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Lipid-Lowering Pregnancy: X — contraindicated

Atorvastatin

Brand names: Lipitor

Adult dose

Dose: Primary prevention: 20mg OD. Secondary prevention / high risk: 40–80mg OD
Route: Oral
Frequency: Once daily (any time — long half-life)
Max: 80mg/day
NICE recommends 20mg OD for primary prevention (10-year CVD risk ≥10%). 40–80mg OD for established CVD, diabetes with end-organ damage, CKD, or familial hypercholesterolaemia.

Dose adjustments

Renal

No dose adjustment required.

Hepatic

Contraindicated in active liver disease or unexplained persistent elevated transaminases.

Clinical pearls

  • Atorvastatin has a long half-life (~14h) — timing of dose is flexible, unlike some other statins (e.g. simvastatin, best taken at night).
  • Muscle symptoms: check CK. If CK <10× ULN and mild symptoms, can continue with monitoring. If CK >10× ULN or rhabdomyolysis suspected, stop immediately.
  • HPS trial: simvastatin 40mg vs placebo — 33% reduction in CV events regardless of baseline LDL. Applies to atorvastatin class.
  • JUPITER trial: rosuvastatin 20mg in patients with elevated CRP even with normal LDL — 44% CV event reduction.
  • Aim for LDL cholesterol <1.8 mmol/L (secondary prevention) or <2.0 mmol/L (primary prevention, high risk).

Contraindications

  • Active liver disease or unexplained persistent elevated transaminases
  • Pregnancy and breastfeeding
  • Concomitant ciclosporin (risk of severe myopathy)

Side effects

  • Muscle pain / myalgia (most common — 5–10%)
  • Myopathy / rhabdomyolysis (rare — particularly with interactions)
  • Elevated transaminases (usually transient and benign — <3× ULN acceptable)
  • New-onset diabetes (modest risk — NNH ~255)
  • GI disturbance: nausea, constipation, flatulence
  • Headache

Interactions

  • Clarithromycin / erythromycin (CYP3A4 inhibitors): increase statin levels — suspend statin during short course
  • Amiodarone: increased statin levels
  • Fibrates (gemfibrozil): increased myopathy risk — avoid combination
  • Ciclosporin: significantly increases statin levels — contraindicated
  • Grapefruit juice: modest increase in atorvastatin levels

Monitoring

  • Lipid profile at 3 months (aim ≥40% LDL reduction). LFTs before and if symptomatic. CK only if myalgia present.

Reference: NICE NG238 Lipid Modification; HPS Trial Lancet 2002; NICE BNF 84. Verify against your local formulary and the latest BNF before prescribing.

Related

Curated clinical cross-links plus same-class fallbacks.

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