Atorvastatin

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Atorvastatin, sold under the brand name Lipitor among others, is a statin medication used to prevent cardiovascular disease in those at high risk and to treat abnormal lipid levels.<ref name=AHFS2018/> For the prevention of cardiovascular disease, statins are a first-line treatment in reducing cholesterol.<ref name=AHFS2018/> It is taken by mouth.<ref name=AHFS2018/>

Common side effects may include diarrhea, heartburn, nausea, muscle pain (typically mild and dose-dependent) and, less frequently, joint pain. Muscle symptoms often occur during the first year and are commonly influenced by pre-existing health issues and the nocebo effect.<ref name = "Reith_2022" /><ref>Template:Cite journal</ref> Most patients can continue therapy with dose adjustment or statin switching. Rare (<0.1%) but serious side effects may include rhabdomyolysis (severe muscle disorder), liver problems and diabetes.<ref name=":1">{{#invoke:citation/CS1|citation |CitationClass=web }}</ref> Use during pregnancy may harm the fetus.<ref name=AHFS2018/> Like all statins, atorvastatin works by inhibiting HMG-CoA reductase, an enzyme found in the liver that plays a role in producing cholesterol.<ref name=AHFS2018/>

Atorvastatin was patented in 1986, and approved for medical use in the United States in 1996.<ref name=AHFS2018>{{#invoke:citation/CS1|citation |CitationClass=web }}</ref><ref name=Fis2006>Template:Cite book</ref> It is on the World Health Organization's List of Essential Medicines.<ref name="WHO23rd">Template:Cite book</ref> It is available as a generic medication.<ref name=AHFS2018/><ref name=Hit2014/> In 2022, it was the most commonly prescribed medication in the United States, with more than 109Template:Nbspmillion prescriptions filled for over 27 million people.<ref>{{#invoke:citation/CS1|citation |CitationClass=web }}</ref><ref>{{#invoke:citation/CS1|citation |CitationClass=web }}</ref> In Australia, it was one of the top ten most prescribed medications between 2017 and 2023.<ref>{{#invoke:citation/CS1|citation |CitationClass=web }}</ref>

Medical uses

The primary uses of atorvastatin are for the treatment of dyslipidemia and for the prevention of cardiovascular disease.<ref name="AHFS"/>

Dyslipidemia

• Hypercholesterolemia<ref name="pmid12915827"/> (heterozygous familial and nonfamilial) and mixed dyslipidemia (Fredrickson types IIa and IIb) to reduce total cholesterol, LDL-C,<ref name="Nissen_2006"/> apo-B,<ref name="pmid7749881"/> triglycerides<ref name="pmid8531308"/> levels, and CRP<ref name="pmid16908955"/> as well as increase HDL levels.
• Heterozygous familial hypercholesterolemia<ref name="pmid12915827" /> in children
• Homozygous familial hypercholesterolemia<ref name="pmid12915827" /><ref name="pmid9301631"/>
• Hypertriglyceridemia (Fredrickson Type IV)
• Primary dysbetalipoproteinemia (Fredrickson Type III)
• Combined hyperlipidemia<ref name="AMH_2006"/>

Cardiovascular disease

• Primary prevention of heart attack, stroke, and need for revascularization procedures in people who have risk factors such as age, smoking, high blood pressure, low HDL-C, and a family history of early heart disease, but have not yet developed evidence of coronary artery disease.<ref name="Lipitor FDA label" />
• Secondary prevention of all-cause mortality, myocardial infarction, stroke, major coronary events, ischaemic heart disease and revascularization in people with established coronary artery disease.<ref>Template:Cite journal</ref><ref name="LaRosa_2005">Template:Cite journal</ref><ref>Template:Cite journal</ref> The effect is dose-dependent and is amplified at higher doses. Close monitoring of liver function tests is required when high doses are used.<ref name="LaRosa_2005" /><ref>Template:Cite journal</ref>
• Myocardial infarction and stroke prevention in people with type 2 diabetes<ref name="pmid15325833"/><ref name="pmid17065671"/><ref name="pmid11225965"/>

A 2014 meta-analysis showed high-dose statin therapy was significantly superior compared to moderate or low-intensity statin therapy in reducing plaque volume in people with acute coronary syndrome.<ref name="Banach_2015">Template:Cite journal</ref> The SATURN trial, which compared the effects of high-dose atorvastatin and rosuvastatin, also confirmed these findings.<ref name="Nicholls_2011">Template:Cite journal</ref>

