Statins are one of the most commonly prescribed medications, consistently landing on the list of the top 10 most frequently prescribed meds (depending on the list you’re looking at). Since Americans’ love of pizza, burgers and fries doesn’t appear to be going anywhere, as nurse practitioners we must be familiar with these medications – and most of us are. So, let’s go a bit beyond the basics today and look at a handful of little known facts about the statins you’re prescribing day-to-day.
1. Asians are more responsive to therapy than Caucasians and African Americans
As with many drugs, there are genetic and ethnic differences in the way statins are metabolized. When it comes to statins, genetic differences in the CYP2D6 enzyme play a role in the lipid lowering capacity and tolerability of statins. Asian patients respond more readily to statins given genetic differences in CYP2D6. So, start these patients at a lower dose than their Caucasian and African American counterparts. Rosuvastatin (Crestor) actually includes this ethnic tip as an official recommendation on its label.
2. CoQ10 doesn’t actually help myalgia
In my nurse practitioner program, I was taught that CoQ10 supplementation helps prevent that pesky myalgia patients may experience when taking statins. In theory, this makes sense. Statins interfere with CoQ10 production. CoQ10 plays a role in muscle metabolism. So, theoretically, CoQ10 supplementation would counteract the effects statins have on muscles. Studies, however, show that CoQ10 has no bearing on statin side effects. So, save your patient from popping an extra pill and skip the supplements to counteract statin SEs.
3. Atorvastatin (Lipitor) and Rosuvastatin (Crestor) have the greatest LDL lowering capacity
High-intensity statins are those with an expected LDL reduction of 50% or greater. The STELLAR trial published in the American Journal of Cardiology looked at which statins make this high-intensity mark and two medications fit the bill – Atorvastatin (Lipitor) and Rosuvastatin (Crestor). Atorvastatin lowers LDL by an expected 37 – 51% and Rosuvastatin by an expected 46 – 55%. So, which should you choose? Aside from clinical considerations, Atorvastatin tends to be cheaper than its other high-intensity counterpart making it a good place to start for patients that quality for max LDL lowering criteria.
4. Ideally, take statins at bedtime
Cholesterol synthesis occurs in the body at night. Statins act by inhibiting HMG CoA reductase, which controls synthesis of cholesterol in the liver. Since statins have a short-half life, ideally patients should take them when cholesterol synthesis occurs, in the evening/night. To get even more specific, based on its unique metabolic properties, lovastatin should be taken with dinner as it isn’t absorbed as well with food. If your patient can’t remember to take their cholesterol meds at night, statins are still effective taken in the daytime just not to the same extent.
5. You don’t need to routinely check liver enzymes
As nurse practitioners, we’ve all heard that statins can affect liver function. So, many of us dutifully check liver enzymes when patients follow up looking for upward trends in AST and ALT. Significant effects of statins on liver function, however, are rare. Elevated liver enzymes may be found in about 0.5 – 3% of statin users. Typically, liver enzyme elevation that does occur is not clinically significant. UpToDate recommends changing medications or lowering statin dose only in patients whose ALT is more than 3x the upper level of normal, confirmed on a second occasion. Furthermore, actual hepatotoxicity is exceedingly rare, occurring in just 0.001% of statin users. It’s no longer recommended to routinely monitor liver enzymes for patients on statins. Rather, check AST and ALT on initiation of therapy and then again only if the patient has symptoms.
6. Use caution in coadministration with (some) anticoagulants
Most statins likely potentiate warfarin, increasing bleeding risk and calling for close monitoring of patients taking both drugs simultaneously (though we still need more research on this topic). There are a few exceptions to this rule, however. Pravastatin (Pravachol) is metabolized a bit differently and therefore does not interact with warfarin. So, this is a good option for your anticoagulated patients. Unlike warfarin, clopidogrel (Plavix) does not interact with statins – one less drug drug interaction to keep in mind.
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