Statins
also: atorvastatin · simvastatin · rosuvastatin
Overview
Cornerstone of CVD primary and secondary prevention. Atorvastatin 20 mg (primary, QRISK ≥10%) / 80 mg (secondary).
Mechanism
Competitively inhibit HMG-CoA reductase, the rate-limiting enzyme of hepatic cholesterol synthesis → ↓intracellular cholesterol → upregulated LDL receptors → ↑LDL clearance from blood. Pleiotropic plaque-stabilising effects.
Indications
- Primary prevention (QRISK2 ≥10%)
- Secondary prevention (established CVD)
- Familial hypercholesterolaemia
- Type 1/2 diabetes with risk factors
The agents
CYP3A4, OD any time
First-line UK (NICE).
minimal CYP
Fewer interactions.
CYP3A4, take at night
Many interactions; dose caps with CYP3A4 inhibitors.
not CYP-metabolised
Preferred with interacting drugs.
OD
Blocks intestinal cholesterol absorption (NPC1L1) — add when statin alone insufficient or not tolerated.
Adverse effects
Check CK if severe; raised risk with fibrates, CYP3A4 inhibitors.
Rare; CK >10× ULN + myoglobinuria.
Stop if ALT >3× ULN.
Cautions & contraindications
Cholesterol needed for fetal development — stop before conception.
Macrolides, azoles → myopathy/rhabdo.
Interactions
- Simvastatin + clarithromycin/erythromycin → stop statin during course
- Simvastatin + amlodipine/diltiazem/verapamil → cap simvastatin 20 mg
- Grapefruit juice (simvastatin)
- Fibrates (gemfibrozil) → myopathy
Monitoring & kinetics
Lipids (baseline + ~3 months, aim ≥40% non-HDL reduction),LFTs (baseline, 3 and 12 months),CK only if muscle symptoms
Oral. Simvastatin at night (short t½); atorvastatin/rosuvastatin any time.
Source: BNF — Statins · NICE NG238 — CVD risk