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LIPITOR (atorvastatin calcium)

Health Professional Information

SUMMARY PRODUCT INFORMATION

Route of Administration

Dosage Form / Strength

Nonmedicinal Ingredients

oral

Tablets: 10 mg, 20 mg, 40 mg and 80 mg atorvastatinCalcium carbonate, candelilla wax (10, 20 and 40 mg), croscarmellose sodium, hydroxypropyl cellulose, hydroxypropyl methylcellulose, lactose monohydrate, magnesium stearate, microcrystalline cellulose, polyethylene glycol, polysorbate 80, simethicone emulsion, talc, and titanium dioxide.

Indications And Clinical Use

LIPITOR (atorvastatin calcium) is indicated as an adjunct to lifestyle changes, including diet, for the reduction of elevated total cholesterol (total-C), LDL-C, triglycerides (TG), apolipoprotein B (apo B), the Total-C/HDL-C ratio and for increasing HDL-C in hyperlipidemic and dyslipidemic conditions, including:

  • Primary hypercholesterolemia (Type IIa);
  • Combined (mixed) hyperlipidemia (Type IIb), including familial combined hyperlipidemia, regardless of whether cholesterol or triglycerides are the lipid abnormality of concern;
  • Dysbetalipoproteinemia (Type III);
  • Hypertriglyceridemia (Type IV);
  • Familial hypercholesterolemia (homozygous and heterozygous). For homozygous familial hypercholesterolemia, LIPITOR should be used as an adjunct to treatments such as LDL apheresis, or as monotherapy if such treatments are not available.

 

  • An adjunct to diet to reduce total-C, LDL-C, and apo B levels in boys and postmenarchal girls, 10 to 17 years of age with heterozygous familial hypercholesterolemia, if after an adequate trial of diet therapy the following findings are still present:
    a. LDL-C remains >4.9 mmol/L (190 mg/dL) or
    b. LDL-C remains >4.1 mmol/L (160 mg/dL) and:
    - there is a positive family history of premature cardiovascular disease or
    - two or more other CVD risk factors are present in the pediatric patient

Prior to initiating therapy with LIPITOR, secondary causes should be excluded for elevations in plasma lipid levels (e.g. poorly controlled diabetes mellitus, hypothyroidism, nephrotic syndrome, dysproteinemias, obstructive liver disease, and alcoholism), and a lipid profile performed to measure total cholesterol, LDL-C, HDL-C, and TG. For patients with TG <4.52 mmol/L (<400 mg/dL), LDL-C can be estimated using the following equation:

LDL-C (mmol/L) = total-C - [(0.37 x (TG) + HDL-C)]
LDL-C (mg/dL) = total-C - [(0.2 x (TG) + HDL-C)]

For patients with TG levels >4.52 mmol/L (>400 mg/dL), this equation is less accurate and LDL-C concentrations should be measured directly or by ultracentrifugation.

Patients with high or very high triglyceride levels, i.e. > 2.2 mmol/L (200 mg/dL) or > 5.6 mmol/L (500 mg/dL), respectively, may require triglyceride-lowering therapy (fenofibrate, bezafibrate or nicotinic acid) alone or in combination with LIPITOR.

In general, combination therapy with fibrates must be undertaken cautiously and only after risk-benefit analysis (see WARNINGS AND PRECAUTIONS, Muscle Effects, Pharmacokinetic Interactions and DRUG INTERACTIONS).

Elevated serum triglycerides are most often observed in patients with the metabolic syndrome (abdominal obesity, atherogenic dyslipidemia {elevated triglycerides, small dense LDL particles and low HDL-cholesterol}, insulin resistance with or without glucose intolerance, raised blood pressure and prothrombic and proinflammatory states).

When drugs are prescribed attention to therapeutic lifestyle changes (reduced intake of saturated fats and cholesterol, weight reduction, increased physical activity, ingestion of soluble fibers) should always be maintained and reinforced.

Prevention of Cardiovascular Disease
LIPITOR is indicated to reduce the risk of myocardial infarction in adult hypertensive patients without clinically evident coronary heart disease, but with at least three additional risk factors for coronary heart disease such as age ≥55 years, male sex, smoking, type 2 diabetes, left ventricular hypertrophy, other specified abnormalities on ECG, microalbuminuria or proteinuria, ratio of plasma total cholesterol to HDL-cholesterol ≥6, or premature family history of coronary heart disease.

LIPITOR is also indicated to reduce the risk of myocardial infarction and stroke in adult patients with type 2 diabetes mellitus and hypertension without clinically evident coronary heart disease, but with other risk factors such as age ≥55 years, retinopathy, albuminuria or smoking.

LIPITOR is indicated to reduce the risk of myocardial infarction in patients with clinically evident coronary heart disease.

Contraindications

Hypersensitivity to any component of this medication (for a complete listing of the components, see DOSAGE FORMS, COMPOSITION AND PACKAGING).

Active liver disease or unexplained persistent elevations of serum transaminases exceeding 3 times the upper limit of normal (see WARNINGS AND PRECAUTIONS).

Pregnancy and nursing women: Cholesterol and other products of cholesterol biosynthesis are essential components for fetal development (including synthesis of steroids and cell membranes). LIPITOR should be administered to women of childbearing age only when such patients are highly unlikely to conceive and have been informed of the possible harm. (If the patient becomes pregnant while taking LIPITOR, the drug should be discontinued immediately and the patient apprised of the potential harm to the fetus. Atherosclerosis being a chronic process, discontinuation of lipid metabolism regulating drugs during pregnancy should have little impact on the outcome of long-term therapy of primary hypercholesterolemia (see PRECAUTIONS – Use in Pregnancy, Use in Nursing Mothers).

Warnings And Precautions

General
Before instituting therapy with LIPITOR (atorvastatin calcium), an attempt should be made to control elevated serum lipoprotein levels with appropriate diet, exercise, and weight reduction in overweight patients, and to treat other underlying medical problems (see INDICATIONS AND CLINICAL USE). Patients should be advised to inform subsequent physicians of the prior use of LIPITOR or any other lipid-lowering agents.

Pharmacokinetic Interactions
The use of HMG- CoA reductase inhibitors has been associated with severe myopathy, including rhabdomyolysis, which may be more frequent when they are co-administered with drugs that inhibit the cytochrome P-450 enzyme system. Atorvastatin is metabolized by cytochrome P-450 isoform 3A4 and as such may interact with agents that inhibit this enzyme (see WARNINGS AND PRECAUTIONS, Muscle effects, and DRUG INTERACTIONS).

Muscle Effects
Effects on skeletal muscle such as myalgia, myositis, myopathy and rarely, rhabdomyolysis have been reported in patients treated with LIPITOR.

Rare cases of rhabdomyolysis, with acute renal failure secondary to myoglobinuria, have been reported with LIPITOR and with other HMG-CoA reductase inhibitors.

