INSTRUCTION

for medical use of the medicinal product

 

ATORVASTATIN 10 ANANTA,

ATORVASTATIN 20 ANANTA

 

 

Composition:

active substance: atorvastatin;

1 tablet contains atorvastatin calcium equivalent to atorvastatin 10 mg or 20 mg;

excipients: lactose, monohydrate; microcrystalline cellulose; magnesium stearate; croscarmellose sodium; corn starch; hydroxypropylcellulose; hydroxypropylmethylcellulose; polyethylene glycol; titanium dioxide (E 171).

 

Pharmaceutical form. Film-coated tablets.

Basic physical and chemical properties: white or almost white, round, biconvex, film-coated tablets.

 

Pharmacotherapeutic group. Lipid-lowering agents, multicomponent. HMG-CoA-reductase inhibitors.  ATC code С10А А05.           

 

Pharmacological properties.

Pharmacodynamics.

Atorvastatin is a synthetic hypolipidemic drug. It is an inhibitor of 3-hydroxy-3-methylglutaryl coenzyme A (HMG-CoA) reductase, an enzyme that catalyzes the conversion of HMG-CoA into mevalonate – the initial and limiting phase of cholesterol biosynthesis.

Atorvastatin is a selective, competitive inhibitor of HMG-CoA reductase, the rate-limiting enzyme responsible for the conversion of 3-hydroxy-3-methyl-glutaryl-coenzyme A to mevalonate, a precursor of sterols, including cholesterol. 

In experimental animals atorvastatin lowers plasma cholesterol and lipoprotein serum concentrations by inhibiting HMG-CoA reductase and subsequently cholesterol biosynthesis in the liver and increases the number of hepatic LDL receptors on the cell surface for enhanced uptake and catabolism of LDL; atorvastatin also reduces LDL production and the number of LDL particles.

Atorvastatin and some of its metabolites are pharmacologically active in humans. The main site of action of atorvastatin is the liver, which plays a major role in cholesterol synthesis and LDL clearance. The drug dose, in contrast to the systemic concentration of the drug, is better correlated with the decreased LDL cholesterol. Individual dose adjustments should be made depending on the therapeutic response (see section “Method of administration and dosage”).

Pharmacokinetics.

Absorption. Atorvastatin is rapidly absorbed after oral administration; maximum plasma concentrations (C_max) occur within 1 to 2 hours. Extent of absorption increases in proportion to atorvastatin dose. The absolute bioavailability 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 hepatic first-pass metabolism. Despite food reduces the rate and rate of drug absorption by approximately 25% and 9% according to Cmax and AUC (area under the “concentration-time” curve), the reduction in LDL cholesterol is similar when taking atorvastatin both with food, and separately. When taking atorvastatin in the evening its concentration in blood plasma was lower (approximately 30% by Cmax and AUC) than at morning intake. However, the reduction in LDL cholesterol is the same regardless of the time of administration (see section "Method of administration and dosage").

Distribution. Mean volume of distribution of atorvastatin is approximately 381 l. Atorvastatin is ≥ 98% bound to plasma proteins.  Concentration blood / plasma ratio is approximately 0.25 indicating a poor drug penetration into erythrocytes. Based on rat trials, it is suggested that atorvastatin can excrete into breast milk (see section "Contraindications" and “Precautions for use”).

Biotransformation. Atorvastatin is metabolized to ortho- and parahydroxylated derivatives and various beta-oxidation products. In vitro, inhibition of HMG-CoA reductase by ortho- and parahydroxylated metabolites is equivalent to that of atorvastatin. Approximately 70% of circulating inhibitory activity for HMG-CoA reductase is attributed to active metabolites. In vitro studies have demonstrated the importance of metabolism of atorvastatin by cytochrome P450 3A4, which is consistent with increased concentrations of the drug in human plasma after concomitant use with erythromycin, a known inhibitor of this isoenzyme (see section "Interactions with other medicinal products and other forms of interaction”).

Elimination. Atorvastatin is eliminated primarily in bile following hepatic and/or extrahepatic metabolism. However, atorvastatin does not appear to undergo significant enterohepatic recirculation. Mean plasma elimination half-life of atorvastatin in humans is approximately 14 hours. The half-life of inhibitory activity for HMG-CoA reductase is approximately 20 to 30 hours due to the contribution of active metabolites. Less than 2% of the dose is excreted in the urine after oral administration.

Special populations

Elderly. Plasma atorvastatin concentrations are higher (approximately 40% for Cmax and 30% for AUC) in healthy elderly subjects (65 years of age) than in young adult patients. Clinical evidence indicates a greater LDL reduction when using any dose in elderly patients compared to young patients (see section “Precautions for use”).

Children. Apparent oral clearance of atorvastatin in paediatric subjects appeared similar to adults when scaled allometrically by body weight. Body weight was the only significant covariate in the population pharmacokinetic model of atorvastatin with data included children with heterozygous familial hypercholesterolemia (aged 10 to 17 years, n = 29), in an open 8-week study.

Gender. Concentrations of atorvastatin in women differ from those in men (approx. 20% higher for Cmax and approx. 10% lower for AUC). However, there is no clinically significant difference in the reduction of LDL cholesterol when administered to men and women.

Renal insufficiency. Kidney diseases do not affect the concentration of atorvastatin in blood plasma or the reduction of cholesterol-LDL, therefore no dose adjustment is required for patients with impaired renal function (see section “Method of administration and dose”, “Precautions of use”).

Haemodialysis. Despite the fact that no studies have been carried out with patients with end-stage renal disease, haemodialysis is not thought to significantly increase the drug clearance. The drug is highly bound to plasma proteins.

Hepatic insufficiency. Atorvastatin plasma concentrations are markedly elevated in patients with chronic alcoholic liver disease. Cmax and AUC values are 4-fold higher in patients with Child-Pugh class A. In patients with Child-Pugh class B, Cmax and AUC values are approximately 16-fold and 11-fold higher (see “Contraindications”).

 

Table 1. Effect of co-administered medicinal products on the pharmacokinetics of atorvastatin

Co-administered medicinal product and dosage regimen	Atorvastatin
	Dose (mg)	Change in AUC&	Change in Cmax&
# Ciclosporin 5.2 mg/kg/day, stable dose	10 mg OD for 28 days	­8.69	­10.66
# Tipranavir 500 mg BID/ Ritonavir 200 mg BID, 7 days	10 mg OD	­9.36	­8.58
# Tipranavir 750 mg every 8 hours, 10 days	20 mg OD	­7.88	­10.60
#, ‡Saquinavir 400 mg BID/ Ritonavir  400 mg BID, 15 days	40 mg OD for 4 days	­ 3.93	­ 4.31
#Clarithromycin 500 mg BID, 9 days	80 mg OD for 8 days	­ 4.54	­ 5.38
#Darunavir 300 mg BID/ Ritonavir 100 mg BID, 9 days	10 mg OD for 4 days	3.45	2.25
#Itraconazole 200 mg OD, 4 days	40 mg OD	3.32	1.20
#Fosamprenavir 700 mg BID/ Ritonavir 100 mg BID, 14 days	10 mg OD for 4 days	2.53	2.84
#Fosamprenavir 1400 mg BID, 14 days	10 mg OD for 4 days	2.30	4.04
#Nelfinavir 1250 mg BID, 14 days	10 mg OD for 28 days	1.74	2.22
#Grapefruit Juice, 240 mL OD*	40 mg, OD	1.37	1.16
Diltiazem 240 mg OD, 28 days	40 mg, OD	1.51	1.00
Erythromycin 500 mg QID, 7 days	10 mg. OD	1.33	1.38
Amlodipine 10 mg, single dose	80 mg, OD	1.18	0.91
Cimetidine 300 mg OD, 4 weeks	10 mg OD for 2 weeks	1.00	0.89
Colestipol 10 mg BID, 28 weeks	40 mg OD for 8 weeks	Не застосовується	0.74**
Maalox TC® 30 ml OD, 17 days	10 mg OD for 15 days	0.66	0.67
Efavirenz 600 mg OD, 14 days	10 mg for 3 days	0.59	1.01
#Rifampin 600 mg OD, 7 days (co-administered) †	40 mg OD	1.12	2.90
#Rifampin 600 mg OD, 5 days (doses separated) †	40 mg OD	0.20	0.60
#Gemfibrozil 600 mg BID, 7 days	40 mg OD	1.35	1.00
#Fenofibrate 160 mg OD, 7 days	40 mg OD	1.03	1.02
#Boceprevir 800 mg 3 times a day, 7 days	40 mg OD	2.32	2.66

