starting dose should be 5/10 mg once daily. Consider risks/benefits of doses > 20/10 mg. Exposure to rosuvastatin is higher in Asian patients (see statins in Asian patients for more).
- Kidney disease:
- CrCl ≥ 30 ml/min: no dose adjustment necessary
- CrCl < 30 ml/min: recommended starting dose is 5/10 mg once daily. Do not exceed 10/10 mg once daily.
- May take without regard to food
- Do not crush, dissolve, or chew tablets
Generic / Price
- NO/$$$$
Vytorin®
Simvastatin + ezetimibe
Simvastatin + ezetimibe
Dosage forms
Tablet
- Ezetimibe - Simvastatin
- 10 mg - 10 mg
- 10 mg - 20 mg
- 10 mg - 40 mg
- 10 mg - 80 mg
Dosing
High cholesterol
- Starting: 10/10 - 10/20 mg once daily in the evening
- Maintenance: 10/10 - 10/40 mg once daily in the evening
- Max: 10/40 mg once daily
- May take without regard to food
- For patients requiring > 55% LDL reduction, recommended starting dose is 10/40 mg/day
- Due to increased risk of myopathy, the 10/80 mg dose should be restricted to patients who have been taking 10/80 mg chronically (> 12 months) without evidence of muscle toxicity
Generic / Price
- YES/$$-$$$
Caduet®
Amlodipine + atorvastatin
Amlodipine + atorvastatin
Dosage forms
Tablet
- Amlodipine - Atorvastatin
- 2.5 mg - 10 mg
- 2.5 mg - 20 mg
- 2.5 mg - 40 mg
- 5 mg - 10 mg
- 5 mg - 20 mg
- 5 mg - 40 mg
- 5 mg - 80 mg
- 10 mg - 10 mg
- 10 mg - 20 mg
- 10 mg - 40 mg
- 10 mg - 80 mg
Dosing
Hypertension / Hyperlipidemia
- Starting: 2.5/10 mg once daily
- Maintenance: 2.5/10 - 10/80 mg once daily
- Max: 10/80 mg once daily
- May take without regard to food
Generic / Price
- YES/$$
- Kidney disease
- Atorvastatin (Lipitor®)
- No dose adjustment necessary in kidney disease
- Fluvastatin (Lescol®)
- CrCl ≥ 30 ml/min: no dose adjustment necessary
- CrCl < 30 ml/min: has not been studied at doses greater than 40 mg; use caution
- Lovastatin (Mevacor®)
- CrCl ≥ 30 ml/min: no dose adjustment necessary
- CrCl < 30 ml/min: dosage increases above 20 mg /day should be carefully considered and, if deemed necessary, implemented cautiously
- Pitavastatin (Livalo®)
- CrCl < 60 ml/min: recommended starting dose is 1 mg once daily; do not exceed 2 mg/day
- Pravastatin (Pravachol®)
- CrCl < 30 ml/min: starting dose of 10 mg is recommended
- Rosuvastatin (Crestor®)
- CrCl < 30 ml/min: recommended starting dose is 5 mg once daily; do not exceed 10 mg/day
- Simvastatin (Zocor®)
- CrCl < 30 ml/min: recommended starting dose is 5 mg once daily
- Liver disease dosing
- Statins have been linked to rare cases of hepatotoxicity, and all products carry warnings about their use in active liver disease. However, in studies, statins have been found to be mostly safe in liver disease and may even be beneficial in some conditions. Recommendations from the AHA on statin use in liver disease are provided below, and guidance on monitoring liver enzymes is available here - statins and hepatotoxicity. [7,8]
- AHA recommendations
- Statins appear to be safe to use and do not cause progression of liver disease in patients with fatty liver disease or chronic hepatitis C. On that basis, there is no need to avoid statin therapy in patients with stable chronic liver disease and normal or modestly elevated transaminases (up to 3 X ULN).
