Posted by ed_uk2010 on November 24, 2013, at 5:46:37
In reply to Re: How ridiculous » ed_uk2010, posted by SLS on November 14, 2013, at 22:34:07
Hi Scott,
>If I were in the position of needing a statin, I would try rosuvastatin 40 mg/day first and atorvastatin 80 mg/day second.
Unless I'd just had an ACS/MI, I wouldn't want to initiate with high doses. Not everyone needs maximum intensity statin therapy.
>I know you really like the idea of taking generic drugs.
Where appropriate, but this isn't a brand-generic issue. Rosuvastatin is very potent and yet a lot of people who take it only take 5-10mg. Many of them could quite probably be treated with other statins, especially atorvastatin. If treatment is initiated with rosuvastatin, which seems to be happening very often in the US, there may be slightly less need to switch drugs due to lack of efficacy (which is rarely difficult with statins), but at a very high financial cost. For patients whose lipids are excellent on atorvastatin, I find it hard to see why rosuvastatin would be better. Atorvastatin has a particularly large body of outcome data showing its real world as well as laboratory efficacy. Rosuvastatin might look slightly better on paper in terms of lab stats but it's so easy to switch to rosuvastatin if atorvastatin proves inadequate that I don't think this is relevant in terms of the initial drug chosen.
Also, a high-proportion of statin users are primary prevention pts. Unless their lipids are through the roof, maximum intensity statin treatment is rarely needed, haemorrhagic stroke risk may be increased with little in terms of benefit over standard intensity statins. It seems that their doctors agree (you see low doses of rosuvastatin 5-10mg). So why did the prescriber choose to initiate Crestor first-line at all? ....I suggest it is because they just saw the rep, who has played a far greater role in prescribing than they ought. The attractive and enticing graphs came out and it suddenly looked as if rosuvastatin was the answer to everyone's cholesterol woes. For sure, a 1st line rosuvastatin strategy is very easy for the prescriber, which must account for a lot of its popularity. But is it necessary? I don't think so. Not when so many people achieve stability + excellent labs results on other statins. And yes, cost is very relevant so that fact that generic atorvastatin is available is important. I have little doubt that AstraZeneca are offering seemingly excellent 'patient support' to pay for their expensive drug, but the high cost is always transmitted back to the consumer in one way or another. Be it in insurance costs or whatever ;) which may be difficult to afford.
Low intensity statins: fluvastatin (lowest), pravastatin.
Moderate intesity statins: simvastatin.
High intensity statins: Atorvastatin, rosuvastatin.
For pts who do not achieve targets on high dose atorvastatin, rosuvastatin can be tried. Ezetimibe can be added instead but it is also expensive and not supported by outcome data. Nevertheless, adding ezetimibe appears to have a greater effect on lipids than switching statins.At 80mg/day in particular, the potency of atorvastatin is such that it seems highly sensible to try it before considering rosuvastatin. Whether it is initiated at this dose (as in ACS) or titrated as in primary prevention depends on the circumstances.
The number of patients receiving statin therapy is so immense that the costs of comparable doses must be compared. For example, at current prices to the UK National Health Service, atorvastatin 80mg/day is a massive 10 times less expensive than rosuvastatin 40mg. In practice, few pts receive the 40mg rosuva dose here, the standard maximum dose is 20mg. Atorvastatin 80mg, on the other hand, is very widely used.
Overall, I don't want anyone to be undertreated, but the use of more potent drugs than is necessary for the situation won't benefit anyone.
poster:ed_uk2010
thread:1053481
URL: http://www.dr-bob.org/babble/20131115/msgs/1054830.html