Table 2.

Statin Therapy

• Document normal hepatic panel before initiating therapy.

• If a patient meeting eligibility for statins is a young woman of reproductive age, it is essential to counsel to avoid pregnancy. Statins should be withheld during pregnancy because of the potential for teratogenicity for a developing fetus.

• Dosing:

– Start at lowest dose, usually at bedtime.

– If target LDL-c levels are not achieved, double the dose and repeat lipid profile, creatine kinase (CK), and liver enzymes at 4 weeks. Continue stepped titration up to the maximum recommended dose until the target LDL-c levels are achieved (<130, optimally <110 mg/dL) or there is evidence of toxicity. Repeat blood work at 4 weeks, 3 months, and then every 3–4 months for first year and every 6 months thereafter.

– Suggested titration:

• Pravastatin (Pravachol) 10→20 mg

• Rosuvastatin (Crestor) 5→10→20 mg

• Atorvastatin (Lipitor) 10→20 mg

– Note: Simvastatin (Zocor) is the least expensive, but most lipophilic, and therefore passes readily across the blood–brain barrier (BBB) and suppresses brain cholesterol synthesis. Plasma cholesterol does not cross the BBB. Therefore, to avoid interference with cholesterol needs for adolescent brain development, more hydrophilic statins are favored.

– If LDL-c remains >130 mg/dL on the maximum statin dose, can add a bile acid sequestrant (Cholestyramine or Colestipol, 8 g per day). Do not go higher in statin dose without consulting a lipid specialist.

• Side effects:

– Instruct patient to immediately report side effects suggestive of myopathy. If myopathy is present, the medication should be stopped, and CK level and relation of symptoms to physical activity should be assessed in 4–6 weeks. The patient should be monitored for resolution of the myopathy and any associated increases in CK. Consideration can be given to either an alternate statin or restarting the same statin medication at half the previous dose once symptoms and laboratory abnormalities have resolved.

– Advise female patients about contraindication during pregnancy and contraception if warranted. Advise about drug interactions (cyclosporine, fibric acid derivatives, niacin, erythromycin, azole antifungals, nefazodone, and HIV protease inhibitors).

LDL-c, low-density lipoprotein cholesterol; HIV, human immunodeficiency virus.