Myopathy, defined as muscle pain or muscle weakness in conjunction with increases in creatine kinase (CK) values to greater than ten times the upper limit of normal, should be considered in any patient with diffuse myalgia, muscle tenderness or weakness, and/or marked elevation of CK. Patients should be advised to report promptly any unexplained muscle pain, tenderness or weakness, particularly if accompanied by malaise or fever. Patients who develop any signs or symptoms suggestive of myopathy should have their CK levels measured. LIPITOR therapy should be discontinued if markedly elevated CK levels are measured or myopathy is diagnosed or suspected.

Pre-disposing Factors for Myopathy/Rhabdomyolysis: LIPITOR, as with other HMG-CoA reductase inhibitors, should be prescribed with caution in patients with pre-disposing factors for myopathy/rhabdomyolysis. Such factors include:

  • Personal or family history of hereditary muscular disorders
  • Previous history of muscle toxicity with another HMG-CoA reductase inhibitor
  • Concomitant use of a fibrate, or niacin
  • Hypothyroidism
  • Alcohol abuse
  • Excessive physical exercise
  • Age > 65 years
  • Renal impairment
  • Hepatic impairment
  • Diabetes with hepatic fatty change
  • Surgery and trauma
  • Frailty
  • Situations where an increase in plasma levels of active ingredient may occur

The risk of myopathy and rhabdomyolysis during treatment with HMG-CoA reductase inhibitors is increased with concurrent administration of drugs that interfere with metabolism of atorvastatin via CYP 3A4, such as cyclosporin, fibric acid derivatives, erythromycin, clarithromycin, niacin (nicotinic acid), azole antifungals, nefazodone, colchicine, hepatitis C protease inhibitors telaprevir, boceprevir , HIV protease inhibitor fosamprenavir and each of the following HIV protease inhibitor combinations: saquinavir plus ritonavir, lopinavir plus ritonavir, tipranavir plus ritonavir, darunavir plus ritonavir and fosamprenavir plus ritonavir. The combined therapy with LIPITOR and cyclosporine, gemfibrozil, telaprevir or tipranavir plus ritonavir should be avoided. LIPITOR dose restriction or caution is recommended for combined therapy with other CYP 3A4 inhibitors (see Pharmacokinetic Interactions; DRUG INTERACTIONS, Drug-Drug Interactions; DETAILED PHARMACOLOGY, Human Pharmacokinetics).

The concurrent use of atorvastatin and fusidic acid should be avoided, therefore, temporary suspension of atorvastatin during fusidic acid therapy is advised (see DRUG INTERACTIONS, Drug-Drug Interactions).

Although patients with renal impairment are known to be predisposed to the development of rhabdomyolysis with administration of HMG-CoA reductase inhibitors (also known as statins), those with a history of renal impairment may also be predisposed to the development of rhabdomyolysis. Such patients merit close monitoring for skeletal muscle effects.

LIPITOR therapy should be temporarily withheld or discontinued in any patient with an acute serious condition suggestive of myopathy or having a risk factor predisposing to the development of renal failure secondary to rhabdomyolysis (such as sepsis, severe acute infection, hypotension, major surgery, trauma, severe metabolic, endocrine and electrolyte disorders, and uncontrolled seizures).

LIPITOR therapy should be discontinued if markedly elevated CPK levels occur or myopathy is diagnosed or suspected.

There have been rare reports of immune-mediated necrotizing myopathy (IMNM), an autoimmune myopathy associated with statin use. IMNM is characterized by:

  • proximal muscle weakness and elevated creatine kinase, which persist despite discontinuation of statin treatment
  • muscle biopsy showing necrotizing myopathy without significant inflammation
  • improvement with immunosuppressive agents.

Cardiovascular

Hemorrhagic Stroke in Patients with Recent Stroke or Transient Ischemic Attack (TIA)
A post-hoc analysis of a clinical study in 4,731 patients without coronary heart disease (CHD) who had a stroke or TIA within the preceding six months revealed a higher incidence of hemorrhagic stroke in the atorvastatin 80mg group compared to placebo. Patients with hemorrhagic stroke on entry appeared to be at increased risk for recurrent hemorrhagic stroke. The potential risk of hemorrhagic stroke should be carefully considered before initiating treatment with atorvastatin in patients with recent (1-6 months) stroke or TIA.

Effect on Ubiquinone (CoQ10) Levels
Significant decreases in circulating ubiquinone levels in patients treated with atorvastatin and other statins have been observed. The clinical significance of a potential long-term statin- induced deficiency of ubiquinone has not been established. It has been reported that a decrease in myocardial ubiquinone levels could lead to impaired cardiac function in patients with borderline congestive heart failure (see REFERENCES).

Endocrine and Metabolism

Endocrine Function
HMG-CoA reductase inhibitors interfere with cholesterol synthesis and as such might theoretically blunt adrenal and/or gonadal steroid production. Clinical studies with atorvastatin and other HMG-CoA reductase inhibitors have suggested that these agents do not reduce plasma cortisol concentration or impair adrenal reserve and do not reduce basal plasma testosterone concentration. However, the effects of HMG-CoA reductase inhibitors on male fertility have not been studied in adequate numbers of patients. The effects, if any, on the pituitary-gonadal axis in premenopausal women are unknown.

Patients treated with atorvastatin who develop clinical evidence of endocrine dysfunction should be evaluated appropriately. Caution should be exercised if an HMG-CoA reductase inhibitor or other agent used to lower cholesterol levels is administered to patients receiving other drugs (e.g. ketoconazole, spironolactone or cimetidine) that may decrease the levels of endogenous steroid hormones.

Increases in fasting glucose and HbA1c levels have been reported with inhibitors of HMG-CoA reductase as a class. For some patients, at high risk of diabetes mellitus, hyperglycemia was sufficient to shift them to the diabetes status. The benefit of treatment continues to outweigh the small increased risk. Periodic monitoring of these patients is recommended.

Effect on Lipoprotein (a)
In some patients, the beneficial effect of lowered total cholesterol and LDL-C levels may be partly blunted by a concomitant increase in Lp(a) lipoprotein concentrations. Present knowledge suggests the importance of high Lp(a) levels as an emerging risk factor for coronary heart disease. It is thus desirable to maintain and reinforce lifestyle changes in high risk patients placed on atorvastatin therapy (see REFERENCES).

Patients with Severe Hypercholesterolemia
Higher drug dosages (80 mg/day) required for some patients with severe hypercholesterolemia (including familial hypercholesterolemia) are associated with increased plasma levels of atorvastatin. Caution should be exercised in such patients who are also severely renally impaired, elderly, or are concomitantly being administered digoxin or CYP 3A4 inhibitors (see WARNINGS AND PRECAUTIONS, Pharmacokinetic Interactions, Muscle Effects; DRUG INTERACTIONS; DOSAGE AND ADMINISTRATION).

