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For primary prevention, therapy with a statin should be discussed with patients whose predicted cardiovascular disease risk over 10 years is 20% or more using ASSIGN or JBS3 risk calculators. Patients with rheumatological disease (RA/SLE): estimate the risk using ASSIGN, ticking the box for rheumatoid arthritis (RA).
Patients with diabetes and/or ischaemic stroke should be treated as Patients with Established Vascular Disease and/or Diabetes and/or Ischaemic Stroke.
Patients with chronic kidney disease: follow local guidance for this patient group
Screen for potential candidates for treatment. These are adults who:
Discuss treatment options with the patient taking into consideration that the benefits of therapy, eg absolute reductions in risk of heart attack and stroke are small and may be outweighed by the risk of side-effects, eg muscle pain and development of diabetes mellitus. |
*SUPPLEMENTARY INFORMATION Prevention of atherosclerotic arterial disease in patients with or without established cardiovascular disease requires control of all risk factors. No single risk factor, including cholesterol concentration, should be viewed in isolation.
link to Simon Broome criteria |
Previous MI |
Pre- or post-CABG |
Pre- or post-angiography |
Definite angina* |
Angiographic coronary artery disease |
Definite peripheral artery disease* |
Previous TIA or ischaemic stroke** |
|
|
Retinopathy (requiring opthalmological treatment) – if maculopathy, treat with fibrate |
Nephropathy, including persistent microalbuminuria |
Hypertensive requiring antihypertensive therapy |
Raised total cholesterol (>6 mmol/L) |
Features of metabolic syndrome |
|
**SUPPLEMENTARY INFORMATION Patients diagnosed with high risk acute coronary syndrome or ischaemic stroke will be treated with ATORVASTATIN 80mg DAILY (If not tolerated/side-effects try lower dose or different statin. Review dose annually.) (Also see stroke guidance) link to Simon Broome criteria |
Summary of common statin interactions (this list is not exhaustive; refer to BNF for full information on interactions)
Interacting drug |
Simvastatin prescribing advice |
Atorvastatin prescribing advice |
Rosuvastatin prescribing advice* |
Clarithromycin |
Contra-indicated with simvastatin |
Use lowest necessary dose of atorvastatin. Close monitoring advised for atorvastatin doses above 20mg daily. Avoid clarithromycin if possible. |
No information of interaction |
Erythromycin |
Contra-indicated with simvastatin |
Use lowest necessary dose of atorvastatin*** |
Possible reduction in rosuvastatin levels – not clinically relevant in short courses of erythromycin. |
Verapamil Amiodarone Diltiazem |
Do not exceed 20mg simvastatin daily |
Use lowest necessary dose of atorvastatin (monitor lipid levels)*** |
No information of interaction |
Amlodipine |
Do not exceed 20mg simvastatin daily |
No clinically significant interaction expected*** |
No information of interaction |
Warfarin |
Monitor INR |
Monitor INR |
Monitor INR |
Ciclosporin |
Contra-indicated with simvastatin |
Do not exceed 10mg atorvastatin daily.*** Avoid if possible. |
Contra-indicated with rosuvastatin |
Grapefruit juice |
Avoid grapefruit juice |
Limit or avoid grapefruit juice intake |
No information of interaction |
HIV protease inhibitors** |
Contra-indicated with simvastatin |
Use lowest necessary dose of atorvastatin (monitor lipid levels). Consult manufacturers’ literature for maximum recommended doses. Avoid if possible. |
Not recommended for combination use. Consult manufacturers’ literature for maximum recommended doses. |
Itraconazole
|
Contra-indicated with simvastatin |
Contra-indicated with atorvastatin |
Increased level of rosuvastatin – not expected to be clinically significant.*** |
Posaconazole |
Contra-indicated with simvastatin |
Contra-indicated with atorvastatin |
No information of interaction |
Fluconazole | Use lowest necessary dose of simvastatin*** | Use lowest necessary dose of atorvastatin*** | No clinically significant interaction expected*** |
Miconazole oral gel | Contra-indicated with simvastatin | Contra-indicated with atorvastatin | No clinically significant interaction expected*** |
Sodium fusidate | Not recommended for combination use*** | Not recommended for combination use*** | Not recommended for combination use*** |
Ticagrelor | Do not exceed 40mg simvastatin daily | No clinically significant interaction expected*** | No information of interaction |
*If changing to rosuvastatin, start at 5 or 10mg daily and titrate up to 20mg daily if necessary (patients of Asian origin start at 5mg and do not exceed 20mg)
**See summary of product characteristics (SPC) for advice regarding specific drugs ***Monitor closely for signs of side-effects (eg myopathy, rhabdomyolysis)
Abbreviation | Meaning |
MI | Myocardial infarction |
CABG | Coronary artery bypass graft |
CVD | Cardiovascular disease |
INR | International Normalised Ratio |
Last reviewed: 13 June 2019
Next review: 13 June 2021
Author(s): Stroke Review Group
Version: 5
Approved By: TAM subgroup of ADTC
Document Id: TAM139