 

^&        Ratio by treatment modalities (concomitant use of medicinal products with atorvastatin compared to atorvastatin alone).

 ^#     See sections “Precautions for use” and “Interaction with other medicinal products and other forms of interaction” for clinical significance.

*     When excessive consumption of grapefruit juice (750 ml - 1.2 litres per day or more) the increase of AUC (2.5-fold) and / or the Cmax (71%) became bigger.

 **  Single sample that was obtained in 8-16 hours after taking the dose.

      ^†   By means of a dual mechanism of interaction of rifampin the concomitant use of atorvastatin with rifampin is recommended. Since, there was shown that delayed atorvastatin use after rifampin is associated with a significant decrease in plasma concentrations of atorvastatin.

^‡      The dose of drug combination saquinavir + ritonavir in this study is not a clinically applied dose. The increased exposure of atorvastatin when it used in a clinical conditions might be higher than that one which was observed in this study. Therefore, the drug should be used with caution in the lowest necessary dose.

 

Table 2. Effect of atorvastatin on the pharmacokinetics of co-administered medicinal products

Atorvastatin	Co-administered medicinal product and dosage regimen
	Medicinal product/dose (mg)	Change in AUC	Change in Cmax
80 mg OD for 15 days	Antipyrine 600 mg OD	1.03	0.89
80 mg OD for 10 days	# Digoxin 0.25 mg OD for 20 days	1.15	1.20
40 mg OD for 22 days	Oral contraceptives 1 OD for 2 months - norethisterone 1 mg - ethinyl estradiol 35 mcg	1.28  1.19	1.23  1.30
10 mg OD	Tipranavir 500 mg BID / ritonavir 200 mg BID for 7 days	1.08	0.96
10 mg OD for 4 days	Fosamprenavir 1400 mg BID for 14 days	0.73	0.82
10 mg OD for 4 days	Fosamprenavir 700 mg BID / ritonavir 100 mg BID for 14 days	0.99	0.94

^# See sections “Precautions for use” and “Interaction with other medicinal products and other forms of interaction” for clinical significance.

 

Clinical particulars.

Indications.

Prevention of cardiovascular disease

For adults without clinically significant ischemic heart disease but with several risk factors for ischemic heart disease, such as age, smoking, hypertension, low HDL levels or the presence of early ischemic heart disease in the family history, the medicinal product is indicated for:

• - the risk reduction of myocardial infarction;
• - the risk reduction of stroke;
• - the risk reduction of revascularization procedures and stenocardia.

For patients with type II diabetes and without clinically significant ischemic heart disease but with several risk factors for ischemic heart disease such as retinopathy, albuminuria, smoking or hypertension, the medicinal product indicated for:

• - the risk reduction of myocardial infarction;
• - the risk reduction of stroke.

For patients with clinical ischemic heart disease, the medicinal product is indicated for:

• - the risk reduction of non-fatal myocardial infarction;
• - the risk reduction of non-fatal and fatal stroke;
• - the risk reduction of revascularization procedures;
• - the risk reduction of hospitalization due to congestive heart failure;
• - the risk reduction of stenocardia.

Hyperlipidaemia

      Adults

• - As an adjunct to diet to reduce increased levels of total cholesterol, LDL cholesterol, apolipoprotein B and triglycerides and to increase the level of HDL cholesterol in patients with primary hypercholesterolemia (heterozygous familial and non-family) and mixed dyslipidemia (Types IIa and IIb on the classification of Fredrickson) .
• - As an adjunct to diet for the treatment of patients with increased levels of triglycerides in the blood serum (type IV on the classification of Fredrickson).
• - For the treatment of patients with primary dysbetalipoproteinemia (type III on the classification of Fredrickson) in case when the diet is not effective.
• - For reduction of total cholesterol and LDL cholesterol in patients with homozygous familial hypercholesterolemia as an adjunct to other lipid-lowering treatments (e.g. LDL apheresis) or if such methods of treatment are unavailable.

Children

• - As an adjunct to diet to reduce levels of total cholesterol, LDL cholesterol and apolipoprotein B in boys and girls after the start of menstruation aged 10 to 17 years old with heterozygous familial hypercholesterolemia if after proper diet the test results are:

1. a) LDL cholesterol ³ 190 mg/dL or
2. b) LDL cholesterol ³ 160 mg/dL and:

• a family history has early cardiovascular disease or
• paediatric patients have two or more other risk factors for cardiovascular disease.

 

Contraindications.

Active liver disease, which may include a persistent increase of hepatic transaminase levels of unknown etiology.

Hypersensitivity to the active substance or to any of the excipients of this medicinal product.

Pregnancy.

Breastfeeding.

 

Interaction with other medicinal products and other forms of interaction.

During the treatment with statins the risk of myopathy is increased in case of concomitant use of derivatives of fibric acid, lipidomodified doses of niacin, ciclosporin or potent CYP3A4 inhibitors (e.g. clarithromycin, HIV protease inhibitors and itraconazole) (see sections "Precautions for use" and "Pharmacological properties").

CYP3A4 inhibitors. Atorvastatin is metabolized by cytochrome P450 3A4. Concomitant administration of atorvastatin with potent inhibitors of CYP 3A4 can lead to increased concentrations of atorvastatin in plasma (see Table 3 and details below). The extent of interaction and potentiation depend on variability of effect on CYP 3A4. Co-administration of potent CYP3A4 inhibitors (e.g. ciclosporin, telithromycin, clarithromycin, delavirdine, stiripentol, ketoconazole, voriconazole, itraconazole, posaconazole and HIV protease inhibitors including ritonavir, lopinavir, atazanavir, indinavir, darunavir, etc.) should be avoided if possible.In cases where co- administration of these medicinal products with atorvastatin cannot be avoided lower starting and maximum doses of atorvastatin should be considered and appropriate clinical monitoring of the patient is recommended (see Table 3).

Moderate CYP3A4 inhibitors (e.g. erythromycin, diltiazem, verapamil and fluconazole) may increase plasma concentrations of atorvastatin (see Table 1). An increased risk of myopathy has been observed with the use of erythromycin in combination with statins. Interaction studies evaluating the effects of amiodarone or verapamil on atorvastatin have not been conducted. Both amiodarone and verapamil are known to inhibit CYP3A4 activity and co-administration with atorvastatin may result in increased exposure to atorvastatin. Therefore, a lower maximum dose of atorvastatin should be considered and appropriate clinical monitoring of the patient is recommended when concomitantly used with moderate CYP3A4 inhibitors. Appropriate clinical monitoring is recommended after initiation or following dose adjustments of the inhibitor.