Hepatic/Biliary/Pancreatic

Hepatic Effects
In clinical trials, persistent increases in serum transaminases greater than three times the upper limit of normal occurred in <1% of patients who received LIPITOR. When the dosage of LIPITOR was reduced, or when drug treatment was interrupted or discontinued, serum transaminase levels returned to pretreatment levels. The increases were generally not associated with jaundice or other clinical signs or symptoms. Most patients continued treatment with a reduced dose of LIPITOR without clinical sequelae. If increases in alanine aminotransferase (ALT) or aspartate aminotransferase (AST) show evidence of progression, particularly if they rise to greater than 3 times the upper limit of normal and are persistent, the dosage should be reduced or the drug discontinued.

Liver function tests should be performed before the initiation of treatment, and repeated as clinically indicated. There have been rare postmarketing reports of fatal and non-fatal hepatic failure in patients taking statins, including atorvastatin. If serious liver injury with clinical symptoms and/or hyperbilirubinemia or jaundice occurs during treatment with LIPITOR, promptly interrupt therapy. If an alternate etiology is not found, do not restart LIPITOR.

LIPITOR, as well as other HMG-CoA reductase inhibitors, should be used with caution in patients who consume substantial quantities of alcohol and/or have a past history of liver disease. Active liver disease or unexplained transaminase elevations are contraindications to the use of LIPITOR; if such a condition should develop during therapy, the drug should be discontinued.

Ophthalmologic

Effect on the Lens
Current long-term data from clinical trials do not indicate an adverse effect of atorvastatin on the human lens.

Renal

Renal Insufficiency
Plasma concentrations and LDL-C lowering efficacy of LIPITOR was shown to be similar in patients with moderate renal insufficiency compared with patients with normal renal function. However, since several cases of rhabdomyolysis have been reported in patients with a history of renal insufficiency of unknown severity, as a precautionary measure and pending further experience in renal disease, the lowest dose (10 mg/day) of LIPITOR should be used in these patients. Similar precautions apply in patients with severe renal insufficiency [creatinine clearance <30 mL/min (<0.5 mL/sec)]; the lowest dosage should be used and implemented cautiously (see WARNINGS AND PRECAUTIONS, Muscle Effects; DRUG INTERACTIONS). Refer also to DOSAGE AND ADMINISTRATION.

Sensitivity/Resistance

Hypersensitivity
An apparent hypersensitivity syndrome has been reported with other HMG-CoA reductase inhibitors which has included 1 or more of the following features: anaphylaxis, angioedema, lupus erythematous-like syndrome, polymyalgia rheumatica, vasculitis, purpura, thrombocytopenia, leukopenia, hemolytic anemia, positive ANA, ESR increase, eosinophilia, arthritis, arthralgia, urticaria, asthenia, photosensitivity, fever, chills, flushing, malaise, dyspnea, toxic epidermal necrolysis, erythema multiforme, including Stevens-Johnson syndrome. Although to date hypersensitivity syndrome has not been described as such, LIPITOR should be discontinued if hypersensitivity is suspected.

Special Populations

Use in Pregnancy: LIPITOR is contraindicated during pregnancy (see CONTRAINDICATIONS).

There are no data on the use of LIPITOR during pregnancy. LIPITOR should be administered to women of childbearing age only when such patients are highly unlikely to conceive and have been informed of the potential hazards. If the patient becomes pregnant while taking LIPITOR, the drug should be discontinued and the patient apprised of the potential risk to the fetus.

There is evidence from animal experimental studies that HMG-CoA reductase inhibitors may affect the development of embryos or fetuses. In rats, rabbits and dogs atorvastatin had no effect on fertility and was not teratogenic, however, at maternally toxic doses fetal toxicity was observed in rats and rabbits. The development of the rat offspring was delayed and post-natal survival reduced during exposure of the dams to high doses of atorvastatin. In rats, there is evidence of placental transfer.

Use in Nursing Mothers: In rats, milk concentrations of atorvastatin are similar to those in plasma. It is not known whether this drug is excreted in human milk. Because of the potential for adverse reactions in nursing infants, women taking LIPITOR should not breast-feed (see CONTRAINDICATIONS).

Pediatric Use: Safety and effectiveness of LIPITOR in patients 10-17 years of age (N=140) with heterozygous familial hypercholesterolemia have been evaluated in a controlled clinical trial of 6 months duration in adolescent boys and postmenarchal girls. Patients treated with LIPITOR had a safety and tolerability profile generally similar to that of placebo. Doses greater than 20 mg have not been studied in this patient population.

Safety and effectiveness of LIPITOR in pediatric patients has not been determined in the prevention of myocardial infarction.

LIPITOR had no effect on growth or sexual maturation in boys and in girls. The effects on menstrual cycle were not assessed [see PHARMACOLOGY, Clinical Studies section; ADVERSE REACTIONS, Pediatric Patients; and DOSAGE AND ADMINISTRATION for Heterozygous Familial Hypercholesterolemia in Pediatric Patients (10-17 years of age)].

Adolescent females should be counselled on appropriate contraceptive methods while on LIPITOR therapy (see CONTRAINDICATIONS and PRECAUTIONS, Use in Pregnancy). LIPITOR has not been studied in controlled clinical trials involving pre-pubertal patients or patients younger than 10 years of age.

Doses of LIPITOR up to 80 mg/day for 1 year have been evaluated in 8 pediatric patients with homozygous familial hypercholesterolemia (see Clinical Studies - Heterozygous Familial Hypercholesterolemia in pediatric patients).

Geriatric Use: Treatment experience in adults 70 years or older (N=221) with doses of LIPITOR up to 80 mg/day has demonstrated that the safety and effectiveness of atorvastatin in this population was similar to that of patients <70 years of age. Pharmacokinetic evaluation of atorvastatin in subjects over the age of 65 years indicates an increased AUC. As a precautionary measure, the lowest dose should be administered initially (see DETAILED PHARMACOLOGY, Human Pharmacokinetics; REFERENCES).

Elderly patients may be more susceptible to myopathy (see WARNINGS – Muscle Effects – Pre- disposing Factors for Myopathy/Rhabdomyolysis).

Adverse Reactions

Adverse reactions with LIPITOR have usually been mild and transient. In the atorvastatin placebo-controlled clinical trial database of 16,066 (8755 Lipitor versus 7311 placebo) patients treated for a median period of 53 weeks , 5.2% of patients on atorvastatin discontinued due to adverse reactions compared to 4.0% of the patients on placebo.