- There are no reliable data showing that statins are safe in advanced or decompensated liver disease [9]
STATIN INTENSITY CHART
| High-intensity statin therapy (lowers LDL by ≥ 50%) |
Moderate-intensity statin therapy (lowers LDL by 30 - 49%) |
Low-intensity statin therapy (lowers LDL by < 30%) |
|---|---|---|
|
|
|
DRUG INTERACTIONS
- NOTE: The drug interactions presented here are NOT all-inclusive. Other interactions may exist. Drug interaction checkers provide the most efficient and practical way to check for interactions among multiple medications. A free interaction checker is available from Drugs.com (see Drugs.com interactions checker).
- All statins
- Antacids (Tums®, Mylanta®, etc) - antacids may decrease statin absorption. Separate statin and antacid dosing by at least 2 hours.
- Bile acid sequestrants (Questran®, Welchol®, Colestid®) - cholestyramine may interfere with the absorption of statins. Statins should be taken one hour before or four hours after cholestyramine is consumed.
- Colchicine (Colcrys®) - colchicine may raise statin levels and increase the risk of toxicity. Consider alternative therapy.
- Fibrates other than gemfibrozil - use caution when combining statins with fibrates. Risk of myopathy may be increased. Do not combine statins with gemfibrozil.
- Gemfibrozil (Lopid®) - DO NOT COMBINE. Gemfibrozil may raise levels of statins and increase the risk for toxicity.
- Niacin - both niacin and statins have been shown to cause muscle toxicity. When taken together, the risk may be greater. Use caution when combining niacin with statins.
- OATP inhibitors - when statins are taken with OATP inhibitors, the risk of muscle toxicity is increased. OATP inhibitors include gemfibrozil (Lopid®), cyclosporine, erythromycin, clarithromycin, etc.
- Warfarin (Coumadin®) - statins may affect warfarin levels. Patients on warfarin should monitor INR levels after starting a statin.
- Atorvastatin (Lipitor®)
- Antifungals (e.g. itraconazole, ketoconazole, and voriconazole) - azole antifungals may increase atorvastatin levels. Atorvastatin doses should not exceed 20 mg/day when taken with itraconazole. Consider the risk/benefit of concomitant use of azole antifungals with atorvastatin. Monitor all patients for signs and symptoms of myopathy particularly during initiation of therapy and during upward dose titration of either drug.
- Cyclosporine - DO NOT COMBINE. Cyclosporine raises atorvastatin levels and may increase the risk of toxicity.
- CYP3A4 inhibitors - combination may increase risk for muscle toxicity
- Digoxin - atorvastatin may increase levels of digoxin. Monitor digoxin levels when starting or changing therapy. [59]
- Grapefruit juice - large quantities of grapefruit juice (> 1.2 liters/day) can raise atorvastatin levels and increase the risk of toxicity. Avoid large intakes of grapefruit juice while taking atorvastatin.
- Harvoni® (ledipasvir and sofosbuvir) - Harvoni can increase blood levels of atorvastatin. Monitor patients closely for statin-related adverse events such as myopathy and rhabdomyolysis when taken together.
- HIV medications - In patients taking lopinavir plus ritonavir, consider the risk/benefit of concomitant use with atorvastatin. In patients taking saquinavir plus ritonavir, darunavir plus ritonavir, fosamprenavir, fosamprenavir plus ritonavir, or letermovir, atorvastatin dose should not exceed 20 mg/day. In patients taking nelfinavir, atorvastatin dose should not exceed 40 mg/day.
- Letermovir (Prevymis®) - letermovir increases exposure to atorvastatin. Doses of atorvastatin should not exceed 20 mg/day if prescribed concomitantly. In patients receiving cyclosporine and letermovir, atorvastatin is not recommended.
- Macrolide antibiotics (e.g. erythromycin, clarithromycin) - macrolide antibiotics may increase atorvastatin levels. Atorvastatin dose should not exceed 20 mg/day when taken with clarithromycin. Consider the risk/benefit of concomitant use of macrolide antibiotics with atorvastatin. Monitor all patients for signs and symptoms of myopathy particularly during initiation of therapy and during upward dose titration of either drug.
- Mavyret® (Glecaprevir and pibrentasvir) - DO NOT COMBINE. Mavyret may raise atorvastatin levels and increase the risk of toxicity.