Grapefruit juice. Contains one or more components that inhibit CYP3A4 and may increase plasma concentrations of atorvastatin, especially with excessive grapefruit juice consumption (1.2 litres per day).

Clarithromycin. Atorvastatin AUC values are significantly increased in co-administration of atorvastatin 80 mg and clarithromycin (500 mg twice daily) compared with the use of atorvastatin alone (see section "Pharmacological properties"). Therefore, atorvastatin at the doses above 20 mg should be used with caution in patients treated with clarithromycin (see sections "Precautions for use" and "Method of administration and dosage").

Protease inhibitor combination. Atorvastatin AUC values are ​​significantly increased in the co-administration of atorvastatin with several combinations of HIV protease inhibitors, as well as protease inhibitor hepatitis C virus telaprevir, compared with the use of atorvastatin alone. Therefore, the patients, treated with HIV protease inhibitor ritonavir + typranavir or protease inhibitor of hepatitis C virus telaprevir, should avoid the co-administration of atorvastatin. The preparation should be prescribed with caution in patients treated with HIV protease inhibitor lopinavir + ritonavir and used in the lowest necessary dose. For the patients treated with protease inhibitors HIV saquinavir + ritonavir, darunavir + ritonavir, fosamprenavir, or fosamprenavir + ritonavir, the dose of atorvastatin should not exceed 20 mg and to be used with caution (see sections "Precautions for use" and "Method of administration and dosage"). For the patients treated with HIV protease inhibitor nelfinavir or protease inhibitor of hepatitis C virus boceprevir, the dose of atorvastatin should not exceed 40 mg, and the close clinical monitoring of patients is recommended.

Itraconazole. Atorvastatin AUC values are increased in the co-administration of atorvastatin 40 mg and itraconazole 200 mg. Therefore, the patients, treated with itraconazole, should be careful if the dose of atorvastatin exceeds 20 mg (see sections "Precautions for use" and "Method of administration and dosage").

Ciclosporin. Atorvastatin and its metabolites are substrates of OATP1B1 transporter. OATP1B1 inhibitors (e.g. ciclosporin) may increase the bioavailability of atorvastatin. Atorvastatin AUC values are significantly increased in the co-administration of atorvastatin 10 mg and ciclosporin in the dose of 5.2 mg/kg/day compared with the use of atorvastatin alone (see section "Pharmacological properties"). You should avoid the co-administration of atorvastatin and ciclosporin (see section "Precautions for use").

Medical recommendations for the interactions of medical products are summarized in Table 3 (see sections "Precautions for use" and "Method of administration and dosage").

Table 3

Interactions of medical products associated with increased risk of myopathy/rhabdomyolysis

Interacting medical products	Medical recommendations for use
Ciclosporin, HIV protease inhibitors (typranavir + ritonavir),  protease inhibitor of hepatitis C virus  (telaprevir)	Avoid the use of atorvastatin
HIV protease inhibitor (lopinavir + ritonavir)	Use with caution and in the smallest  necessary dose
Clarithromycin, itraconazole, HIV protease inhibitors (saquinavir + ritonavir*, darunavir + ritonavir, fosamprenavir, fosamprenavir + ritonavir)	Do not exceed the daily dose of  atorvastatin 20 mg
HIV protease inhibitor (nelfinavir) Protease inhibitors of hepatitis C virus (boceprevir)	Do not exceed the  daily dose of  atorvastatin 40 mg

* Use with caution and in the lowest necessary dose.

 

Gemfibrozil. The co-administration of Atorvastatin Ananta with gemfibrozil should be avoided due to the increased risk of myopathy/rhabdomyolysis in the co-administration of HMG-CoA reductase inhibitors and gemfibrozil (see section "Precautions for use").

Other fibrates. Since it is known that during the treatment with HMG-CoA reductase inhibitors, in concomitant use of other fibrates, the risk of myopathy is increased, so atorvastatin should be used with caution in concomitant use with other fibrates (see section "Precautions for use").

Niacin. The risk of adverse reactions of the skeletal muscles could be increased in co-administration of niacin. Therefore, in such circumstances the possibility of atorvastatin dose reduction should be considered (see section "Precautions for use").

Rifampin or other inducers of P450 3A4 cytochrome. Co-administration with inducers of P450 3A4 cytochrome (e.g. efavirenz, rifampin) can lead to unstable reduction of the plasma concentration of atorvastatin. Because of dual mechanism of interaction of rifampin, the concomitant administration of atorvastatin with rifampin is recommended. It was shown that after rifampin introduction, the delayed use of the preparation is associated with a significant decrease in plasma atorvastatin concentrations.

Diltiazem hydrochloride

Co-administration of atorvastatin (40 mg) and diltiazem (240 mg) is accompanied by increased plasma atorvastatin concentrations.

Cimetidine

No features of interaction of atorvastatin and cimetidine have been found.

Antacids

Oral co-administration of atorvastatin and antacid suspension containing magnesium and aluminum hydroxide are accompanied by a decrease of plasma atorvastatin concentrations approximately by 35%. The hypolipidemic effect of atorvastatin was unchanged.

Colestipol

Plasma concentrations of atorvastatin and its active metabolites were lower (atorvastatin concentration ratio 0.74) when colestipol was co-administered with atorvastatin. However, lipid effects were greater when Atorvastatin and colestipol were co-administered than when either medicinal product was given alone.

Azithromycin

Concomitant administration of atorvastatin (10 mg once a day) and azithromycin (500 mg once a day) was not accompanied by changes in the plasma concentration of atorvastatin.

Inhibitors of transport proteins

Inhibitors of transport proteins (e.g. ciclosporin) can increase the level of systemic exposure of atorvastatin (see Table 1). Effect of inhibition of cumulative transport proteins on concentration of atorvastatin in liver cells is unknown. If you cannot avoid the concomitant prescription of these preparations, the reduction of the dose and clinical monitoring of the effectiveness of atorvastatin are recommended (see Table 1).

Ezetimibe

The use of ezetimibe as monotherapy is associated with the development of phenomena in the musculoskeletal system, including rhabdomyolysis. Thus, in the concomitant use of ezetimibe and atorvastatin the risk of these events is increased. It is recommended to carry out a proper clinical monitoring of these patients.

Fusidic acid

The concomitant systemic use of fusidic acid with statins may increase the risk of myopathy, including rhabdomyolysis. The mechanism of this interaction (whether pharmacodynamic or pharmacokinetic, or both) is currently unknown. There have been reports of rhabdomyolysis (including fatalities) in patients receiving a combination of these drugs.

If systemic use of fusidic acid is required, atorvastatin should be discontinued for the entire duration of fusidic acid (see section “Precautions for use”).

Digoxin. In concomitant administration of high doses of atorvastatin and digoxin, the balanced levels of plasma concentration of digoxin are increased (see section “Pharmacokinetics”). Patients taking digoxin should be monitored appropriately.

Oral contraceptives. Co-administration of atorvastatin and oral contraceptives increased AUC values for ethinylestradiol and norethisterone (see section “Pharmacological properties”). These increases should be considered when selecting an oral contraceptive for a woman who takes atorvastatin.

Warfarin. Atorvastatin had no clinically significant effect on prothrombin time in patients who had long-term warfarin treatment.