Kidney disease

Atorvastatin may have modest renal protective effects at higher daily oral doses, as shown by a slowed progression or maintenance of the estimated glomerular filtration rate (eGFR) and a reduction in urinary protein excretion.<ref name="Su2016">Template:Cite journal</ref>

Prior to contrast medium (CM) administration, pre-treatment with atorvastatin therapy can reduce the risk of contrast-induced acute kidney injury (CI-AKI) in people with pre-existing chronic kidney disease (CKD) (eGFR < 60mL/min/1.73m2) who undergo interventional procedures such as cardiac catheterisation, coronary angiography (CAG) or percutaneous coronary intervention (PCI).<ref name="Zhou 2018">Template:Cite journal</ref><ref name="Fan 2016">Template:Cite journal</ref><ref name="Cho 2020">Template:Cite journal</ref> A meta-analysis of 21 RCTs confirmed that high dose (80 mg) atorvastatin therapy is more effective than regular dose or low dose statin therapy at preventing CI-AKI.<ref name="Zhou 2018"/> Atorvastatin therapy can also help to prevent in-hospital dialysis post CM administration, however there is no evidence that it reduces all-cause mortality associated with CI-AKI.<ref name="Zhou 2018"/><ref name="Fan 2016"/> Overall, the evidence concludes that statin therapy, irrespective of the dose, is still more effective than no treatment or placebo at reducing the risk of CI-AKI.<ref name="Zhou 2018"/><ref name="Fan 2016"/><ref name="Cho 2020"/><ref name="Zhang 2018">Template:Cite journal</ref>

Administration

Statins (predominantly simvastatin) have been evaluated in clinical trials in combination with fibrates to manage dyslipidemia in people who also have type 2 diabetes, and a high cardiovascular disease risk; however, there is limited clinical benefit noted for most cardiovascular outcomes.<ref>Template:Cite journal</ref><ref>Template:Cite journal</ref>

Statins with shorter half-lives are more effective when taken in the evening, so their peak effect occurs when the body's natural cholesterol production is at its highest. A recent meta-analysis suggested that statins with longer half-lives, including atorvastatin, may also be more effective at lowering LDL cholesterol if taken in the evening.<ref>Template:Cite journal</ref> However, the only study included in the meta-analysis of atorvastatin in people with heart disease did not specifically investigate if morning or evening dosing was more effective for reducing LDL cholesterol.<ref name="Ozaydin_2006">Template:Cite journal</ref> The trial did confirm that, irrespective of dosing time, atorvastatin is very effective at reducing total cholesterol, LDL cholesterol, and triglycerides, and increasing HDL cholesterol levels.<ref name="Ozaydin_2006" /> Hence, atorvastatin should be taken at the same time each day, at a time that is most convenient for the patient, so it does not compromise compliance.Template:Cn

Specific populations

• Geriatric: Plasma concentrations of atorvastatin in healthy elderly subjects are higher than those in young adults.<ref name="Lipitor FDA label" /> Clinical data suggests a comparable reduction in cardiovascular events among geriatric population and adults under 65 years of age. However, limited information is available on the benefits of use in patients over 75 years old who have not already had a cardiovascular event such as a heart attack.<ref>Template:Cite journal</ref><ref>Template:Cite journal</ref><ref>Template:Cite journal</ref>
• Pediatric: Pharmacokinetic data is not available for this population.<ref name="Lipitor FDA label" />
• Gender: Plasma concentrations are generally higher in women than in men, but there is no clinically significant difference in the extent of LDL reduction between men and women.<ref name="Lipitor FDA label" />
• Kidney impairment: Kidney disease has no statistically significant influence on plasma concentrations of atorvastatin and dose adjustment considerations should only be made in context of the patient's overall health.<ref>Template:Cite journal</ref>Template:Unreliable medical source<ref>Template:Cite journal</ref>Template:Unreliable medical source
• Hemodialysis: Previous studies have demonstrated a lack of clear and significant clinical benefit of statins (including atorvastatin 20 mg) in reducing composite cardiovascular and all-cause mortality in adults on hemodialysis (including those with pre-existing cardiovascular disease(s) and/or diabetes), despite a reduction in total/ LDL cholesterol levels.<ref>Template:Cite journal</ref><ref>Template:Cite journal</ref> The SHARP study suggested that the combination of a statin and ezetimibe is effective in reducing the risk of major atherosclerotic events in all CKD populations, including those on dialysis, but could not establish mortality benefit.<ref name=":0">Template:Cite journal</ref>
  • Although limited studies have identified that statins may reduce all-cause mortality and composite cardiac events in hemodialysis patients with a higher baseline LDL-C level (>3.75 mmol/L),<ref>Template:Cite journal</ref> findings are inconsistent and potentially misleading. Evidence suggests that LDL-C levels are not a reliable predictor of mortality in the hemodialysis population given the complex interplay of patient factors in ESRD.<ref name=":0" /><ref>Template:Cite journal</ref> Therefore, LDL-C levels cannot be considered a true predictor of composite risk. Additionally, the impact and relevance of hemodialysis on statin levels and efficacy were not addressed in these trials.
• Liver impairment: Increased drug levels can be seen in people with advanced cirrhosis.<ref name="Lipitor FDA label" /> Despite these concerns, a 2017 systematic review and analysis of available evidence has shown that statins, such as atorvastatin, are relatively safe to use in stable, asymptomatic cirrhosis and may even reduce the risk of liver disease progression and death.<ref>Template:Cite journal</ref>