- Oral contraceptives - atorvastatin may increase blood levels of ethinyl estradiol by 20 - 25% [60]
- Posaconazole (Noxafil®) - DO NOT COMBINE. Posaconazole is a CYP3A4 strong inhibitor, and it increases atorvastatin exposure.
- Resmetirom (Rezdiffra®) - resmetirom may increase atorvastatin exposure. Daily atorvastatin dose should not exceed 40 mg when combining.
- Rifampin - rifampin is a CYP3A4 inducer and OATP1B1 inhibitor. When atorvastatin is taken after rifampin, atorvastatin levels may be reduced. To avoid this interaction, atorvastatin and rifampin should be taken simultaneously.
- Tipranavir plus ritonavir - DO NOT COMBINE. Tipranavir plus ritonavir may raise atorvastatin levels and increase the risk of toxicity.
- Zepatier® (Elbasvir and grazoprevir) - atorvastatin dose should not exceed 20 mg/day when combining
- Fluvastatin (Lescol®)
- Cyclosporine - fluvastatin dose should not exceed 20 mg/day when combining
- CYP2C9 substrates and inhibitors - CYP2C9 inhibitors can increase the risk for muscle toxicity, and fluvastatin can increase blood levels of CYP2C9 substrates
- Fluconazole (Diflucan®) - fluvastatin dose should not exceed 20 mg twice a day when combining
- Glyburide - fluvastatin increases glyburide exposure. Monitor blood sugars when adding fluvastatin to glyburide.
- Phenytoin - fluvastatin increases phenytoin exposure. Monitor phenytoin levels when initiating fluvastatin.
- Lovastatin (Mevacor®)
- Amiodarone (Cordarone®) - lovastatin dose should not exceed 40 mg/day when combining
- Conivaptan (Vaprisol®) - DO NOT COMBINE. Conivaptan may raise lovastatin levels and increase risk for toxicity.
- Cyclosporine (Neoral®, etc.) - DO NOT COMBINE cyclosporine with lovastatin. Cyclosporine may raise levels of these statins and increase the risk for toxicity. [59]
- CYP3A4 strong inhibitors - DO NOT COMBINE lovastatin with CYP3A4 strong inhibitors
- Danazol (Cyclomen®) - Lovastatin starting dose should be 10 mg/day. lovastatin dose should not exceed 20 mg/day when combining.
- Diltiazem (Cardizem®) - lovastatin starting dose should be 10 mg/day. Lovastatin dose should not exceed 20 mg/day when combining.
- Dronedarone (Multaq®) - lovastatin starting dose should be 10 mg/day. Lovastatin dose should not exceed 20 mg/day when combining.
- Erythromycin - DO NOT COMBINE lovastatin with erythromycin
- Fibrates other than gemfibrozil - lovastatin dose should not exceed 20 mg/day when combining.
- Niacin - lovastatin dose should not exceed 20 mg/day when combining
- Tacrolimus (Prograf®) - DO NOT COMBINE tacrolimus with simvastatin, lovastatin, and pitavastatin. Tacrolimus may raise levels of statins and increase the risk for toxicity. [59]
- Ranolazine (Ranexa®) - lovastatin dose should not exceed 20 mg/day when combining
- Ticagrelor (Brilinta®) - lovastatin dose should not exceed 40 mg/day when combining
- Verapamil (Calan®, etc.) - lovastatin starting dose should be 10 mg/day. Lovastatin dose should not exceed 20 mg/day when combining.
- Pitavastatin (Livalo®)
- Cyclosporine (Neoral®, etc.) - DO NOT COMBINE cyclosporine with pitavastatin. Cyclosporine may raise levels of these statins and increase the risk for toxicity. [59]
- Erythromycin - pitavastatin dose should not exceed 1 mg/day when combining
- Rifampin - pitavastatin dose should not exceed 2 mg/day when combining
- Tacrolimus (Prograf®) - DO NOT COMBINE tacrolimus with simvastatin, lovastatin, and pitavastatin. Tacrolimus may raise levels of these statins and increase the risk for toxicity. [59]
- Pravastatin (Pravachol®)
- Bempedoic acid (Nexletol®) - bempedoic acid increases pravastatin exposure. Pravastatin doses should not exceed 40 mg/day when combining.