Colchicine. The cases of myopathy, including rhabdomyolysis were reported in concomitant administration of atorvastatin with colchicine, therefore atorvastatin and colchicine should be used with caution.

Other medicines. Clinical studies have shown that concomitant use of atorvastatin and antihypertensive agents and its use in the oestrogen-replacement therapy are not accompanied by clinically significant side effects. There were no studies regarding the interaction with other preparations.

 

Precautions for use.

Skeletal muscle effects

There are rare cases of rhabdomyolysis with acute renal failure as a result of myoglobinuria when using atorvastatin and other drugs of this class. The history of renal dysfunction may be a risk factor for the development of rhabdomyolysis. Such patients need closer monitoring to detect disorders of the skeletal muscles.

Sometimes atorvastatin, like other agents of statins, causes myopathy, defined as muscle pain or muscle weakness, combined with increased levels of creatine phosphokinase (CPK) more than 10 times of the upper limit of normal. Concomitant use of higher doses of atorvastatin with certain drugs such as ciclosporin and potent inhibitors of CYP3A4 (e.g. clarithromycin, itraconazole and HIV protease inhibitors) increases the risk of myopathy / rhabdomyolysis.

The use of atorvastatin may cause immunologically mediated necrotizing myopathy (IONM) - autoimmune myopathy associated with the use of statins. IONM is characterized by the following features: proximal muscle weakness and elevated levels of creatine in the blood serum which remain despite the discontinuance of statins; muscle biopsy shows necrotizing myopathy without significant inflammation; the use of immunosuppressive agents has a positive action.

The possibility of myopathy should be considered in any patient with diffuse myalgias, muscle pain or weakness, and/or a significant increase of CPK. Patients should be recommended to inform about muscle pain, muscle weakness or pain of unknown etiology, immediately, especially if it is accompanied by a feeling of malaise or fever, or if signs and symptoms remain even after discontinuance of atorvastatin therapy. Treatment should be discontinued if CPK is significantly increased or myopathy is diagnosed or suspected.

During the treatment with the agents of this class, the risk of myopathy is increased with co-administration of ciclosporin, derivatives of fibric acid, erythromycin, clarithromycin, protease inhibitors of hepatitis C virus telaprevir, combinations of HIV protease inhibitors, including saquinavir + ritonavir, lopinavir + ritonavir, typranavir + ritonavir, darunavir + ritonavir, fosamprenavir + ritonavir and fosamprenavir, as well as niacin or azole antimycotics group. Physicians, studying combined therapy of atorvastatin and derivatives of fibric acid, erythromycin, clarithromycin, combinations of saquinavir + ritonavir, lopinavir + ritonavir, darunavir + ritonavir, fosamprenavir, fosamprenavir + ritonavir, antimycotics of azoles or lipidomodified doses of niacin, should fully consider the potential benefits and risks and monitor the state of patients for any signs or symptoms of pain or weakness in muscles, especially during the initial months of therapy and any periods of dose titration towards the increase of any of the drugs. It is necessary to consider the possibility of use of low initial and maintaining doses of atorvastatin in concomitant use of the aforementioned preparations (see section "Interaction with other medicinal products and other forms of interaction"). In such cases the possibility of periodic determination of CPK may be considered. But there is no assurance that such monitoring will prevent the severe cases of myopathy.

In the course of atorvastatin treatment, rare cases of myopathy, including rhabdomyolysis, in concomitant use of atorvastatin with colchicine were reported. That is why colchicine and atorvastatin should be prescribed with caution to patients (see section "Interaction with other medicinal products and other forms of interaction").

Atorvastatin therapy should be discontinued temporarily or completely stopped in any patient with acute serious condition that indicates the development of myopathy, or the presence of risk factors for renal failure due to rhabdomyolysis (e.g. severe acute infection, hypotension, surgery, trauma, severe metabolic, endocrine, and electrolyte disorders, and uncontrolled seizures).

In isolated cases, statins have been reported to induce “de novo” or exacerbate existing myasthenia gravis or ocular myasthenia gravis (see section “Adverse reactions”). In case of exacerbation of symptoms, atorvastatin should be discontinued. Relapses with repeated use of the same or another statin have been reported.

Liver effect

It has been shown that statins, like some other lipid-lowering therapeutic agents, were associated with deviation from the normal biochemical parameters of liver function. Steady increase (more than 3 times the upper limit of the normal range, which is occurred 2 times or more) of the levels of serum transaminases was observed in 0.7% of patients treated with atorvastatin. The incidence of these abnormalities was 0.2%, 0.2%, 0.6% and 2.3% for doses of 10, 20, 40 and 80 mg, respectively.

There is data that jaundice has been developed in one patient treated with the preparation. In the other patients the increased indicators of liver function tests were not associated with jaundice or other clinical signs and symptoms. After a dose reduction of stop when this preparation is used or termination of its use, the transaminase levels were returned to pre-treatment levels or about those without residual effects. 18 of 30 patients with persistent increase of indicators of liver function tests continued the treatment with atorvastatin in lower doses.

Before starting therapy with atorvastatin, it is recommended to get the test results of liver enzymes indicators and to do tests again if there is a clinical necessity. There were rare post-registration reports of lethal and non-lethal liver failure in patients treated with preparations of statins, including atorvastatin. The treatment should be stopped immediately in case of severe liver injury with clinical symptoms and/or hyperbilirubinemia or jaundice during atorvastatin therapy. If there is no alternative etiology, the drug treatment should not be re-started.

Atorvastatin should be used with caution in patients who have alcohol abuse and/or have a history of liver disease. Atorvastatin is contraindicated when active liver disease or stable elevation of liver transaminases of unknown etiology (see section "Contraindications").

Endocrine function

There was reported the increase of HbA1c level and glucose concentration in blood serum when inhibitors of HMG-CoA reductase inhibitors, including atorvastatin.

Statins prevent cholesterol synthesis and theoretically might reduce the secretion of adrenals and/or gonadal steroids. Clinical studies have shown that atorvastatin does not reduce basal plasma cortisol concentration and does not damage the adrenal reserve. Effect of statins on the ability of sperm fertilization was not studied in the sufficient number of patients. It is unknown how the preparation effects on the system of "sex glands-hypophysis-hypothalamus" in women in premenopausal period. Be careful in co-administration of the preparation of statin group with other medical products that can reduce the level or activity of endogenous steroid hormones, such as ketoconazole, spironolactone and cimetidine.

The use in patients with recent cases of stroke or transient ischemic attack.

During the therapy with atorvastatin 80 mg in patients without ischemic heart disease who had a history of stroke or transient ischemic attack within the previous 6 months, a higher incidence rate of haemorrhagic stroke compared to placebo group was reported.

The incidence of lethal haemorrhagic stroke was similar in all treatment groups. The incidence of non-lethal haemorrhagic stroke was significantly higher in atorvastatin group compared to placebo group. Some initial characteristics, including the presence of haemorrhagic and lacunar stroke at the time of study enrolment, were associated with a higher incidence of haemorrhagic stroke in atorvastatin group.

Among patients treated with atorvastatin, aged 65-75 years, there were not observed any general difference in safety and efficacy of this preparation between these patients and younger patients. There were also no differences in response to treatment between elderly and younger patients but we cannot exclude a more sensitivity of some older patients. Since the elderly age (65 years) is the factor of predisposition to myopathy, atorvastatin should be prescribed with caution for elderly people.

Liver failure

Atorvastatin is contraindicated for patients with active liver disease, including persistent increase of liver transaminases of unknown aetiology (see sections "Contraindications" and “Pharmacological properties”).