Adverse experiences occurring at an incidence ≥1% in patients participating in placebo- controlled clinical studies of LIPITOR and reported to be possibly, probably or definitely drug related are shown in Table 1 below:

Table 1: Associated Adverse Events Reported in ≥ 1% of Patients in Placebo Controlled Clinical Trials
 

Atorvastatin % (n=8755)

Placebo % (n=7311)

Gastrointestinal disorders:

  
Diarrhea

6.8

6.3

Dyspepsia

4.6

4.3

Nausea

4.0

3.5

Constipation

3.9

4.3

Flatulence

1.2

1.0

General disorders and administration site conditions:  
Asthenia1.11.1

Infections and Infestations:
Nasopharyngitis

8.3

8.2

Metabolism and nutrition disorders:  
Liver function test abnormal*4.12.0

Blood creatine phosphokinase increased

1.9

1.8

Hyperglycemia

5.9

5.5

Musculoskeletal and connective tissue disorders:  
Arthralgia6.9

6.5

Pain in extremity

6.0

5.9

Musculoskeletal pain

3.8

3.6

Muscle spasms

3.6

3.0

Myalgia

3.5

3.1

Joint swelling

1.3

1.2

Nervous system disorders   
Headache6.56.7
Respiratory,thoracic and mediastinal disorders:  
Pharyngolaryngeal pain2.32.1

Epistaxis

1.2

1.1

*alanine aminotransferase increased, aspartate aminotransferase increased, blood bilirubin increased, hepatic enzyme increased, liver function test abnormal and transaminases increased.

The following additional adverse events were reported in placebo-controlled clinical trials during LIPITOR therapy: Muscle cramps, myositis, muscle fatigue, myopathy, paresthesia, peripheral neuropathy, pancreatitis, hepatitis, cholestatic jaundice, cholestasis, anorexia, vomiting, abdominal discomfort, alopecia, pruritus, rash, urticaria, erectile dysfunction, nightmare, vision blurred, tinnitus, eructation, neck pain, malaise, pyrexia and white blood cells urine positive.

In summary, the adverse events occurring at a frequency <1% are listed below:

General disorders and administration site conditions: malaise; pyrexia
Gastrointestinal disorders: abdominal discomfort, eructation
Hepatobiliary disorders: hepatitis, cholestasis
Musculoskeletal and connective tissue disorders: muscle fatigue, neck pain
Psychiatric disorders: nightmare
Skin and subcutaneous tissue disorders: urticaria
Eye disorders: vision blurred
Ear and labyrinth disorders: tinnitus
Investigations: white blood cells urine positive

Heterozygous Familial Hypercholesterolemia in Pediatric Patients (ages 10-17 years):

In a 26-week controlled study in boys and postmenarchal girls (n=187, where 140 patients received LIPITOR), the safety and tolerability profile of LIPITOR 10 to 20 mg daily was similar to that of placebo. The adverse events reported in ≥1% of patients were as follows: abdominal pain, depression and headache (see PHARMACOLOGY, Clinical Studies and PRECAUTIONS, Pediatric Use).

Laboratory Changes and Adverse Events

The criteria for clinically significant laboratory changes were >3 X the upper limit of normal (ULN) for liver enzymes, and >5 X ULN for creatine kinase. A total of 8 unique subjects met one or more of these criteria during the double-blind phase. Hence, the incidence of patients who experienced abnormally high enzymatic levels (AST/ALT and creatine kinase) was > 4% (8/187).

Five atorvastatin and one placebo subjects had increases in CK >5 X ULN during the double- blind phase; two of the five atorvastatin treated subjects had increases in CK > 10 X ULN.

There were 2 subjects who had clinically significant increases in ALT.

Abnormal Hematologic and Clinical Chemistry Findings

Laboratory Tests: Increases in serum transaminase levels and serum glucose have been noted in clinical trials (see WARNINGS AND PRECAUTIONS, ADVERSE REACTIONS).

Post-Market Adverse Drug Reactions

The following adverse events have also been reported during post-marketing experience with LIPITOR, regardless of causality assessment:

Rare reports: severe myopathy with or without rhabdomyolysis (see WARNINGS AND PRECAUTIONS, Muscle Effects, Renal Insufficiency and DRUG INTERACTIONS).

There have been rare reports of immune-mediated necrotizing myopathy with statins (see WARNINGS AND PRECAUTIONS - Muscle Effects).

Isolated reports: Gynecomastia, thrombocytopenia, arthralgia and allergic reactions including urticaria, angioedema (angioneurotic edema), anaphylaxis and bullous rashes (including erytheme multiforme, Stevens-Johnson syndrome and toxic epidermal necrolysis), fatigue, myositis, back pain, chest pain, malaise, dizziness, amnesia, peripheral edema, weight gain, abdominal pain, insomnia, hypoesthesia, tinnitus, tendon rupture, pancreatitis and dysgeusia.

Ophthalmologic observations: see WARNINGS AND PRECAUTIONS.

Cases of erectile dysfunction have been reported in association with the use of statins.

The following adverse events have been reported with some statins:

  • Sleep disturbances, including insomnia and nightmares;
  • Mood related disorders, including depression;
  • Very rare cases of interstitial lung disease, especially with long term therapy. If it is suspected a patient has developed interstitial lung disease, statin therapy should be discontinued.

Endocrine disorders: Increases in fasting glucose and HbA1c levels have been reported with LIPITOR.

There have been rare post-marketing reports of cognitive impairment (e.g. memory loss, forgetfulness, amnesia, memory impairment, confusion) associated with statin use. These cognitive issues have been reported for all statins. The reports are generally non-serious and reversible upon statin discontinuation, with variable times to symptom onset (1 day to years) and symptom resolution (median of 3 weeks).

Drug Interactions

Overview

Pharmacokinetic interaction studies conducted with drugs in healthy subjects may not detect the possibility of a potential drug interaction in some patients due to differences in underlying diseases and use of concomitant medications (see also WARNINGS AND PRECAUTIONS, Special Populations; Renal Insufficiency; Patients with Severe Hypercholesterolemia; Geriatric Use).

Concomitant Therapy with Other Lipid Metabolism Regulators: Based on post-marketing surveillance, gemfibrozil, fenofibrate, other fibrates, and lipid-modifying doses of niacin (nicotinic acid) may increase the risk of myopathy when given concomitantly with HMG-CoA reductase inhibitors (see WARNINGS, Muscle Effects; DRUG INTERACTIONS, Drug-Drug Interactions, Table 2 – Established or Potential Drug-Drug Interactions.

Cytochrome P-450-mediated Interactions: Atorvastatin is metabolized by the cytochrome P-450 isoenzyme, CYP 3A4. Interaction may occur when LIPITOR is administered with inhibitors of cytochrome P450 3A4 such as grapefruit juice, some macrolide antibiotics (i.e. erythromycin, clarithromycin), immunosuppressants (cyclosporine), azole antifungal agents (i.e. itraconazole, ketoconazole), protease inhibitors, or the antidepressant, nefazodone. Concomitant administration can lead to increased plasma concentrations of atorvastatin. Therefore, special caution should be exercised when atorvastatin is used in combination with such medicinal agents and appropriate clinical assessment is recommended to ensure that the lowest dose necessary of atorvastatin is employed (see WARNINGS AND PRECAUTIONS, Pharmacokinetic Interactions, Muscle Effects, Renal Insufficiency and Endocrine Function; DRUG INTERACTIONS, Drug-Drug Interactions, Table 2 – Established or Potential Drug-Drug Interactions; REFERENCES).

