Atorvastatin is FDA approved, in combination with dietary modifications, to prevent cardiovascular events in patients with cardiac risk factors and for patients with abnormal lipid profiles.

Primary prevention: 

For patients without coronary heart disease, but with multiple risk factors, the FDA has approved atorvastatin to reduce the risk of myocardial infarction, stroke, revascularization procedures, and angina.

For patients diagnosed with type 2 diabetes mellitus without coronary heart disease, but with multiple risk factors, atorvastatin has FDA approval to reduce the risk of myocardial infarction and stroke.  

Secondary prevention: 

For patients with coronary heart disease, atorvastatin has approval as a therapy to reduce the risk of non-fatal myocardial infarction, fatal and non-fatal stroke, revascularization procedures, hospitalizations for congestive heart failure, and angina. 

Atorvastatin has FDA approval for the treatment of the following dyslipidemias: 

• Adults with primary hyperlipidemia (heterozygous familial and nonfamilial) and mixed dyslipidemia
• Hypertriglyceridemia
• Primary dysbetalipoproteinemia
• Homozygous familial hypercholesterolemia
• Pediatric patients with heterozygous familial hypercholesterolemia (after failing dietary modifications)

Atorvastatin has not been studied in Fredrickson Type I and V dyslipidemias.

Atorvastatin competitively inhibits 3-hydroxy-3-methylglutaryl-coenzyme A (HMG-CoA) reductase. By preventing the conversion of HMG-CoA to mevalonate, statin medications decrease cholesterol production in the liver. Atorvastatin also increases the number of LDL receptors on the surface of hepatic cells. 

In patients with homozygous or heterozygous familial hypercholesterolemia, mixed dyslipidemia, isolated hypertriglyceridemia, or nonfamilial hypercholesterolemia, atorvastatin has been shown to reduce total cholesterol (TC), low-density lipoprotein cholesterol (LDL-C), apolipoprotein B (apo B), very-low-density lipoprotein (VLDL-C) and triglycerides (TGs) while increasing high-density lipoprotein cholesterol (HDL-C). 

In patients with dysbetalipoproteinemia, atorvastatin has been shown to decrease intermediate-density lipoprotein (IDL-C).   

Pharmacokinetics: 

Absorption: 

Atorvastatin is rapidly absorbed after oral administration with a peak plasma concentration at 1 to 2 hours. The bioavailability is low at 14% due to extensive first-pass metabolism.

Distribution:

Atorvastatin is highly plasma protein bound (over 98%) and has a volume of distribution of about 380 liters. 

Metabolism:

Atorvastatin is metabolized by cytochrome P450 3A4 (CYP3A4) to active ortho- and para-hydroxylated metabolites. 

Excretion:

Atorvastatin and its metabolites get eliminated in bile. Atorvastatin is not known to go through enterohepatic recirculation. The half-life of atorvastatin is about 14 hours, while its active metabolites have a half-life of about 20 to 30 hours. 

Atorvastatin is available as atorvastatin calcium tablets in strengths of 10, 20, 40, and 80 mg.  

This medication can be administered with or without food and should be taken at the same time every day. 

Adult dosing: 

Dosing of atorvastatin can have its basis in LDL-C lowering ability (intensity), or doses are titratable to specific lipid goals. 

The American College of Cardiology/American Heart Association Guidelines recommends either moderate intensity (atorvastatin 10 to 20 mg) or high intensity (atorvastatin 40 to 80 mg) therapy depending on which statin benefit group a patient belongs. Moderate intensity statins should lower LDL-C by about 30 to 50%, while high-intensity statins should lower LDL-C by over 50 %.[1]

Both the National Lipid Association and the American Association of Clinical Endocrinologists recommend utilizing statin therapy to reach specific lipid goals based on atherosclerotic cardiovascular disease risk.[2][3]

Pediatrics: 

Doses above 20 mg do not have study data for pediatric patients with heterozygous familial hypercholesterolemia. Doses up to 80 mg have been used in a limited number of pediatric patients with familial hypercholesterolemia. Studies have not evaluated atorvastatin use in pre-pubescent patients or those under ten years old. 

Geriatrics: 

Patients over 65 years old may have higher plasma concentrations of atorvastatin when compared to young adults. Older patients may be at increased risk of statin-induced myopathies. 

Renal impairment: 

Atorvastatin and its metabolites do not undergo renal elimination, so no dose adjustments are required with reduced renal function. Hemodialysis will not likely remove atorvastatin due to plasma protein binding. 

Hepatic impairment: 

Increased plasma concentrations of atorvastatin have occurred in patients with chronic alcoholic liver disease. Drug exposure is four times higher in patients with Child-Pugh Class A and 11x higher in patients with Child-Pugh Class B. Atorvastatin is contraindicated in patients with active liver disease. 

Drug Interactions: 

The use of atorvastatin with potent CYP3A4 inhibitors can lead to increased plasma concentrations, which may enhance adverse events, including myopathies. OATP1B1 inhibitors can increase the bioavailability of atorvastatin.

CYP3A4 inducers may cause decreased plasma concentrations of atorvastatin. 

Patients taking digoxin should undergo monitoring when starting atorvastatin as plasma concentrations of digoxin may increase.

Atorvastatin may also increase drug exposure of norethindrone and ethinyl estradiol.

Common adverse effects for patients taking atorvastatin include arthralgia, dyspepsia, diarrhea, nausea, nasopharyngitis, insomnia, urinary tract infection, and pain in extremities.

Myopathies have occurred in patients taking atorvastatin, including muscle aches, muscle tenderness, or muscle weakness, with elevated creatine phosphokinase greater than ten times the upper limit of normal. Rhabdomyolysis has been reported in patients using atorvastatin. Patients with impaired renal function may be at increased risk of developing rhabdomyolysis. Using atorvastatin in combination with other medications that increase atorvastatin plasma concentrations increases the risk for myopathies and rhabdomyolysis. Management of statin-induced myopathies includes temporarily holding therapy, switching to an alternative statin, or reducing the dose. 

Atorvastatin can cause liver function test abnormalities. If patients develop serum transaminases over three times the upper limit of normal, plasma concentrations require more frequent monitoring until normalized or atorvastatin should be dose reduced or discontinued. 

Atorvastatin contraindications include patients with hypersensitivity to any of its components.

While atorvastatin contraindications also include patients with active liver disease, the benefits of lipid-lowering therapy in chronic liver diseases, such as non-alcoholic fatty liver disease and hepatitis, likely outweigh the possible risks.[4]

Atorvastatin is contraindicated during pregnancy or in female patients who may become pregnant. All female patients of childbearing age should receive counseling of the potential risks to a fetus should they become pregnant while on atorvastatin. The patient should discontinue this medication immediately if they become pregnant. 

Female patients should also avoid atorvastatin if they are nursing. If a patient requires atorvastatin therapy, they should receive direction to discontinue breastfeeding.