Before the treatment

Atorvastatin should be prescribed with caution in patients with pre-disposing factors for rhabdomyolysis. CK level should be measured before starting statin treatment in the following situations:

• - renal failure;
• - hypothyroidism;
• - personal or familial history of hereditary muscular disorders;
• - previous history of muscular toxicity with statins or fibrates;
• - previous history of liver disease and/or where substantial quantities of alcohol are consumed.

In elderly (age > 70 years), the necessity of such measurement should be considered, according to the presence of other predisposing factors for rhabdomyolysis.

An increase in plasma levels may occur in cases of interactions and special populations including genetic subpopulations.

In such cases, the risk of treatment should be considered in relation to possible benefit, and clinical monitoring is recommended. If CK levels are significantly elevated (> 5 times ULN) at baseline, treatment should not be initiated.

Creatine kinase measurement

Creatine kinase (CK) should not be measured following strenuous exercise or in the presence of any plausible alternative cause of CK increase as this makes value interpretation difficult. If CK levels are significantly elevated at baseline (> 5 times ULN), levels should be re-measured within 5 to 7 days later to confirm the results.

During the treatment

Patients must be asked to promptly report muscle pain, cramps, or weakness especially if accompanied by malaise or fever.

If such symptoms occur whilst a patient is receiving treatment with atorvastatin, their CK levels should be measured. If these levels are found to be significantly elevated (> 5 times ULN), treatment should be stopped.

If muscular symptoms are severe and cause daily discomfort, even if the CK levels are elevated to ≤ 5 times ULN, treatment discontinuation should be considered.

If symptoms resolve and CK levels return to normal, then re-introduction of atorvastatin or introduction of an alternative statin may be considered at the lowest dose and with close monitoring.

Atorvastatin must be discontinued if clinically significant elevation of CK levels (> 10 times ULN) occur, or if rhabdomyolysis is diagnosed or suspected.

Concomitant treatment with other medicinal products

Risk of rhabdomyolysis is increased when atorvastatin is administered concomitantly with certain medicinal products that may increase the plasma concentration of atorvastatin such as potent inhibitors of CYP3A4 or transport proteins (e.g. ciclosporine, telithromycin, clarithromycin, delavirdine, stiripentol, ketoconazole, voriconazole, itraconazole, posaconazole and HIV protease inhibitors including ritonavir, lopinavir, atazanavir, indinavir, darunavir, etc). The risk of myopathy may also be increased with the concomitant use of gemfibrozil and other fibric acid derivatives, erythromycin, niacin and ezetimibe. If possible, alternative (non-interacting) therapies should be considered instead of above medicinal products.

In cases where co-administration of these medicinal products with atorvastatin is necessary, the benefit and the risk of concurrent treatment should be carefully considered. When patients are receiving medicinal products that increase the plasma concentration of atorvastatin, a lower maximum dose of atorvastatin is recommended. In addition, in the case of potent CYP3A4 inhibitors, a lower starting dose of atorvastatin should be considered and appropriate clinical monitoring of these patients is recommended.

Atorvastatin must not be co-administered with systemic formulations of fusidic acid or within 7 days of stopping fusidic acid treatment. In patients where the use of systemic fusidic acid is considered essential, statin treatment should be discontinued throughout the duration of fusidic acid treatment. There have been reports of rhabdomyolysis (including some fatalities) in patients receiving fusidic acid and statins in combination (see section "Interaction with other medicinal products and other types of interactions"). The patient should be advised to seek medical advice immediately if they experience any symptoms of muscle weakness, pain or tenderness.

Statin therapy may be re-introduced seven days after the last dose of fusidic acid.

In exceptional circumstances, where prolonged systemic fusidic acid is needed, e.g., for the treatment of severe infections, the need for co-administration of Atorvastatin and fusidic acid should only be considered on a case by case basis and under close medical supervision.

Interstitial lung disease

Exceptional cases of interstitial lung disease have been reported with some statins, especially with long-term therapy. Presenting features can include dyspnoea, non- productive cough and deterioration in general health (fatigue, weight loss and fever). If it is suspected a patient has developed interstitial lung disease, statin therapy should be discontinued.

Excipients

The medicinal product includes lactose. This preparation should not be used in patients with rare hereditary diseases associated with intolerance to galactose, Lapp lactase deficiency or disturbance of glucose-galactose malabsorption. Lipidomodified drug therapy should be one of the components of complex therapy for patients with a significantly increased risk for atherosclerotic vascular disease due to hypercholesterolemia.

Drug therapy is recommended as an adjunct to a diet when the results of the diet, limiting consumption of saturated fats and cholesterol, as well as the use of other non-drug measures were not enough. The intake of atorvastatin may be started simultaneously along with the diet for patients with ischemic heart disease or several risk factors for ischemic heart disease.

Limitations of use

Atorvastatin was not studied in conditions where the main deviation from the norm of the lipoprotein is increase of chylomicrons (types I and V on Fredrickson classification).

 

Pregnancy and lactation.

Pregnancy

Risk assessment

Atorvastatin is contraindicated during pregnancy. Safety in pregnant women has not been established. There is no clear benefit of taking lipid-lowering drugs during pregnancy. Since HMG-CoA reductase inhibitors reduce cholesterol synthesis and possibly the synthesis of other biologically active cholesterol derivatives, atorvastatin may affect a foetus. The drug should be discontinued as soon as pregnancy is established (see section “Contraindications”).

The estimated background risk of significant birth defects and miscarriages for the specified population is unknown. In the general US population, the estimated background risk of significant birth defects and miscarriages in clinically determined pregnancies is 2‒4% and 15‒20%, respectively.

Contraception

Atorvastatin may affect a foetus when administered to a pregnant woman. Women of reproductive age should be informed of the need for effective contraception during treatment with this drug.

Clinical data

Limited data from observational studies, meta-analyses and clinical cases on the use of atorvastatin calcium have not shown an increased risk of serious birth defects or miscarriages.

There have been rare reports of congenital abnormalities following intrauterine exposure to other HMG-CoA reductase inhibitors. A prospective follow-up of approximately 100 pregnancies in women treated with simvastatin or lovastatin has shown that the incidence of congenital foetal abnormalities, miscarriages, and prenatal deaths / stillbirths did not exceed the rate expected for the general population.

The number of cases is sufficient to rule out ≥ 3‒4-fold increase in congenital anomalies of foetal development compared to the background frequency. In 89% of pregnant women who were prospectively monitored, treatment with the drug began before pregnancy and stopped during the first trimester after pregnancy.

Breast-feeding

The drug is contraindicated during breastfeeding period. There is no information on the effect of the drug on infants or lactation. It is unknown whether atorvastatin is excreted in breast milk, but it has been shown that another drug in this class is excreted in breast milk; atorvastatin excretes into the milk of rats. Because of the potential for serious adverse reactions, women taking atorvastatin should not breast-feed their infants (see section “Contraindications”).

 

Effects on ability to drive and use machines.

Atorvastatin has negligible influence on reaction rate to drive and use machines.

 

Method of administration and dosage.

Hyperlipidaemia and mixed dyslipidaemia

The recommended initial dose of the drug is 10 or 20 mg once a day. For patients requiring a significant reduction of LDL-C levels (over 45%), the therapy may be started from the dose of 40 mg once a day. Atorvastatin dose rate is between 10 to 80 mg once a day. The preparation can be taken in one-time dose any time regardless of the meal. Initial and maintenance doses of atorvastatin should be adjusted individually, according to the goals of the treatment and patient response. After starting the treatment and/or after titration of atorvastatin dose, the lipid levels should be analysed within a period of 2 to 4 weeks and the dose should be adjusted accordingly.