Transporter Inhibitors: Atorvastatin and atorvastatin-metabolites are substrates of the OATP1B1 transporter. Inhibitors of the OATP1B1 (e.g. cyclosporine) can increase the bioavailability of atorvastatin (see DETAILED PHARMACOLOGY, Human Pharmacokinetics).

Inducers of cytochrome P450 3A: Concomitant administration of atorvastatin with inducers of cytochrome P450 3A4 (eg efavirenz, rifampin) can lead to variable reductions in plasma concentrations of atorvastatin.

Drug-Drug Interactions

The drugs listed in this table are based on either drug interactions studies, case reports, or potential interactions due to the expected magnitude and seriousness of the interaction (i.e. those identified as contraindicated). Interactions with other drugs have not been established.

Table 2- Established or Potential Drug-Drug Interactions

Proper name

Effect

Clinical comment

Bile Acid Sequestrants

Patients with mild to moderate HC: ↑ ­ LDL-C reduction ( -45%) when LIPITOR 10 mg and colestipol 20 g were coadministered than when either drug was administered alone (-35% for LIPITOR and -22% for colestipol).
 

Patients with severe HC:  LDL-C reduction was similar (-53%) when LIPITOR 40 mg and colestipol 20 g were coadministered when compared to that with LIPITOR 80 mg alone.  ↓ plasma concentration (~26%) when LIPITOR 40 mg plus colestipol 20 g were coadministered compared with LIPITOR 40 mg alone.
 

However, the combination drug therapy was less effective in lowering TG than LIPITOR monotherapy in both types of hypercholesterolemic patients.

When LIPITOR is used concurrently with colestipol or any other resin, an interval of at least 2 hours should be maintained between the two drugs, since the absorption of LIPITOR may be impaired by the resin.

Fibric Acid Derivatives (Gemfibrozil, Fenofibrate, Bezafibrate) and Niacin (nicotinic acid)

↑ in the risk of myopathy during treatment with other drugs in this class, including atorvastatin.

The concomitant therapy with LIPITOR and gemfibrozil should be avoided. The benefits and risks of combined therapy with LIPITOR and fenofibrate, bezafibrate and niacin should be carefully considered; lower starting and maintenance doses of atorvastatin should be considered (see WARNINGS AND

PRECAUTIONS, Muscle Effects and REFERENCES).

Coumarin Anticoagulants

No clinically significant effect on prothrombin time

LIPITOR had no clinically significant effect on prothrombin time when administered to patients receiving chronic warfarin therapy (see REFERENCES).

Proper name

Effect

Clinical comment

Digoxin

In healthy subjects, digoxin PK at steady-state were not significantly altered by coadministration of digoxin

0.25 mg and LIPITOR 10 mg daily.
 

­↑ in digoxin steady-state concentrations by ~20% following coadministration of digoxin 0.25 mg and LIPITOR 80 mg daily (see DETAILED PHARMACOLOGY,

Human Pharmacokinetics).

Patients taking digoxin should be monitored appropriately.

Antihypertensive
Agents:

Amlodipine




 


 

In healthy subjects, atorvastatin PK were not altered by the coadministration of LIPITOR 80 mg and amlodipine 10 mg at steady state. No apparent changes in BP or HR.
 

In healthy volunteers, co- administration of multiple 10 mg doses of amlodipine with 80 mg of atorvastatin resulted in no clinical significant change in the AUC (average of 18% increase) or Cmax or Tmax of atorvastatin.

 

See DETAILED PHARMACOLOGY – Human Pharmacokinetics

 

 

Close monitoring is required.

QuinaprilSteady-state quinapril dosing of 80 mg QD did not significantly affect the PK profile of atorvastatin tablets 10 mg QD. 

Oral Contraceptives and Hormone Replacement Therapy

­↑ plasma concentrations (AUC levels) of norethindone by ~30% and ethinyl estradiol by ~20% following coadministration of LIPITOR with an oral contraceptive containing 1 mg norethindone and 35 μg ethinyl estradiol.
 

In clinical studies, LIPITOR was used concomitantly with estrogen replacement therapy without evidence to date of clinically significant adverse interactions.

These increases should be considered when selecting an oral contraceptive.

Proper name

Effect

Clinical comment

Antacids

↓ in plasma concentrations of LIPITOR by ~35% following administration of aluminum and magnesium based antacids, such as Maalox® TC Suspension.

LDL-C reduction was not altered; TG- lowering effect of LIPITOR may be affected.

This decrease in exposure should be considered when prescribing atorvastatin with antacids.

Cimetidine

No effect on plasma concentrations or LDL-C lowering efficacy of LIPITOR

↓ in TG-lowering effect of LIPITOR from 34% to 26%

This decrease in TG-lowering should be considered when prescribing atorvastatin with cimetidine.

Diltiazem Hydrochloride

Steady-state diltiazem increases the exposure, based on AUCLASTs, of a single dose of atorvastatin by approximately 50%.

 

Antipyrine

LIPITOR had no effect on the PK of antipyrine

Antipyrine was used as a non- specific model for drugs metabolized by the microsomal hepatic enzyme system (cytochrome P-450 system).

Interactions with other drugs metabolized via the same cytochrome isozymes are not expected.

Macrolide Antibiotics (azithromycin, clarithromycin, erythromycin).

Clarithromycin and erythromycin are both CYP3A4 inhibitors

In healthy adults, coadministration of LIPITOR (10 mg QD) and

azithromycin (500 mg QD) did not significantly alter the plasma concentrations of atorvastatin.
 