Contraindications

• Active liver disease: cholestasis, hepatic encephalopathy, hepatitis, and jaundice
• Pregnancy: Atorvastatin is classified as a pregnancy category X medication by the U.S. Food and Drug Administration (FDA), indicating that it is contraindicated during pregnancy due to evidence of potential harm to the fetus and a lack of demonstrated benefit in this population.Template:Cn While limited human data suggest that atorvastatin is unlikely to cause major congenital anomalies, some studies have reported an association with adverse pregnancy outcomes such as low birth weight and preterm labor.Template:Cn Statins, including atorvastatin, act by inhibiting HMG-CoA reductase, a key enzyme in the biosynthesis of cholesterol. Cholesterol is essential for fetal development, particularly during early embryogenesis, as it plays a critical role in cell membrane formation and steroid hormone production.Template:Cn Due to these concerns, atorvastatin should be discontinued prior to conception or as soon as pregnancy is confirmed.Template:Cn
• Breastfeeding: Small amounts of other statin medications have been found to pass into breast milk, although atorvastatin has not been studied specifically.<ref name="Lipitor FDA label" /> Due to risk of disrupting a breastfeeding infant's metabolism of lipids, atorvastatin is not regarded as compatible with breastfeeding.<ref name="LactMed Atorvastatin">{{#invoke:citation/CS1|citation

|CitationClass=web }}</ref>

• Markedly elevated CPK levels or if a myopathy is suspected or diagnosed after dosing of atorvastatin has begun. Very rarely, atorvastatin may cause rhabdomyolysis,<ref name="pmid16765141"/> and it may be very serious leading to acute kidney injury due to myoglobinuria. When rhabdomyolysis is suspected or diagnosed, atorvastatin therapy is discontinued immediately.<ref name="pmid12036392" /> The likelihood of developing a myopathy is increased by the co-administration of cyclosporine, fibric acid derivatives, erythromycin, niacin, and azole antifungals.<ref name="Lipitor FDA label" />

Side effects

Major

• Type 2 diabetes is observed in a small number of people, and is an uncommon class effect of all statins.<ref>Template:Cite journal</ref><ref>Template:Cite journal</ref><ref>Template:Cite journal</ref> It appears it may be more likely in people who were already at a higher risk of developing diabetes before starting a statin due to multiple risk factors, for example raised fasting glucose levels.<ref>Template:Cite journal</ref> However, the benefits of statin therapy in preventing fatal and non-fatal stroke, fatal coronary heart disease, and non-fatal myocardial infarction are significant.<ref name=pmid12686036/> For most people the benefits of statin therapy far outweigh the risk of developing diabetes.<ref name=pmid21067804>Template:Cite journal</ref> A 2010 meta-analysis demonstrated that every 255 people treated with a statin for four years produced a reduction of 5.4 major coronary events and induced only one new case of diabetes.<ref name=pmid21067804/>
• In some case and clinical studies mild muscle pain or weakness have been reported (around 3%), compared to a placebo.<ref name = "Reith_2022">Template:Cite journal</ref><ref name = "pmid15755765">Template:Cite journal</ref> However, this increase was not related to statin therapy in 90% of cases in a large meta-analysis of randomized controlled trials.<ref name = "pmid15755765" /> In patients taking higher statin doses, a similarly low increase in muscle pain and weakness was present (5%) with no clear evidence of a dose-response relationship. Duration of treatment with atorvastatin is unlikely to increase the risk of muscle-related side effects as most occur within the first year of treatment, after which the risk is not increased further.<ref name = "pmid15755765" /> The known cardiovascular benefits of atorvastatin over time outweigh the low risk of muscle-related side effects.<ref>Template:Cite journal</ref><ref name = "pmid15755765" />
• Statin-induced rhabdomyolysis is rare, occurring in less than 0.1% of people who take statins.<ref name="Armitage_2010">Template:Cite journal</ref><ref name = "Amarenco_2006" /><ref name="Safitri_2021">Template:Cite journal</ref> Statin induced rhabdomyolysis, as with other statin associated muscle symptoms, occurs most commonly in the first year of treatment but can occur at any time during treatment.<ref name="Armitage_2010" /> Risk factors for statin induced rhabdomyolysis include older age, renal impairment, high dose statins and use of medications that reduce the breakdown of statins (such as CYP3A4 inhibitors) or fibrates.<ref name="Safitri_2021" />
• Persistent liver enzyme abnormalities (usually elevated in hepatic transaminases) have been documented.<ref>Template:Cite journal</ref> Elevations threefold greater than normal were recorded in 0.5% of people treated with atorvastatin 10 mg-80 mg rather than placebo.<ref>Template:Cite journal</ref> Usage instructions in package inserts for this statin define the requirement that hepatic function be assessed with laboratory tests before beginning atorvastatin treatment and repeated periodically as clinically indicated - usually a clinicians' judgement. Package inserts for this statin recommend actions should liver abnormalities be detected. Ultimately, this is the judgment of the prescribing physician.<ref name="Lipitor FDA label" />