Heterozygous familial hypercholesterolaemia in paediatric patients (10 – 17-years of age).

It is recommended to use atorvastatin in the initial dose of 10 mg once a day. The usual dose range is 10 to 20 mg orally once a day. The doses of the drug should be individually selected for each patient according to the purpose of treatment. Dose adjustments should be made at intervals of 4 weeks or more.

Homozygous familial hypercholesterolaemia.

The dose of atorvastatin in patients with homozygous familial hypercholesterolemia is 10 to 80 mg daily. Atorvastatin should be used as an adjunct to other lipid-lowering treatments (e.g. LDL apheresis) in these patients or if such treatments are unavailable.

Concurrent lipid-lowering therapy

Atorvastatin can be used with bile acid sequestrants. The combination of inhibitors of HMG-CoA reductase inhibitors (statins) and fibrates should be used with caution (see sections "Precautions for use", "Interaction with other medicinal products and other forms of interaction").

Renal failure.

Kidney disease does not affect the concentration of atorvastatin or reduction of LDL-C in blood plasma. So, there is no need for dose adjustment (see sections "Interaction with other medicinal products and other forms of interaction", "Pharmacokinetics").

The dosage for patients treated with ciclosporin, clarithromycin, itraconazole or certain protease inhibitors

You should avoid treatment with atorvastatin in patients treated with ciclosporin or HIV protease inhibitors (typranavir + ritonavir) or protease inhibitor of hepatitis C virus (telaprevir). Atorvastatin should be used with caution in patients with HIV treated with lopinavir + ritonavir and to be used in the lowest necessary dose. In patients treated with clarithromycin, itraconazole or in patients with HIV treated in a combination with saquinavir + ritonavir, darunavir + ritonavir, fosamprenavir, or fosamprenavir + ritonavir, the therapeutic dose of atorvastatin should be limited to the dose of 20 mg, and it is recommended to conduct the proper clinical examinations to ensure the application of the lowest necessary dose of atorvastatin. In patients treated with protease inhibitor of HIV nelfinavir or protease inhibitor of HCV boceprevir, treatment with atorvastatin should be limited to the dose to 40 mg, and it is recommended to conduct the proper clinical examinations to ensure the application of the lowest necessary dose of atorvastatin (see sections "Precautions for use" and "Interaction with other medicinal products and other forms of interaction").

 

children.

Patients aged 10-17 years with heterozygous familial hypercholesterolemia, in particular adolescent boys and girls after beginning of menstruation period, the significant effect of the preparation on growth or sexual maturation in boys or duration of menstrual cycle in girls has  not been revealed (see sections "Adverse reactions", "Method of administration and dosage"). Adolescent girls should be informed regarding the appropriate methods of contraception during the treatment period with atorvastatin (see section "Pregnancy and lactation").

Efficacy and safety of atorvastatin treatment of children under 10 years-old have not been studied. Therefore the use of atorvastatin in patients of this age group is not recommended.

 

Overdose.

Specific treatment is not available for atorvastatin overdose. Should an overdose occur, the patient should be treated symptomatically and supportive measures instituted, as required. Due to extensive atorvastatin binding to plasma proteins, haemodialysis is not expected to significantly enhance atorvastatin clearance.

 

Adverse reactions.

Table 4 shows the incidence of clinical adverse reactions, regardless of causality, reported in 2% of patients or more and at a frequency higher than in the placebo group in patients treated with atorvastatin (n = 8755), according to 17 placebo-controlled studies.

Clinical adverse reactions occurring in more than 2% of patients treated with any dose of atorvastatin and at a frequency higher than that in the placebo group, regardless of causation (% of patients).

Table 4

Adverse reaction*	Any dose N=8755	10 mg N=3908	20 mg N=188		40 mg N=604		80 mg N=4055	Placebo N=7311
Nasopharyngitis	8.3	12.9	5.3	7		4.2		8.2
Arthralgia	6.9	8.9	11.7	10.6		4.3		6.5
Diarrhea	6.8	7.3	6.4	14.1		5.2		6.3
Pain in extremities	6	8.5	3.7	9.3		3.1		5.9
Urinary tract infection	5.7	6.9	6.4	8		4.1		5.6
Dyspepsia	4.7	5.9	3.2	6		3.3		4.3
Nausea	4	3.7	3.7	7.1		3.8		3.5
Musculoskeletal pain	3.8	5.2	3.2	5.1		2.3		3.6
Muscle spasms	3.6	4.6	4.8	5.1		2.4		3
Myalgia	3.5	3.6	5.9	8.4		2.7		3.1
Insomnia	3	2.8	1.1	5.3		2.8		2.9
Pharyngolaryngeal pain	2.3	3.9	1.6	2.8		0.7		2.1

* Adverse reaction> 2% at any dose is more than the placebo group

 

Other adverse reactions include:

- general disorders: chest pain, swelling of the face, fever, asthenia, rigid neck, fatigue, photosensitivity reaction, generalized oedema, pyrexia, peripheral oedema;

- nervous system disorders: insomnia, dizziness, paraesthesia, drowsiness, amnesia, sleep disturbance, nightmares, decreased libido, emotional lability, incoordination, peripheral neuropathy, torticollis, facial nerve paralysis, hyperkinesia, depression, hypoesthesia, hypertension, headache, dysgeusia;

- gastrointestinal disorders: gastroenteritis, liver dysfunction, colitis, vomiting, nausea, gastritis, dry mouth, rectum haemorrhage, esophagitis, glossitis, mouth ulcers, anorexia, increased appetite, stomatitis, cheilitis, duodenal ulcer, dysphagia, enteritis, melena, bleeding gums, gastric ulcer, tenesmus, ulcerative stomatitis, hepatitis, pancreatitis, cholestatic jaundice, diarrhea, abdominal pain, dyspepsia, constipation, meteorism, epigastrium discomfort, belching, cholestasis;

- musculoskeletal and connective tissue disorders: arthritis, myopathy, myalgia, myositis, muscle cramps; bursitis, tendosynovitis, myasthenia gravis, tendon contracture, musculoskeletal pain, muscle spasms, increased muscle fatigue, neck pain, swollen joints, tendonopathy (sometimes complicated by rupture of a tendon), joint pain, back pain, rhabdomyolysis;

- metabolism and nutrition disorders: peripheral oedema, hyperglycaemia, increase of creatine phosphokinase, gout, weight gain, hypoglycaemia, anorexia, increased transaminases, abnormal liver function tests, increased alkaline phosphatase levels;

- hepatobiliary disorders: hepatic failure;

- skin and subcutaneous tissue disorders: alopecia, pruritus, contact dermatitis, dry skin, increased sweating, acne, urticaria, eczema, seborrhoea, skin ulcers, skin rash, angioedema, bullous dermatitis (including erythema multiforme), Stevens-Johnson syndrome and toxic epidermal necrolysis;

- respiratory, thoracic and mediastinal disorders: sore throat and larynx, bronchitis, rhinitis, pneumonia, dyspnoea, asthma, epistaxis, nasopharyngitis;

- blood and lymphatic system disorders: ecchymosis, anaemia, lymphadenopathy, thrombocytopenia, petechiae;

- immune system disorders: allergic reactions; anaphylaxis;

- sense organs disorders: amblyopia, parosmia, loss of taste, perverted appetite;

- eye disorders: blurred vision, visual disturbance, dry eyes, refraction disturbance, cataract, eye haemorrhage, glaucoma;

- ear and labyrinth disorders: tinnitus, hearing loss;

- reproductive and urinary system disorders: urinary tract infection, haematuria, albuminuria, frequent urinary, cystitis, dysuria, urolithiasis, nocturia, epididymitis, mastopathy, vaginal haemorrhage, uterine bleeding, increase of breast, metrorrhagia, nephritis, urinary incontinence, urinary retention, acute urinary retention, impotence, ejaculation disturbance, leukocyturia, gynaecomastia;

- cardiovascular disorders: palpitation, vasodilatation, syncope, migraine, postural hypotension, phlebitis, arrhythmia, angina, hypotension;

- laboratory disorders: common: liver function test abnormal, blood creatine kinase increased; uncommon: white blood cells urine positive.