­↑ plasma concentration by ~40% with erythromycin (500 mg QID) and ~80% with clarithromycin (500 mg BID) when coadministered with atorvastatin (10 mg QD)

See WARNINGS AND
PRECAUTIONS, Muscle Effects; DETAILED PHARMACOLOGY
– Human Pharmacokinetics

Proper name

Effect

Clinical comment

Protease Inhibitors (nelfinavir mesylate, lopinavir/ritonavir, tipranavir/ritonavir, telaprevir, boceprevir, saquinavir/ritonavir, darunavir/ritonavir, fosamprenavir/ritonavir, fosamprenavir)

­↑ plasma concentrations of atorvastatin when atorvastatin 10 mg QD is coadministered with nelfinavir mesylate 1250 mg BID. ­ ↑ AUC by 74% and ↑ ­ Cmax by 122%
 

­↑ AUC by 5.9 fold and ­ ↑ Cmax by 4.7 fold with atorvastatin 20mg QD and  Lopinavir 400mg / Ritonavir 100mg BID*
 

­↑ AUC by 8.4 fold and ­ ↑ Cmax by 7.6 fold with atorvastatin 10mg SD and Tipranavir 500mg BID / Ritonavir 200mg           
BID, 7 days. Atorvastatin 10 mg SD had no effect on the PK of Tripanavir 500mg BID / Ritonavir 200 mg BID, 7 days*
 

­ ↑ AUC by 6.9 fold and ­ ↑ Cmax by 9.6 fold with atorvastatin 20mg SD and Telaprevir 750mg q8h, 10 days*
 

­ ↑ AUC by 2.30 fold and ­ ↑ Cmax by 2.66 fold with atorvastatin 40mg SD and Boceprevir 800 mg TID, 7 days*
 

­ ↑ AUC by 2.9 fold and ­ ↑ Cmax by 3.3 fold with atorvastatin 40mg QD for 4 days and Ritonavir 400mg BID, 15 days / Saquinavir 400mg BID*

 

­ ↑ AUC by 2.4 fold and ­ ↑ Cmax by 1.3 fold with atorvastatin 10mg QD for 4 days and Darunavir 300mg BID/ Ritonavir 100 mg BID, 9 days*
 

­ ↑ AUC by 1.5 fold and ↑ ­ Cmax by 1.8 fold with atorvastatin 10mg QD for 4 days and Fosamprenavir 700 mg BID/ritonavir 100mg BID,14 days*
 

­ ↑ AUC by 1.3 fold and ↑ ­ Cmax by 3.0 fold with atorvastatin 10mg QD for 4 days and Fosamprenavir 1400 mg BID, 14 days*. Atorvastatin 10mg QD for 4 days had the following effect on the PK of Fosamprenavir 1400 mg BID, 14 days: ↓ AUC by 0.27 fold and ↓ Cmax by 0.18 fold*
 

Atorvastatin 10mg QD, 4 days had no effect on the PK of Fosamprenavir 700mg BID/ Ritonavir 100 mg BID, 14 days*

The dose of LIPITOR used in combination with nelfinavir should not exceed 40 mg daily.

 

The concomitant therapy with LIPITOR and the combination of lopinavir plus ritonavir should be used with caution and lowest LIPITOR dose necessary. (See Warnings and Precautions, Muscle Effect)

 

The concomitant therapy with LIPITOR and the combination of tipranavir plus ritonavir or LIPITOR and telaprevir should be avoided.

 

The dose of LIPITOR should be restricted to 20 mg daily when used in combination with boceprevir, saquinavir plus ritonavir, darunavir plus ritonavir, fosamprenavir alone or fosamprenavir plus ritonavir.

The dose of saquinavir plus ritonavir in this study is not the clinically used dose. The increase in atorvastatin exposure when used clinically is likely to be higher than what was observed in this study.
Therefore caution should be applied and the lowest dose necessary should be used

 

 

 

 

 

 

 

 

 

 

Proper name

Effect

Clinical comment

Cyclosporine

Concomitant administration of atorvastatin 10 mg and cyclosporine 5.2 mg/kg/day resulted in a 7.7 fold increase in exposure to atorvastatin.

Concomitant use should be avoided.
 

See WARNINGS and
PRECAUTIONS - Muscle
Effects; DETAILED
PHARMACOLOGY – Human
Pharmacokinetics

Itraconazole

Concomitant administration of atorvastatin 20-40mg and itraconazole 200mg daily resulted in a 2.5-3.3-fold increase in atorvastatin AUC.

The dose of LIPITOR used in combination with itraconazole should not exceed 20 mg daily (see DETAILED PHARMACOLOGY – Human Pharmacokinetics).

Efavirenz

↓ AUC by 41 %and ↓ Cmax by 1% with  atorvastatin 10mg and Efavirenz 600mg daily.

This decrease in exposure should be considered when prescribing atorvastatin with efavirenz.

Rifampin

Co-administration*:

Ratios of AUC and Cmax are 1.12 and 2.9, respectively, for co-administered atorvastatin 40mg single dose and 7 day Rifampin 600mg daily vs. atorvastatin 40mg single dose alone.
 

Separate administration*

↓ in AUC by 80% and ↓ Cmax by 40% with atorvastatin 40mg single dose and  Rifampin 600mg daily (doses separated )

Due to the dual interaction mechanism of rifampin (cytochrome P450 3A4 induction and inhibition of hepatocyte uptake transporter OATP1B1), simultaneous co-administration of atorvastatin with rifampin is recommended, as delayed administration of atorvastatin after administration of rifampin has been associated with a significant reduction in atorvastatin plasma concentrations.

Proper name

Effect

Clinical comment

Fusidic Acid

Although interaction studies with atorvastatin and fusidic acid have not been conducted, rhabdomyolysis resulting in fatal outcome has been reported in patients receiving a combination of statins, including atorvastatin, and fusidic acid. The mechanism of this interaction is not known.

The concurrent use of atorvastatin and fusidic acid should be avoided.
 

In patients where the use of systemic fusidic acid is considered essential, statin treatment should be discontinued throughout the duration of fusidic acid treatment. Statin therapy may be re-introduced at least seven days after the last dose of fusidic acid.
 

Patients should be advised to seek medical advice immediately if they experience any symptoms of muscle weakness, pain or tenderness. (see WARNINGS AND PRECAUTIONS - Muscle

Effects).

Colchicine

Although interaction studies with atorvastatin and colchicine have not been conducted, cases of myopathy have been reported with atorvastatin co-administrated with colchicine.

Caution should be exercised when prescribing atorvastatin with colchicine. (See Warnings and Precautions, Muscle Effect).

Legend: HC = hypercholesterolemia; TG = Triglycerides; PK = pharmacokinetics; BP = Blood Pressure; HR = Heart Rate; AUC = Area under the curve
* Data given as x-fold change represent a simple ratio between co-administration and atorvastatin alone (i.e., 1-fold = no change). Data given as % change represent % difference relative to atorvastatin alone (i.e., 0% = no change).

Drug-Food Interactions

Coadministration of grapefruit juice has the potential to increase plasma concentrations of HMG CoA reductase inhibitors including LIPITOR. The equivalent of 1.2 litres per day resulted in a 2.5 fold increase in AUC of atorvastatin. Consumption of excessive grapefruit juice with atorvastatin is not recommended.

Drug-Herb Interactions

Interactions with herbal products have not been established.

Drug/Laboratory Test Interactions

LIPITOR may elevate serum transaminase and creatine kinase levels (from skeletal muscle). In the differential diagnosis of chest pain in a patient on therapy with LIPITOR, cardiac and noncardiac fractions of these enzymes should be determined.

Dosage And Administration

Patients should be placed on a standard cholesterol-lowering diet before receiving LIPITOR, and should continue on this diet during treatment with LIPITOR. If appropriate, a program of weight control and physical exercise should be implemented.