- Clarithromycin (Biaxin®) - pravastatin dose should not exceed 40 mg/day when combining
- Erythromycin - pravastatin dose should not exceed 40 mg/day when combining
- Cyclosporine - pravastatin starting dose should be 10 mg/day. Pravastatin dose should not exceed 20 mg/day when combining.
- Resmetirom (Rezdiffra®) - resmetirom may increase pravastatin exposure. Daily pravastatin dose should not exceed 40 mg when combining.
- Rosuvastatin (Crestor®)
- Capmatinib (Tabrecta®) - capmatinib increases rosuvastatin exposure more than 2.1-fold. Rosuvastatin dosing should not exceed 10 mg/day when combining.
- Cyclosporine - cyclosporine increases rosuvastatin exposure 7-fold. Rosuvastatin dosing should not exceed 5 mg/day when combining.
- Darolutamide (Nubeqa®) - darolutamide increases rosuvastatin exposure more than 5-fold. Rosuvastatin dosing should not exceed 5 mg/day when combining.
- Enasidenib (IDHIFA®) - enasidenib increases rosuvastatin exposure more than 2.4-fold. Rosuvastatin dosing should not exceed 10 mg/day when combining.
- Epclusa® (sofosbuvir and velpatasvir) - Epclusa increases rosuvastatin exposure. Use a starting dose of 5 mg/day and do not exceed 10 mg/day when combining.
- Febuxostat (Ullori®) - febuxostat increases rosuvastatin exposure more than 1.9-fold. Rosuvastatin dosing should not exceed 20 mg/day when combining.
- Fostamatinib (Tavalisse®) - fostamatinib increases rosuvastatin exposure more than 2-fold. Rosuvastatin dosing should not exceed 20 mg/day when combining.
- Harvoni™ (ledipasvir and sofosbuvir) - DO NOT COMBINE. Harvoni increases rosuvastatin exposure.
- HIV protease inhibitors (lopinavir or atazanavir + ritonavir) - rosuvastatin exposure is increased. Use a starting dose of 5 mg/day and do not exceed 10 mg/day.
- Mavyret® (glecaprevir and pibrentasvir) - rosuvastatin exposure is increased. Use a starting dose of 5 mg/day and do not exceed 10 mg/day.
- Oral contraceptives - rosuvastatin and atorvastatin may increase blood levels of ethinyl estradiol by 20 - 25% [60]
- Regorafenib (Stivarga®) - regorafenib increases rosuvastatin exposure. Rosuvastatin dosing should not exceed 10 mg/day when combining.
- Resmetirom (Rezdiffra®) - resmetirom may increase rosuvastatin exposure. Daily rosuvastatin dose should not exceed 20 mg when combining.
- Tafamidis (Vyndaqel®) - tafamidis can cause myopathy, and it increases rosuvastatin exposure. Concomitant use should be avoided if possible. If taken together, initiate rosuvastatin at 5 mg/day and do not exceed 10 mg/day.
- Teriflunomide (Aubagio®) - teriflunomide increases rosuvastatin exposure more than 2.5-fold. Rosuvastatin dose should not exceed 10 mg/day when combining.
- Viekira pak™ (ombitasvir, paritaprevir, dasabuvir, ritonavir) - Viekira pak increases rosuvastatin exposure. Use a starting dose of 5 mg/day and do not exceed 10 mg/day.
- Vosevi™ (sofosbuvir, velpatasvir, voxilaprevir) - DO NOT COMBINE. Rosuvastatin exposure is increased.
- Warfarin - rosuvastatin may increase the anticoagulant effect of warfarin. Monitor INR values closely when combining, particularly during initiation, dose changes, and discontinuation.
- Zepatier® (elbasvir and grazoprevir) - Zepatier increases rosuvastatin exposure. Use a starting dose of 5 mg/day and do not exceed 10 mg/day.
- Simvastatin (Zocor®)
- Amiodarone (Cordarone®) - simvastatin dose should not exceed 20 mg/day when combining
- Amlodipine (Norvasc®) - simvastatin dose should not exceed 20 mg/day when combining
- Bempedoic acid (Nexletol®) - bempedoic acid increases simvastatin exposure. Simvastatin doses should not exceed 20 mg/day when combining.