As with other HMG-CoA reductase inhibitors elevated serum transaminases have been reported in patients receiving Atorvastatin. These changes were usually mild, transient, and did not require interruption of treatment. Clinically important (> 3 times upper normal limit) elevations in serum transaminases occurred in 0.8% patients treated with atorvastatin. These elevations were dose related and were reversible in all patients.

Elevated serum creatine kinase (CK) levels greater than 3 times upper limit of normal occurred in 2.5% of patients treated with atorvastatin, similar to other HMG-CoA reductase inhibitors in clinical trials. Levels above 10 times the normal upper range occurred in 0.4% patients treated with atorvastatin.

Paediatric population (10-17 years-old). Patients, treated with atorvastatin, have noted that adverse reactions are similar to those in patients of the placebo group. The most common adverse reaction, observed in both groups, regardless causal relationship, was infections.

Post-marketing period

In the post-marketing period the following adverse reactions have been reported. Since these reactions have been reported on a voluntary basis by a population of unknown numbers, it is not always possible to reliably estimate their frequency or to establish a cause and effect relationship with the drug.

The adverse reactions associated with atorvastatin treatment include: anaphylaxis, angioneurotic oedema, bullous rash (including exudative multiform erythema, Stevens-Johnson syndrome, epidermal necrolysis), rhabdomyolysis, myositis, fatigue, tendon rupture, lethal and non-lethal liver failure, dizziness, depression, peripheral neuropathy, pancreatitis and interstitial lung disease.

There have been rare reports of immunologically mediated necrotizing myopathy associated with statin use (see section “Precautions for use”).

There have been rare post-registration reports of cognitive disorders (such as memory loss, forgetfulness, amnesia, memory disorders, confusion) associated with statins. These cognitive disorders have been reported with the use of all statins. In general, they did not belong to the category of serious adverse reactions and were reversible after discontinuation of statins, had different times before onset (1 day to several years) and disappearance (median duration was 3 weeks).

The following adverse reactions have been reported with the use of some statins: sexual function disorder; exceptional cases of interstitial lung disease, especially during long-term treatment.

The following adverse reactions have been reported in post-marketing period.

Blood and lymphatic system disorders: thrombocytopenia.

Immune system disorders: allergic reactions, anaphylaxis (including anaphylactic shock).

Metabolism and nutrition disorders: weight gain.

Nervous system disorders: headache, hypaesthesia, dysgeusia; myasthenia gravis (the incidence of this disorder is unknown).

Gastrointestinal tract disorders: abdominal pain.

Ear and labyrinth disorders: tinnitus.

Eye disorders: ocular myasthenia gravis (the incidence of this disorder is unknown).

Skin and subcutaneous tissue disorders: urticaria.

Musculoskeletal and connective tissue: arthralgia, back pain.

General disorders: chest pain, peripheral oedema, malaise, fatigue.

Laboratory disorders: increase in alanine aminotransferase activity, increase in blood creatine phosphokinase activity.

 

Shelf life. 3 years.

 

Storage conditions.

Store in the original package at a temperature not exceeding 30 °С.

Keep out of the reach of children.

 

Packaging.  10 tablets in a blister, 3 blisters in a box.

 

Terms of dispensing. On prescription.

 

 

Date of last update.

28.01.2025

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

INSTRUCTION

for medical use of the medicinal product

 

ATORVASTATIN 10 ANANTA,

ATORVASTATIN 20 ANANTA

 

 

Composition:

active substance: atorvastatin;

1 tablet contains atorvastatin calcium equivalent to atorvastatin 10 mg or 20 mg;

excipients: lactose, monohydrate; microcrystalline cellulose; magnesium stearate; croscarmellose sodium; corn starch; hydroxypropylcellulose; hydroxypropylmethylcellulose; polyethylene glycol; titanium dioxide (E 171).

 

Pharmaceutical form. Film-coated tablets.

Basic physical and chemical properties: white or almost white, round, biconvex, film-coated tablets.

 

Pharmacotherapeutic group. Lipid-lowering agents, multicomponent. HMG-CoA-reductase inhibitors.  ATC code С10А А05.           

 

Pharmacological properties.

Pharmacodynamics.

Atorvastatin is a synthetic hypolipidemic drug. It is an inhibitor of 3-hydroxy-3-methylglutaryl coenzyme A (HMG-CoA) reductase, an enzyme that catalyzes the conversion of HMG-CoA into mevalonate – the initial and limiting phase of cholesterol biosynthesis.

Atorvastatin is a selective, competitive inhibitor of HMG-CoA reductase, the rate-limiting enzyme responsible for the conversion of 3-hydroxy-3-methyl-glutaryl-coenzyme A to mevalonate, a precursor of sterols, including cholesterol. 

In experimental animals atorvastatin lowers plasma cholesterol and lipoprotein serum concentrations by inhibiting HMG-CoA reductase and subsequently cholesterol biosynthesis in the liver and increases the number of hepatic LDL receptors on the cell surface for enhanced uptake and catabolism of LDL; atorvastatin also reduces LDL production and the number of LDL particles.

Atorvastatin and some of its metabolites are pharmacologically active in humans. The main site of action of atorvastatin is the liver, which plays a major role in cholesterol synthesis and LDL clearance. The drug dose, in contrast to the systemic concentration of the drug, is better correlated with the decreased LDL cholesterol. Individual dose adjustments should be made depending on the therapeutic response (see section “Method of administration and dosage”).

Pharmacokinetics.

Absorption. Atorvastatin is rapidly absorbed after oral administration; maximum plasma concentrations (C_max) occur within 1 to 2 hours. Extent of absorption increases in proportion to atorvastatin dose. The absolute bioavailability 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 hepatic first-pass metabolism. Despite food reduces the rate and rate of drug absorption by approximately 25% and 9% according to Cmax and AUC (area under the “concentration-time” curve), the reduction in LDL cholesterol is similar when taking atorvastatin both with food, and separately. When taking atorvastatin in the evening its concentration in blood plasma was lower (approximately 30% by Cmax and AUC) than at morning intake. However, the reduction in LDL cholesterol is the same regardless of the time of administration (see section "Method of administration and dosage").

Distribution. Mean volume of distribution of atorvastatin is approximately 381 l. Atorvastatin is ≥ 98% bound to plasma proteins.  Concentration blood / plasma ratio is approximately 0.25 indicating a poor drug penetration into erythrocytes. Based on rat trials, it is suggested that atorvastatin can excrete into breast milk (see section "Contraindications" and “Precautions for use”).

