Patient Selection
- Begin with the present criteria of the expert panel of the National Cholesterol Education Program (NCEP) for drug initiation.
- The age and low-density lipoprotein (LDL) level at which statin therapy is initiated may be influenced by the presence, magnitude, and number of other cardiovascular risk factors, as well as by the presence of cutaneous xanthomas.
- Include the preferences of patient and family in the decision making.
- In general, do not start before 10 years of age in boys and preferably after onset of menses in girls. Patients should ideally be at Tanner stage II or higher.
- Ensure that there are no contraindications for statin therapy (e.g., important hepatic disease).
Initiation and Titration
- The choice of the particular statin is a matter of preference.
- Start with the lowest dose given once daily, usually at bedtime. Measure baseline creatine kinase (CK), alanine aminotransferase (ALT), and aspartate aminotransferase (AST).
- Instruct the patient to report all potential adverse effects, especially myopathy (muscle cramps, weakness, asthenia, and more diffuse symptoms), immediately. If myopathy is present, its relation to recent physical activity should be assessed, the medication stopped, and CK assessed. The patient should be monitored for resolution of the myopathy and any associated increases in CK. Consideration can be given to restarting the medication once symptoms and laboratory abnormalities have resolved.
- Advise female patients about concerns with regard to pregnancy and the need for appropriate contraception if warranted.
- Advise about drug interactions, especially cyclosporine, fibric acid derivatives, niacin, erythromycin, azole antifungals, nefazodone, and many human immunodeficiency virus (HIV) protease inhibitors.
- After 4 weeks, measure fasting lipoprotein profile, CK, ALT and AST and compare with laboratory-specific reported normal values.
The threshold for worrisome level of CK is 10 times above the upper limit of reported normal; consider impact of physical activity
The threshold for worrisome level of ALT and AST is 3 times above the upper limit of reported normal
- Target levels for LDL: minimal, <3.35 mmol/L (130 mg/dL); ideal, <2.85 mmol/L (110 mg/dL)
- If target LDL levels are achieved and there are no laboratory abnormalities, continue therapy and recheck in 8 weeks and then 3 months.
- If laboratory abnormalities are noted or symptoms are reported, temporarily withhold the drug and repeat the blood work in approximately 2 weeks. When abnormalities return to normal, the drug may be restarted with close monitoring.
- If target LDL levels are not achieved, double the dose, and repeat the blood work in 4 weeks. Continue stepped titration up to the maximum recommended dose until target LDL levels are achieved or there is evidence of toxicity.
Monitoring
- Monitor growth (height, weight, and body mass index and relate to normal growth charts), sexual maturation, and development (Tanner staging).
- Monitor fasting lipoprotein profile, CK, ALT, and AST every 3 to 6 months.
- Monitor and encourage compliance with lipid-lowering dietary and drug therapy. Serially assess and counsel for other risk factors, such as weight gain, smoking, and inactivity.
- Counsel adolescent females about statin contraindications in pregnancy and the need for abstinence or use of appropriate contraceptive measures. Seek referral to an adolescent medicine or gynecologic specialist as appropriate
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