Common

The following have been shown to occur in 1–10% of people taking atorvastatin in clinical trials:

• Joint pain<ref name="Lipitor FDA label" />
• Loose stools<ref name="Lipitor FDA label" />
• Indigestion<ref name="Lipitor FDA label" />
• Muscle pain<ref name="Lipitor FDA label" />
• Nausea<ref name="Lipitor FDA label" />

Other

• muscle pain, tenderness, or weakness
• lack of energy or extreme tiredness and weakness
• fever
• chest pain
• unusual bleeding or bruising
• loss of appetite
• pain in the upper right part of the stomach
• flu-like symptoms
• dark colored urine
• yellowing of the skin or eyes
• rash
• hives
• itching
• difficulty breathing or swallowing
• swelling of the face, throat, tongue, lips, eyes, hands, feet, ankles, or lower legs
• hoarseness<ref>{{#invoke:citation/CS1|citation

|CitationClass=web }}</ref>

Increased fasting blood glucose

Atorvastatin has been associated with a small increase in fasting blood glucose levels over a 2-year period, particularly in patients with Type 2 Diabetes, however evidence is conflicting and clinical significance of this increase has not been determined.<ref>Template:Cite journal</ref><ref>Template:Cite journal</ref><ref>Template:Cite journal</ref> Regular blood glucose monitoring may be advised in patients with Type 2 Diabetes.Template:Citation needed

Cognitive

While rare cases of reversible memory loss and confusion have been reported with statin use, including atorvastatin, multiple systematic review and meta-analyses have found no consistent evidence of a causal relationship. Current evidence, including large-scale observational studies and randomised trials, supports the continued use of atorvastatin, as its cardiovascular and cerebrovascular benefits outweigh the unproven risks related to cognition.<ref>Swiger KJ, Manalac RJ, Blumenthal RS, Blaha MJ, Martin SS. Statins and cognition: a systematic review and meta-analysis of short- and long-term cognitive effects. Mayo Clin Proc. 2013;88(11):1213–1221. doi:10.1016/j.mayocp.2013.07.013.</ref><ref>Template:Cite journal</ref><ref>Template:Cite journal</ref>

Pancreatitis

A 2012 meta-analysis found that statin therapy might reduce the risk of pancreatitis in people with normal or mildly elevated blood triglyceride levels.<ref name="Preiss_2012">Template:Cite journal</ref>

Erectile dysfunction

Statins seem to have a positive effect on erectile dysfunction.<ref>Template:Cite journal</ref><ref>Template:Cite journal</ref>