- Conivaptan (Vaprisol®) - DO NOT COMBINE. Conivaptan may raise simvastatin levels and increase risk for toxicity.
- Cyclosporine (Neoral®, etc.) - DO NOT COMBINE cyclosporine with simvastatin. Cyclosporine may raise levels of these statins and increase the risk for toxicity. [59]
- CYP3A4 strong inhibitors - DO NOT COMBINE simvastatin with CYP3A4 strong inhibitors
- Danazol (Cyclomen®) - DO NOT COMBINE. Danazol may raise simvastatin levels and increase the risk of toxicity.
- Daptomycin - DO NOT COMBINE. Both drugs can cause rhabdomyolysis and myopathy, and the risk may be greater when taken together. Temporarily suspend simvastatin if daptomycin must be given.
- Diltiazem (Cardizem®) - simvastatin dose should not exceed 10 mg/day when combining. Diltiazem dose should not exceed 240 mg/day when combining.
- Dronedarone (Multaq®) - simvastatin dose should not exceed 10 mg/day when combining.
- Erythromycin - DO NOT COMBINE simvastatin with erythromycin
- Lomitapide (Juxtapid®) - lomitapide increases simvastatin exposure two-fold, raising the risk of myopathy. Reduce simvastatin dose by 50% when starting lomitapide and do not exceed 20 mg daily (or 40 mg daily for patients who have previously taken an 80 mg daily dosage of simvastatin chronically).
- Niacin - DO NOT COMBINE niacin (≥ 1 gram/day) with simvastatin in Chinese patients. See Asian patients above.
- Ranolazine (Ranexa®) - simvastatin dose should not exceed 20 mg/day when combining
- Resmetirom (Rezdiffra®) - resmetirom may increase simvastatin exposure. Daily simvastatin dose should not exceed 20 mg when combining.
- Tacrolimus (Prograf®) - DO NOT COMBINE tacrolimus with simvastatin, lovastatin, and pitavastatin. Tacrolimus may raise levels of these statins and increase the risk for toxicity. [59]
- Ticagrelor (Brilinta®) - simvastatin dose should not exceed 40 mg/day when combining
- Verapamil (Calan®, etc.) - simvastatin dose should not exceed 10 mg/day when combining.
- Metabolism and clearance
- Atorvastatin (Lipitor®)
- CYP3A4 - Substrate
- P-glycoprotein - Substrate and inhibitor
- OATP1B1 and OATP1B3 - Substrate
- Fluvastatin (Lescol®)
- CYP2C9 - Major substrate and weak inhibitor
- CYP3A4 - Minor substrate
- CYP2C8 - Minor substrate
- P-glycoprotein - Substrate and inhibitor
- OATP1B3 - Substrate
- Lovastatin (Mevacor®)
- CYP3A4 - Sensitive substrate
- P-glycoprotein - Substrate and inhibitor
- OATP1B1 - Substrate
- Pitavastatin (Livalo®)
- CYP2C9 - Substrate
- CYP2C8 - Minor substrate
- P-glycoprotein - Substrate
- OATP1B1 - Substrate
- Pravastatin (Pravachol®)
- P-glycoprotein - Substrate
- OATP1B1 and OATP1B3 - Substrate
- Rosuvastatin (Crestor®)
- Simvastatin (Zocor®)
- CYP3A4 - Substrate
- CYP2C8 - Substrate and inhibitor
- P-glycoprotein - Substrate and inhibitor
- OATP1B1 - Substrate
PRICE ($) INFO
- $ = 0 - $50
- $$ = $51 - $100
- $$$ = $101 - $150
- $$$$ = > $151
- Pricing based on one month of therapy at standard dosing in an adult
- Pricing based on information from GoodRX.com®
- Pricing may vary by region and availability
BIBLIOGRAPHY
- Manufacturer's package insert
- 2 - PMID 20842109
- 3 - PMID 21109302
- 4 - PMID 27754879 - AHA statin interaction recommendations
- 5 - Seasonale PI
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