Prior to initiating therapy with LIPITOR, secondary causes for elevations in plasma lipid levels should be excluded. A lipid profile should also be performed.

Primary Hypercholesterolemia and Combined (Mixed) Dyslipidemia, Including Familial Combined Hyperlipidemia

The recommended starting dose of LIPITOR is 10 or 20 mg once daily, depending on patient’s LDL-C reduction required. Patients who require a large reduction in LDL-C (more than 45%) may be started at 40 mg once daily. The dosage range of LIPITOR is 10 to 80 mg once daily. Doses can be given at any time of the day with or without food, and should preferably be given in the evening. A significant therapeutic response is evident within 2 weeks, and the maximum response is usually achieved within 2-4 weeks. The response is maintained during chronic therapy. Adjustments of dosage, if necessary, should be made at intervals of 2 to 4 weeks. The maximum dose is 80 mg/day.

The dosage of LIPITOR should be individualized according the baseline LDL-C, total-C/HDL-C ratio and/or TG levels to achieve the recommended desired lipid values at the lowest dose needed to achieve LDL-C desired level. Lipid levels should be monitored periodically and, if necessary, the dose of LIPITOR adjusted based on desired lipid levels recommended by guidelines.

Severe Dyslipidemias

In patients with severe dyslipidemias, including homozygous and heterozygous familial hypercholesterolemia and dysbetalipoproteinemia (Type III), higher dosages (up to 80 mg/day) may be required (see WARNINGS AND PRECAUTIONS, Pharmacokinetic Interactions, Muscle Effects; DRUG INTERACTIONS).

Heterozygous Familial Hypercholesterolemia in Pediatric Patients (10-17 years of age)

In this population, the recommended starting dose of LIPITOR is 10 mg/day; the maximum recommended dose is 20 mg/day (doses greater than 20 mg/day have not been studied in this patient population). Doses should be individualized according to the recommended goal of therapy (see INDICATIONS AND CLINICAL USE and PHARMACOLOGY, Clinical Studies). Adjustments should be made at intervals of 4 weeks or more.

Prevention of Cardiovascular Disease

Clinical trials conducted that evaluated atorvastatin in the primary prevention of myocardial infarction used a dose of 10 mg atorvastatin once daily.

For secondary prevention of myocardial infarction, optimal dosing may range from 10 mg to 80 mg atorvastatin once daily, to be given at the discretion of the prescriber, taking into account the expected benefit and safety considerations relevant to the patient to be treated.

Concomitant Therapy

See DRUG INTERACTIONS.

Dosage in Patients with Renal Insufficiency

(See WARNINGS AND PRECAUTIONS)

Overdosage

There is no specific treatment for atorvastatin overdosage. Should an overdose occur, the patient should be treated symptomatically and supportive measures instituted as required. Due to extensive drug binding to plasma proteins, hemodialysis is not expected to significantly enhance atorvastatin clearance (see ADVERSE REACTIONS).

For the management of a suspected drug overdose, contact your regional Poison Control Centre.

Action And Clinical Pharmacology

Mechanism of Action

LIPITOR (atorvastatin calcium) is a synthetic lipid-lowering agent. It is a selective, competitive inhibitor of 3-hydroxy-3-methylglutaryl-coenzyme A (HMG-CoA) reductase. This enzyme catalyzes the conversion of HMG-CoA to mevalonate, which is an early and rate-limiting step in the biosynthesis of cholesterol.

LIPITOR lowers plasma cholesterol and lipoprotein levels by inhibiting HMG-CoA reductase and cholesterol synthesis in the liver and by increasing the number of hepatic Low Density Lipoprotein (LDL) receptors on the cell-surface for enhanced uptake and catabolism of Low Density Lipoprotein (LDL).

LIPITOR reduces LDL-Cholesterol (LDL-C) and the number of LDL particles. Lipitor also reduces Very Low Density Lipoprotein-Cholesterol (VLDL-C), serum triglycerides (TG) and Intermediate Density Lipoproteins (IDL), as well as the number of apolipoprotein B (apo B) containing particles, but increases High Density Lipoprotein-Cholesterol (HDL-C). Elevated serum cholesterol due to elevated LDL-C is a major risk factor for the development of cardiovascular disease. Low serum concentration of HDL-C is also an independent risk factor.

Elevated plasma TG is also a risk factor for cardiovascular disease, particularly if due to increased IDL, or associated with decreased HDL-C or increased LDL-C.

Epidemiologic, clinical and experimental studies have established that high LDL-C, low HDL-C and high plasma TG promote human atherosclerosis and are risk factors for developing cardiovascular disease. Some studies have also shown that the total (TC):HDL-C ratio (TC:HDL-C) is the best predictor of coronary artery disease. In contrast, increased levels of HDL-C are associated with decreased cardiovascular risk. Drug therapies that reduce levels of LDL-C or decrease TG while simultaneously increasing HDL-C have demonstrated reductions in rates of cardiovascular mortality and morbidity.

Pharmacodynamics

The lowering of total cholesterol, LDL-C and ApoB have been shown to reduce the risk of cardiovascular events and mortality.

LIPITOR (atorvastatin calcium) is a selective, competitive inhibitor of HMG-CoA reductase. In both subjects and in patients with homozygous and heterozygous familial hypercholesterolemia, nonfamilial forms of hypercholesterolemia, mixed dyslipidemia, hypertriglyceridemia, and dysbetalipoproteinemia, LIPITOR has been shown to reduce levels of total cholesterol (total-C), LDL-C, apo B and total TG, and raises HDL-C levels.

Epidemiologic and clinical studies have associated the risk of coronary artery disease (CAD) with elevated levels of total-C, LDL-C and decreased levels of HDL-C. These abnormalities of lipoprotein metabolism are considered as major contributors to the development of the disease. Like LDL, cholesterol-enriched lipoproteins, including VLDL, IDL and remnants can also promote atherosclerosis. Elevated plasma triglycerides are frequently found in a triad with low HDL-C levels and small LDL particles, as well as in association with non-lipid metabolic risk factors for coronary heart disease (metabolic syndrome). Clinical studies have also shown that serum triglycerides can be an independent risk factor for CAD. CAD risk is especially increased if the hypertriglyceridemia is due to increased intermediate density lipoproteins (IDL) or associated with decreased HDL or increased LDL-C. In addition, high TG levels are associated with an increased risk of pancreatitis. Although epidemiological and preliminary clinical evidence link low HDL-C levels and high triglyceride levels with coronary artery disease and atherosclerosis, the independent effect of raising HDL or lowering TG on the risk of coronary and cerebrovascular morbidity and mortality has not been demonstrated in prospective, well- controlled outcome studies. Other factors, e.g. interactions between lipids/lipoproteins and endothelium, platelets and macrophages, have also been incriminated in the development of human atherosclerosis and of its complications. Regardless of the intervention used (low- fat/low-cholesterol diet, partial ileal bypass surgery or pharmacologic therapy), effective treatment of hypercholesterolemia/ dyslipidemia has consistently been shown to reduce the risk of CAD.