Interactions

Co-administration of atorvastatin with one of CYP3A4 inhibitors such as itraconazole,<ref name="pmid11061579"/> telithromycin, and voriconazole, may increase serum concentrations of atorvastatin, which may lead to adverse reactions. This is less likely to happen with other CYP3A4 inhibitors such as diltiazem, erythromycin, fluconazole, ketoconazole, clarithromycin, cyclosporine, protease inhibitors, or verapamil,<ref name="pmid17178259"/> and only rarely with other CYP3A4 inhibitors, such as amiodarone and aprepitant.<ref name="pmid12036392" /> Often, bosentan, fosphenytoin, and phenytoin, which are CYP3A4 inducers, can decrease the plasma concentrations of atorvastatin. Only rarely, though, barbiturates, carbamazepine, efavirenz, nevirapine, oxcarbazepine, rifampin, and rifamycin,<ref name="pmid16084850"/> which are also CYP3A4 inducers, can decrease the plasma concentrations of atorvastatin. Oral contraceptives increased AUC values for norethisterone and ethinylestradiol; these increases should be considered when selecting an oral contraceptive for a woman taking atorvastatin.<ref name="Lipitor FDA label" />

Antacids can rarely decrease the plasma concentrations of statin medications, but do not affect the LDL-C-lowering efficacy.<ref name="pmid15901588">Template:Cite journal</ref>

Niacin also is proved to increase the risk of myopathy or rhabdomyolysis.<ref name="pmid12036392" />

Some statins may also alter the concentrations of other medications, such as warfarin or digoxin, leading to alterations in effect or a requirement for clinical monitoring.<ref name="pmid12036392" /> The increase in digoxin levels due to atorvastatin is a 1.2 fold elevation in the area under the curve (AUC), resulting in a minor drug-drug interaction. The American Heart Association states that the combination of digoxin and atorvastatin is reasonable.<ref name="Wiggins et al">Template:Cite journal</ref> In contrast to some other statins, atorvastatin does not interact with warfarin concentrations in a clinically meaningful way (similar to pitavastatin).<ref name="Wiggins et al" />

Vitamin D supplementation lowers atorvastatin and active metabolite concentrations, yet synergistically reduces LDL and total cholesterol concentrations.<ref name="pmid18754003"/>

Grapefruit juice components are known inhibitors of intestinal CYP3A4. Drinking grapefruit juice with atorvastatin may cause an increase in C_max and area under the curve (AUC). This finding initially gave rise to concerns of toxicity, and in 2000, it was recommended that people taking atorvastatin should not consume grapefruit juice "in an unsupervised manner."<ref name="Kane2000">Template:Cite journal</ref> Small studies (using mostly young participants) examining the effects of grapefruit juice consumption on mainly lower doses of atorvastatin have shown that grapefruit juice increases blood levels of atorvastatin, which could increase the risk of adverse effects.<ref name="Ando_2005">Template:Cite journal</ref><ref name="Reddy_2011">Template:Cite journal</ref><ref name="Lilja_1999">Template:Cite journal</ref> No studies assessing the impact of grapefruit juice consumption have included participants taking the highest dose of atorvastatin (80 mg daily),<ref name="Ando_2005" /><ref name="Reddy_2011" /><ref name="Lilja_1999" /> which is often prescribed for people with a history of cardiovascular disease (such as heart attack or ischaemic stroke) or in people at high risk of cardiovascular disease. People taking atorvastatin should consult with their doctor or pharmacist before consuming grapefruit juice, as the effects of grapefruit juice consumption on atorvastatin will vary according to factors such as the amount and frequency of juice consumption in addition to differences in juice components, quality and method of juice preparation between different batches or brands.<ref>Template:Cite journal</ref>

A few cases of myopathy have been reported when atorvastatin is given with colchicine.<ref name="Lipitor FDA label" />

Mechanism of action

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As with other statins, atorvastatin is a competitive inhibitor of HMG-CoA reductase. Unlike most others, however, it is a completely synthetic compound. HMG-CoA reductase catalyzes the reduction of 3-hydroxy-3-methylglutaryl-coenzyme A (HMG-CoA) to mevalonate, which is the rate-limiting step in hepatic cholesterol biosynthesis. Inhibition of the enzyme decreases de novo cholesterol synthesis, increasing expression of low-density lipoprotein receptors (LDL receptors) on hepatocytes. This increases LDL uptake by the hepatocytes, decreasing the amount of LDL-cholesterol in the blood. Like other statins, atorvastatin also reduces blood levels of triglycerides and slightly increases levels of HDL-cholesterol.

