Atorvastatin

How it works

It competitively inhibits HMG-CoA reductase, the rate-limiting enzyme in hepatic cholesterol synthesis, upregulating LDL receptors and lowering circulating LDL cholesterol.

Prescribing in practice

• In older patients, who often have comorbidity, polypharmacy and reduced muscle mass, watch closely for muscle symptoms and myopathy, and weigh predisposing factors before high-intensity dosing.
• Avoid concurrent strong CYP3A4 inhibitors and limit certain interacting drugs that raise statin exposure and rhabdomyolysis risk.
• Review for clinically significant transaminase rise and, where relevant, an increased risk of new-onset diabetes.

Monitoring

Check baseline lipids, liver enzymes and (where indicated) creatine kinase, with a lipid response check after starting and review of any muscle symptoms.

Counselling the patient

• Report unexplained muscle pain, tenderness or weakness promptly.
• Avoid grapefruit juice and tell clinicians about any new medicines.
• Continue long term, as benefit comes from sustained cholesterol lowering.

Evidence & guidelines

Cardiovascular benefit of statins extends to older adults in Cholesterol Treatment Trialists' meta-analyses and underpins NICE lipid-modification guidance.