Statins

Key points

• Inhibit HMG-CoA reductase, the rate-limiting enzyme in hepatic cholesterol synthesis (reduces intrinsic cholesterol synthesis).
• Primary prevention: offer atorvastatin 20 mg if 10-year QRISK3 is 10% or more (consider also if under 10% with informed preference, and for age 85+). Secondary prevention (established CVD — IHD, stroke/TIA, PAD): atorvastatin 80 mg. Also offer in CKD, and in type 1 diabetes (consider if age over 40, duration over 10 years, or nephropathy).
• Lipid targets (NG238): primary prevention aim for a >40% reduction in non-HDL cholesterol at 3 months; secondary prevention aim for LDL 2.0 mmol/L or lower (or non-HDL 2.6 mmol/L or lower). If not met, check adherence and consider adding ezetimibe or injectable therapies.
• Take at night (especially simvastatin, short half-life); grapefruit juice inhibits CYP3A4. Myopathy (myalgia, myositis, rhabdomyolysis, or asymptomatic raised CK): risk with advanced age, low BMI, multisystem disease; commoner with lipophilic statins (simvastatin, atorvastatin) than hydrophilic (rosuvastatin, pravastatin, fluvastatin).
• Check CK before starting if unexplained muscle symptoms — do not start if CK is over 5x the upper limit of normal. Check LFTs at baseline, 3 and 12 months; stop if transaminases persist above 3x ULN. Avoid statins after intracerebral haemorrhage.