In people with acute coronary syndrome, high-dose atorvastatin treatment may play a plaque-stabilizing role.<ref name="Liberale et al 2020">Template:Cite journal</ref><ref name="Rosa 501–15">Template:Cite journal</ref> At high doses, statins have anti-inflammatory effects, incite reduction of the necrotic plaque core, and improve endothelial function, leading to plaque stabilization and, sometimes, plaque regression.<ref name="Rosa 501–15"/><ref name="Liberale et al 2020"/> There is a similar thought process with using high-dose atorvastatin as a form of secondary thrombotic stroke recurrence prevention.<ref name="Furie 1994–5">Template:Cite journal</ref><ref name = "Amarenco_2006">Template:Cite journal</ref><ref>Template:Cite journal</ref>

Pharmacodynamics

The liver is the primary site of action of atorvastatin, as this is the principal site of both cholesterol synthesis and LDL clearance. It is the dosage of atorvastatin, rather than systemic medication concentration, which correlates with extent of LDL-C reduction.<ref name="Lipitor FDA label" /> In a Cochrane systematic review the dose-related magnitude of atorvastatin on blood lipids was determined. Over the dose range of 10 to 80 mg/day total cholesterol was reduced by 27.0% to 37.9%, LDL cholesterol by 37.1% to 51.7% and triglycerides by 18.0% to 28.3%.<ref>Template:Cite journal</ref>

Pharmacokinetics

Absorption

Atorvastatin undergoes rapid absorption when taken orally, with an approximate time to maximum plasma concentration (T_max) of 1–2 h. The absolute bioavailability of the medication is about 14%, but the systemic availability for HMG-CoA reductase activity is approximately 30%. Atorvastatin undergoes high intestinal clearance and first-pass metabolism, which is the main cause for the low systemic availability. Administration of atorvastatin with food produces a 25% reduction in C_max (rate of absorption) and a 9% reduction in AUC (extent of absorption), although food does not affect the plasma LDL-C-lowering efficacy of atorvastatin. Evening dose administration is known to reduce the C_max and AUC by 30% each. However, time of administration does not affect the plasma LDL-C-lowering efficacy of atorvastatin.

Distribution

The mean volume of distribution of atorvastatin is approximately 381 L. It is highly protein bound (≥98%), and studies have shown it is likely secreted in human breastmilk.

Metabolism

Atorvastatin metabolism is primarily through cytochrome P450 3A4 hydroxylation to form active ortho- and parahydroxylated metabolites, as well as various beta-oxidation metabolites. The ortho- and parahydroxylated metabolites are responsible for 70% of systemic HMG-CoA reductase activity. The ortho-hydroxy metabolite undergoes further metabolism via glucuronidation. As a substrate for the CYP3A4 isozyme, it has shown susceptibility to inhibitors and inducers of CYP3A4 to produce increased or decreased plasma concentrations, respectively. This interaction was tested in vitro with concurrent administration of erythromycin, a known CYP3A4 isozyme inhibitor, which resulted in increased plasma concentrations of atorvastatin. It is also an inhibitor of cytochrome 3A4.

Excretion

Atorvastatin is primarily eliminated via hepatic biliary excretion, with less than 2% recovered in the urine. Bile elimination follows hepatic and/or extrahepatic metabolism. There does not appear to be any entero-hepatic recirculation. Atorvastatin has an approximate elimination half-life of 14 hours. Noteworthy, the HMG-CoA reductase inhibitory activity appears to have a half-life of 20–30 hours, which is thought to be due to the active metabolites. Atorvastatin is also a substrate of the intestinal P-glycoprotein efflux transporter, which pumps the medication back into the intestinal lumen during medication absorption.<ref name="pmid12036392"/>

In hepatic insufficiency, plasma concentrations of atorvastatin are significantly affected by concurrent liver disease. People with Child-Pugh Stage A liver disease show a four-fold increase in both C_max and AUC. People with Child Pugh stage B liver disease show a 16-fold increase in C_max and an 11-fold increase in AUC.

Geriatric people (>65Template:Nbspyears old) exhibit altered pharmacokinetics of atorvastatin compared to young adults, with mean AUC and C_max values that are 40% and 30% higher, respectively. Additionally, healthy elderly people show a greater pharmacodynamic response to atorvastatin at any dose; therefore, this population may have lower effective doses.<ref name="Lipitor FDA label" />

Pharmacogenetics

Several genetic polymorphisms may be linked to an increase in statin-related side effects with single nucleotide polymorphisms (SNPs) in the SLCO1B1 gene showing a 45 fold higher incidence of statin related myopathy<ref>Template:Cite journal</ref> than people without the polymorphism.

