1. STATINS AGAIN

9. Atorvastatin Off patent Atorvastatin 40 = £36 PA Simvastatin 40 = £14 PA Atorvastatin 80 = £72 PA Simvastatin 80 = £24 PA

10. Simvastatin 80 ? > adverse events than atorva V AE all 80mg in comparison to lower doses ?? Simva excess 1 case in 200,000 FDA in America no new simva 80 because a. Increased simva events vs other statins including pravastatin b. Trials show >AE simva 80 vs simva 20 MHRA says caution

11. What action should you take? Amlodipine/diltiazem At the next routine review or prescription (or an earlier consultation if it arises) Primary prevention: reduce to simvastatin 20mg. Secondary prevention: change to atorvastatin 40/80 to reduce cholesterol to <4mmol/l. Alternatively if clinically appropriate, switch to another anti-hypertensive and leave simvastatin unchanged.

12. Simva contraind avoid atorva: ?pravastatin Potent CYP3A4 inhibitors clarithromycin /erythromycin/telithromycin ciclosporin itraconazole /ketoconazole HIV protease inhibitors (eg nelfinavir) gemfibrozil and fibrates danazol

13. Secondary prevention 40mg simvastatin £14 PA if TC >4mmols/l 80mg simvastatin £24 PA OR Atorvastatin 40mg £36 PA Acute coronary syndrome 80mg atorvastatin £72 PA

14. AVOID EZETIMIBE Negative evidence CVD benefit Evidence cancer adverse events

15. Statins: diabetes, amlodipine

16. Diabetes and statins There is a small increased risk of T2 diabetes with statins. 9% increased risk for incident diabetes 255 patients statins 4 years = 1 case of diabetes. Meta-analysis trials Sattar Lancet 2010; 375: 735–742

17. TRIALS : High dose statins 2 per 1000 extra diabetes on high vs moderate statins 124 people on high vs moderate statin = 1 new case diabetes in 4 yrs. 6.5 fewer CVD events 1000 patient on high vs moderate statin Treat 40 people high dose prevent 1 CVD event in 4 yrs Preiss. JAMA,2011;305:2556-2564

18. Observational data Canadian observational study 17,000 people with MI: No difference in diabetes rates in older people >65 between high and moderate dose users but a 4% reduction in death or ACS in high users.

19. High dose statins Simvastatin 80 or atorvastatin 80 or 40? High vs moderate gives 16% more reduction in CVD events. Each doubling of dose confers smaller and smaller advantage. In people at HIGH risk (recent CVD) this is worth doing. Choose either simva 80 or atorva 40 as 1 st line high dose Atorva 80 after ACS

20. What to consider RISK – recent ACS highest risk Titrate to atorva 80 starting at 20 or 40 depending on age Other CVD commence simva 40 – if don’t achieve <4mmols choose atorvastatin 40 or simvastatin 80

21. Is atorva 40 preferable to simva 80? Why might atorva 40 be preferable to simva 80? It might not be – there are no head to head studies But there are more reported serious adverse events in large voluntary datasets - so even if harms v small, because of huge use of statins, using atorva 40 may be better