Mitigating Cardiovascular Risk Through Effective Lipid Management - Episode 6

Finding the Optimal Statin Dose

Eliot Brinton, MD, provides a warning concerning “maximally-tolerated statin dosing” and provides general guidance for optimal dosing.

Eliot Brinton, MD: One of the mantras that we’ve had for many years now, even decades in statin use has been maximally tolerated statin dose. That’s a great idea because we’re not sure how much of a given statin, what dose of a given statin a patient may tolerate, and it could be low, but it could be high. If a patient tolerates a high or the very highest dose of a statin, we know that that is more effective. I would like to just inject a note of caution though, in the concept of maximally tolerated, and here’s why. When all we had was statins, then we just had to do our best with statins. We had to keep trying over and over and over, but sometimes it’s better to listen to your patient and realize that they’re very concerned about statins. Maybe they themselves have tried statins, have had bad adverse effects, maybe a family member, a friend, whomever, or maybe they’re just relieved, very worried about statins as a class,because of what they’ve read on the internet. I don’t think we should take maximally tolerated so seriously. We don’t need to push every patient until they become intolerant and then say, oh, so you don’t tolerate at that dose. We’re going to back off 1 or 2 doses lower. Let’s be wise, let’s choose carefully. It’s most efficient if we can get the dose right from the very beginning and don’t have to keep adjusting up and down. If we can listen carefully to the patient, look at their LDL levels, and consider this abundant availability of statin adjuncts, then sometimes we can take the shortcut to the optimal statin dose and not keep butting up against statin intolerance in our quest for maximum tolerated. Maximum tolerated is a great concept, but don’t take it so literally that everybody must be pushed to their brink and then back off. Just say, OK, what’s a reasonable dose and realizing that you get most of the benefit with the lowest dose of any statin. Rosuvastatin 5 mg gives you almost the same LDL lowering as rosuvastatin 40 mg. It’s great to do rosuvastatin 40 mg, but rosuvastatin 5 mg along with, let’s say, ezetimibe or some other statin adjunct, maybe PCSK9 if you need a bigger gun, that’s a smarter way to do it and so don’t feel like you have to push the statins to the point that the patient doesn’t like you, and doesn’t want to come back to see you and they swear off all pharma therapy whatsoever and they’re just going to try to do it with herbs or with diet. We need the diet, we need the exercise, but we also need a flexible and adjustable adaptable use of medications. We need to change our perspective on statin use from what it used to be a decade or so ago.

This transcript has been edited for clarity.