There are several studies showing genetic variants and variable response to atorvastatin.<ref name="pmid22368281"/><ref name="Thompson JF">Template:Cite journal</ref> The polymorphisms that showed genome wide significance in Caucasian population were the SNPs in the apoE region; rs445925,<ref name="pmid22368281"/> rs7412,<ref name="pmid22368281"/><ref name="Thompson JF" /> rs429358<ref name="Thompson JF" /> and rs4420638<ref name="pmid22368281"/> which showed variable LDL-c response depending on the genotype when treated with atorvastatin.<ref name="pmid22368281"/><ref name="Thompson JF" /> Another genetic variant that showed genome wide significance in Caucasians was the SNP rs10455872 in the LPA gene that lead to higher Lp(a) levels which cause an apparent lower LDL-c response to atorvastatin.<ref name="pmid22368281"/> These studies were in Caucasian population, more research with a large cohort need to be conducted in different ethnicities to identify more polymorphisms that can affect atorvastatin pharmacokinetics and treatment response.<ref name="pmid22368281"/>

Chemical synthesis

File:Atorvastatin synthesis stereocenter commercial.png

Atorvastatin synthesis in commercial production (process) chemistry. The key step of establishing this medication's stereocenters, through initial use of an inexpensive natural product (chiral pool approach).

File:Atorvastatin synthesis stereocenter firstdiscovery.png

Atorvastatin synthesis during discovery chemistry. The key step of establishing stereocenters, using of a chiral ester auxiliary approach.

The first synthesis of atorvastatin at Parke-Davis that occurred during drug discovery was racemic followed by chiral chromatographic separation of the enantiomers. An early enantioselective route to atorvastatin made use of an ester chiral auxiliary to set the stereochemistry of the first of the two alcohol functional groups via a diastereoselective aldol reaction.<ref name=Roth_2002/><ref>Template:Cite journal</ref>

Once the compound entered pre-clinical development, process chemistry developed a cost-effective and scalable synthesis.<ref name="Roth_2002"/> In atorvastatin's case, a key element of the overall synthesis was ensuring stereochemical purity in the final drug substance, and hence establishing the first stereocenter became a key aspect of the overall design. The final commercial production of atorvastatin relied on a chiral pool approach, where the stereochemistry of the first alcohol functional group was carried into the synthesis—through the choice of isoascorbic acid, an inexpensive and easily sourced plant-derived natural product.<ref name=Roth_2002/><ref>Template:Cite book</ref>

The atorvastatin calcium complex involves two atorvastatin ions, one calcium ion and three water molecules.<ref>{{#invoke:citation/CS1|citation |CitationClass=web }}</ref>Template:Better source needed

History

Bruce Roth, who was hired by Warner-Lambert as a chemist in 1982, had synthesized an "experimental compound" codenamed CI 981 – later called atorvastatin.<ref name="Fortune_2003" /><ref name="FT_nov_2009">Template:Cite news</ref> It was first made in August 1985.<ref name="Roth_2002">Template:Cite book</ref><ref name="Fortune_2003">{{#invoke:citation/CS1|citation |CitationClass=web }}</ref><ref name = "US4681893">Template:Cite patent</ref><ref name="History_Parke-Davis">Template:Cite journal</ref><ref name="NYT_2000">Template:Cite news</ref> Warner-Lambert management was concerned that atorvastatin was a me-too version of rival Merck & Co.'s orphan drug lovastatin (brand name Mevacor). Mevacor, which was first marketed in 1987, was the industry's first statin and Merck's synthetic version – simvastatin – was in the advanced stages of development.<ref name="FT_nov_2009" /> Nevertheless, Bruce Roth and his bosses, Roger Newton and Ronald Cresswell, in 1985, convinced company executives to move the compound into expensive clinical trials. Early results comparing atorvastatin to simvastatin demonstrated that atorvastatin appeared more potent and with fewer side effects.<ref name="FT_nov_2009" />

In 1994, the findings of a Merck-funded study were published in The Lancet concluding the efficacy of statins in lowering cholesterol proving for the first time not only that a "statin reduced 'bad' LDL cholesterol but also that it led to a sharp drop in fatal heart attacks among people with heart disease."<ref name="FT_nov_2009" /><ref name="Lancet_1994_scandinavia">Template:Cite journal</ref>