LIPITOR reduces LDL-C and the number of LDL particles, lowers Very Low Density Lipoprotein-Cholesterol (VLDL-C) and serum triglyceride, reduces the number of apo B containing particles, and also increases HDL-C. LIPITOR is effective in reducing LDL-C in patients with homozygous familial hypercholesterolemia, a condition that rarely responds to any other lipid-lowering medication. In addition to the above effects, LIPITOR reduces IDL-C and apolipoprotein E (apo E) in patients with dysbetalipoproteinemia (Type III).

In patients with type II hyperlipidemia, atorvastatin improved endothelial dysfunction. Atorvastatin significantly improved flow-mediated endothelium-dependent dilatation induced by reactive hyperemia, as assessed by brachial ultrasound (p<0.01).

Pharmacokinetics

Absorption: Atorvastatin is rapidly absorbed after oral administration; maximal plasma concentrations occur within 1 to 2 hours. Extent of absorption and plasma atorvastatin concentrations increases in proportion to atorvastatin dose. Atorvastatin tablets are 95-99% bioavailable compared to solutions. The absolute bioavailability (parent drug) of atorvastatin is approximately 12% and the systemic availability of HMG-CoA reductase inhibitory activity is approximately 30%. The low systemic availability is attributed to presystemic clearance in gastrointestinal mucosa and/or first-pass metabolism in the liver. Although food decreases the rate and extent of drug absorption by approximately 25% and 9%, as assessed by Cmax and AUC respectively, LDL-C reduction and HDL-C elevation are similar when atorvastatin is given with and without food. Plasma atorvastatin concentrations are lower (approximately 30% for Cmax and AUC) following drug administration in the evening compared with morning dosing.
However, LDL-C reduction and HDL-C elevation are the same regardless of the time of drug administration.

Distribution: Mean volume of distribution of atorvastatin is approximately 381 liters. Atorvastatin is ≥98% bound to plasma proteins. A blood/plasma ratio of approximately 0.25 indicates poor drug penetration into red blood cells. Based on observations in rats, atorvastatin is likely to be secreted in human milk.

Metabolism: Atorvastatin is extensively metabolized to ortho- and para-hydroxylated derivatives by cytochrome P-450 3A4 (CYP 3A4) and to various beta-oxidation products. In vitro, inhibition of HMG-CoA reductase by ortho- and para-hydroxylated metabolites is equivalent to that of atorvastatin. Approximately 70% of circulating inhibitory activity for HMG-CoA reductase is attributed to active metabolites. In animals, the ortho-hydroxy metabolite undergoes further glucuronidation. Atorvastatin and its metabolites are eliminated by biliary excretion.

Excretion: Atorvastatin is eliminated primarily in bile following hepatic and/or extrahepatic metabolism; however, the drug does not appear to undergo significant enterohepatic recirculation. Mean plasma elimination half-life of atorvastatin in humans is approximately 14 hours, but the half-life for inhibitory activity for HMG-CoA reductase is 20 to 30 hours due to the contribution of longer-lived active metabolites. Less than 2% of a dose of atorvastatin is recovered in urine following oral administration.

Special Populations and Conditions

Pediatrics: Assessment of pharmacokinetic parameters such as Cmax, AUC and bioavailability of LIPITOR in pediatric patients (>10-<17 years old, postmenarche) was not performed during the 6-month, placebo-controlled trial referred to earlier (see Clinical Studies - Heterozygous Familial Hypercholesterolemia in Pediatric Patients and PRECAUTIONS - Pediatric Use).

Geriatrics: Plasma concentrations of atorvastatin are higher (approximately 40% for Cmax and 30% for AUC) in healthy elderly subjects (age 65 years or older) compared with younger individuals. LDL-C reduction, however, is comparable to that seen in younger patient populations.

Gender: Plasma concentrations of atorvastatin in women differ (approximately 20% higher for Cmax and 10% lower for AUC) from those in men; however, there is no clinically significant difference in LDL-C reduction between men and women.

Race: Plasma concentrations of atorvastatin are similar in black and white subjects.

Hepatic Insufficiency: Plasma concentrations of atorvastatin are markedly increased (approximately 16-fold in Cmax and 11-fold in AUC) in patients with chronic alcoholic liver disease (Childs-Pugh B).

Renal Insufficiency: Plasma concentrations and LDL-C lowering efficacy of LIPITOR are similar in patients with moderate renal insufficiency compared with patients with normal renal function. However, since several cases of rhabdomyolysis have been reported in patients with a history of renal insufficiency of unknown severity, as a precautionary measure and pending further experience in renal disease, the lowest dose (10 mg/day) of LIPITOR should be used in these patients. Similar precautions apply in patients with severe renal insufficiency [creatinine clearance <30 mL/min (<0.5 mL/sec)]; the lowest dosage should be used and implemented cautiously (see WARNINGS AND PRECAUTIONS, Muscle Effects; DRUG INTERACTIONS; DOSAGE AND ADMINISTRATION).

Storage And Stability

Store at controlled room temperature 15 to 30°C.

Special Handling Instructions

Not applicable.

Dosage Forms, Composition And Packaging

Dosage Forms

LIPITOR (atorvastatin calcium) tablets are formulated for oral administration and are available in tablet doses of 10 mg, 20 mg, 40 mg and 80 mg.

Tablet Composition

Each tablet contains either 10 mg, 20 mg, 40 mg or 80 mg atorvastatin as the active ingredient. Each tablet also contains the following non-medicinal ingredients: calcium carbonate, croscarmellose sodium, hydroxypropyl cellulose, hydroxypropyl methylcellulose, lactose monohydrate, magnesium stearate, microcrystalline cellulose, polyethylene glycol, polysorbate 80, simethicone emulsion, talc, and titanium dioxide. The 10mg, 20mg, and 40mg tablets also contain candelilla wax.

LIPITOR (atorvastatin calcium) is available in dosage strengths of 10 mg, 20 mg, 40 mg and 80 mg atorvastatin per tablet.

Packaging

10 mg: White, elliptical, film-coated tablet, coded "10" on one side and "PD 155" on the other. Available in bottles of 90 tablets.

20 mg: White, elliptical, film-coated tablet, coded "20" on one side and "PD 156" on the other. Available in bottles of 90 tablets.

40 mg: White, elliptical, film-coated tablet, coded "40" on one side and "PD 157" on the other. Available in bottles of 90 tablets.

80 mg: White, elliptical, film-coated tablet, coded "80" on one side and "PD 158" on the other. Available in blisters of 30 tablets (3 strips X 10).

 

Control #: 200017
March 20, 2017

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