Statins and their interactions

In the hypothetical polypill a statin is an essential ingredient. Although I have deep reservations against the cholesterol hypothesis per se, I do believe in the efficacy of statins, even judging their effect higher in proven arteriosclerotic strokes (such as embolism from a high grade carotid or media stenosis) than that of ASA. Their side effects are also impressive: you hear that from young strokes that receive statins as part of their prophylactic package, but then aren’t able to perform as well in sports as before.

It is (at least to me) totally unclear what dose to give to your stroke, but I titrate the dose along the arteriosclerotic burden – a pure cardioembolic stroke receives the minimum dose of, say, simvastatin 10-20 (unless he has coronary disease or PAD); a microangiopathic stroke might get some more (say 40 mg). A medium grade stenosis would receive 80 mg and a high grade or multiple stenoses gets the advanced stuff such as atorvastatin or rosuvastatin (maximum dose). Repeat offenders always get the maximum dose.

The problem with this titrated approach is that the dose given does not match the dose aimed at, because of pharmacologic interactions, of which there are plenty. E.g. some amlodipine and ticagrelor (a frequent combination after emergency stent) might lead to multiplication of the effective dose. I expect our residents to check these interactions before giving more then the minimal dose and refer them to this review for details. We also use Medscape’s interaction checker to screen in complicated regimens. Obviously, a pharmacologist would be even better, but we are poor in Germany and reduction of medication errors does not pay…

Here is a list of the standard drugs to be aware. For antibiotics and other absurd drugs refer to the above article.

Amiodarone, Amlodipine and other Ca antagonists, Cholestyramine, Cimetidine, Colchicine, Cyclosporine, Digoxine, Dronedarone, Glyburide, Fibrates/Niacin, Phenytoin, HIV drugs, Ranolazine, Ticagrelor

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