In 1996, Warner-Lambert entered into a co-marketing agreement with Pfizer to sell Lipitor, and in 2000, Pfizer acquired Warner-Lambert for $90.2Template:Nbspbillion.<ref name="WSJ_blockbuster_2000">Template:Cite news</ref><ref name="Roth_2002" /><ref name = "US4681893" /><ref name="History_Parke-Davis" /> Lipitor was on the market by 1996.<ref name="NYT_2000" /><ref name="FDA_Lipitor">{{#invoke:citation/CS1|citation |CitationClass=web }}</ref> By 2003, Lipitor had become the best selling pharmaceutical in the United States.<ref name="Fortune_2003" /> From 1996 to 2012, under the trade name Lipitor, atorvastatin became the world's best-selling medication of all time, with more than $125Template:Nbspbillion in sales over approximately 14.5Template:Nbspyears.<ref name="Crain_2011">{{#invoke:citation/CS1|citation |CitationClass=web }}</ref> and $13 billion a year at its peak,<ref name="Ann Arbour Observer">{{#invoke:citation/CS1|citation |CitationClass=web }}</ref> Lipitor alone "provided up to a quarter of Pfizer Inc.'s annual revenue for years."<ref name="Crain_2011"/>

Pfizer's patent on atorvastatin expired in November 2011.<ref name="CNN Wire Staff">Template:Cite news</ref>

Society and culture

Economics

Atorvastatin is relatively inexpensive.<ref name=Hit2014>Template:Cite book</ref> Under provisions of the Patient Protection and Affordable Care Act (PPACA) in the United States, health plans may cover the costs of atorvastatin 10 mg and 20 mg for adults aged 40–75 years based on United States Preventive Services Task Force (USPSTF) recommendations.<ref>{{#invoke:citation/CS1|citation |CitationClass=web }}</ref><ref>Template:Cite journal</ref><ref>{{#invoke:citation/CS1|citation |CitationClass=web }}</ref> Some plans only cover other statins.<ref>{{#invoke:citation/CS1|citation |CitationClass=web }}</ref><ref>{{#invoke:citation/CS1|citation |CitationClass=web }}</ref>

Brand names

File:Atorvastatin40mg.jpg

Pack and tablet of atorvastatin (Lipitor) 40mg

Atorvastatin calcium tablets are sold under the brand name Lipitor.<ref name=MPR>{{#invoke:citation/CS1|citation |CitationClass=web }}</ref> Pfizer also packages the medication in combination with other medications, such as atorvastatin/amlodipine.<ref name=NewsMed>{{#invoke:citation/CS1|citation |CitationClass=web }}</ref>

Pfizer's U.S. patent on Lipitor expired on 30 November 2011.<ref>{{#invoke:citation/CS1|citation |CitationClass=web }}</ref> Initially, generic atorvastatin was manufactured only by Watson Pharmaceuticals and India's Ranbaxy Laboratories. Prices for the generic version did not drop to the level of other generics—$10 or less for a month's supply—until other manufacturers began to supply the medication in May 2012.<ref>{{#invoke:citation/CS1|citation |CitationClass=web }}</ref>

In other countries, atorvastatin calcium is made in tablet form by generic medication makers under various brand names including Atoris, Atorlip, Atorva, Atorvastatin Teva, Atorvastatina Parke-Davis, Avas, Cardyl, Liprimar, Litorva, Mactor, Orbeos, Prevencor, Sortis, Stator, Tahor, Torid, Torvacard, Torvast, Totalip, Tulip, Xarator, and Zarator.<ref name="Drugs.com 2020">{{#invoke:citation/CS1|citation |CitationClass=web }}</ref><ref name="Lipitor referral">{{#invoke:citation/CS1|citation |CitationClass=web }}</ref> Pfizer also makes its own generic version under the name Zarator.<ref>Template:Cite news</ref>

In the US, Lipitor is marketed by Viatris after Upjohn was spun off from Pfizer.<ref>{{#invoke:citation/CS1|citation |CitationClass=web }}</ref><ref>{{#invoke:citation/CS1|citation |CitationClass=web }}</ref>

Medication recalls

On 9 November 2012, Indian drugmaker Ranbaxy Laboratories Ltd. voluntarily recalled 10-, 20- and 40-mg doses of its generic version of atorvastatin in the United States.<ref name=fdarecall /><ref>Template:Cite news</ref><ref>Template:Cite news</ref> The lots of atorvastatin, packaged in bottles of 90 and 500 tablets, were recalled due to possible contamination with very small glass particles similar to the size of a grain of sand (less than 1Template:Nbspmm in size). The FDA received no reports of injury from the contamination.<ref name=fdarecall >{{#invoke:citation/CS1|citation |CitationClass=web }}</ref> Ranbaxy also issued recalls of bottles of 10-milligram tablets in August 2012 and March 2014, due to concerns that the bottles might contain larger, 20-milligram tablets and thus cause potential dosing errors.<ref>Template:Cite news</ref><ref name="Washington Post 2014">Template:Cite news</ref>

Further reading

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