Biotransformation. Atorvastatin is metabolized to ortho- and parahydroxylated derivatives and various beta-oxidation products. In vitro, inhibition of HMG-CoA reductase by ortho- and parahydroxylated metabolites is equivalent to that of atorvastatin. Approximately 70% of circulating inhibitory activity for HMG-CoA reductase is attributed to active metabolites. In vitro studies have demonstrated the importance of metabolism of atorvastatin by cytochrome P450 3A4, which is consistent with increased concentrations of the drug in human plasma after concomitant use with erythromycin, a known inhibitor of this isoenzyme (see section "Interactions with other medicinal products and other forms of interaction”).

Elimination. Atorvastatin is eliminated primarily in bile following hepatic and/or extrahepatic metabolism. However, atorvastatin does not appear to undergo significant enterohepatic recirculation. Mean plasma elimination half-life of atorvastatin in humans is approximately 14 hours. The half-life of inhibitory activity for HMG-CoA reductase is approximately 20 to 30 hours due to the contribution of active metabolites. Less than 2% of the dose is excreted in the urine after oral administration.

Special populations

Elderly. Plasma atorvastatin concentrations are higher (approximately 40% for Cmax and 30% for AUC) in healthy elderly subjects (65 years of age) than in young adult patients. Clinical evidence indicates a greater LDL reduction when using any dose in elderly patients compared to young patients (see section “Precautions for use”).

Children. Apparent oral clearance of atorvastatin in paediatric subjects appeared similar to adults when scaled allometrically by body weight. Body weight was the only significant covariate in the population pharmacokinetic model of atorvastatin with data included children with heterozygous familial hypercholesterolemia (aged 10 to 17 years, n = 29), in an open 8-week study.

Gender. Concentrations of atorvastatin in women differ from those in men (approx. 20% higher for Cmax and approx. 10% lower for AUC). However, there is no clinically significant difference in the reduction of LDL cholesterol when administered to men and women.

Renal insufficiency. Kidney diseases do not affect the concentration of atorvastatin in blood plasma or the reduction of cholesterol-LDL, therefore no dose adjustment is required for patients with impaired renal function (see section “Method of administration and dose”, “Precautions of use”).

Haemodialysis. Despite the fact that no studies have been carried out with patients with end-stage renal disease, haemodialysis is not thought to significantly increase the drug clearance. The drug is highly bound to plasma proteins.

Hepatic insufficiency. Atorvastatin plasma concentrations are markedly elevated in patients with chronic alcoholic liver disease. Cmax and AUC values are 4-fold higher in patients with Child-Pugh class A. In patients with Child-Pugh class B, Cmax and AUC values are approximately 16-fold and 11-fold higher (see “Contraindications”).

 

Table 1. Effect of co-administered medicinal products on the pharmacokinetics of atorvastatin

Co-administered medicinal product and dosage regimen	Atorvastatin
	Dose (mg)	Change in AUC&	Change in Cmax&
# Ciclosporin 5.2 mg/kg/day, stable dose	10 mg OD for 28 days	­8.69	­10.66
# Tipranavir 500 mg BID/ Ritonavir 200 mg BID, 7 days	10 mg OD	­9.36	­8.58
# Tipranavir 750 mg every 8 hours, 10 days	20 mg OD	­7.88	­10.60
#, ‡Saquinavir 400 mg BID/ Ritonavir  400 mg BID, 15 days	40 mg OD for 4 days	­ 3.93	­ 4.31
#Clarithromycin 500 mg BID, 9 days	80 mg OD for 8 days	­ 4.54	­ 5.38
#Darunavir 300 mg BID/ Ritonavir 100 mg BID, 9 days	10 mg OD for 4 days	3.45	2.25
#Itraconazole 200 mg OD, 4 days	40 mg OD	3.32	1.20
#Fosamprenavir 700 mg BID/ Ritonavir 100 mg BID, 14 days	10 mg OD for 4 days	2.53	2.84
#Fosamprenavir 1400 mg BID, 14 days	10 mg OD for 4 days	2.30	4.04
#Nelfinavir 1250 mg BID, 14 days	10 mg OD for 28 days	1.74	2.22
#Grapefruit Juice, 240 mL OD*	40 mg, OD	1.37	1.16
Diltiazem 240 mg OD, 28 days	40 mg, OD	1.51	1.00
Erythromycin 500 mg QID, 7 days	10 mg. OD	1.33	1.38
Amlodipine 10 mg, single dose	80 mg, OD	1.18	0.91
Cimetidine 300 mg OD, 4 weeks	10 mg OD for 2 weeks	1.00	0.89
Colestipol 10 mg BID, 28 weeks	40 mg OD for 8 weeks	Не застосовується	0.74**
Maalox TC® 30 ml OD, 17 days	10 mg OD for 15 days	0.66	0.67
Efavirenz 600 mg OD, 14 days	10 mg for 3 days	0.59	1.01
#Rifampin 600 mg OD, 7 days (co-administered) †	40 mg OD	1.12	2.90
#Rifampin 600 mg OD, 5 days (doses separated) †	40 mg OD	0.20	0.60
#Gemfibrozil 600 mg BID, 7 days	40 mg OD	1.35	1.00
#Fenofibrate 160 mg OD, 7 days	40 mg OD	1.03	1.02
#Boceprevir 800 mg 3 times a day, 7 days	40 mg OD	2.32	2.66

 

^&        Ratio by treatment modalities (concomitant use of medicinal products with atorvastatin compared to atorvastatin alone).

 ^#     See sections “Precautions for use” and “Interaction with other medicinal products and other forms of interaction” for clinical significance.

*     When excessive consumption of grapefruit juice (750 ml - 1.2 litres per day or more) the increase of AUC (2.5-fold) and / or the Cmax (71%) became bigger.

 **  Single sample that was obtained in 8-16 hours after taking the dose.

      ^†   By means of a dual mechanism of interaction of rifampin the concomitant use of atorvastatin with rifampin is recommended. Since, there was shown that delayed atorvastatin use after rifampin is associated with a significant decrease in plasma concentrations of atorvastatin.

^‡      The dose of drug combination saquinavir + ritonavir in this study is not a clinically applied dose. The increased exposure of atorvastatin when it used in a clinical conditions might be higher than that one which was observed in this study. Therefore, the drug should be used with caution in the lowest necessary dose.

 

Table 2. Effect of atorvastatin on the pharmacokinetics of co-administered medicinal products

Atorvastatin	Co-administered medicinal product and dosage regimen
	Medicinal product/dose (mg)	Change in AUC	Change in Cmax
80 mg OD for 15 days	Antipyrine 600 mg OD	1.03	0.89
80 mg OD for 10 days	# Digoxin 0.25 mg OD for 20 days	1.15	1.20
40 mg OD for 22 days	Oral contraceptives 1 OD for 2 months - norethisterone 1 mg - ethinyl estradiol 35 mcg	1.28  1.19	1.23  1.30
10 mg OD	Tipranavir 500 mg BID / ritonavir 200 mg BID for 7 days	1.08	0.96
10 mg OD for 4 days	Fosamprenavir 1400 mg BID for 14 days	0.73	0.82
10 mg OD for 4 days	Fosamprenavir 700 mg BID / ritonavir 100 mg BID for 14 days	0.99	0.94

^# See sections “Precautions for use” and “Interaction with other medicinal products and other forms of interaction” for clinical significance.

 

Clinical particulars.

Indications.

Prevention of cardiovascular disease

For adults without clinically significant ischemic heart disease but with several risk factors for ischemic heart disease, such as age, smoking, hypertension, low HDL levels or the presence of early ischemic heart disease in the family history, the medicinal product is indicated for:

• - the risk reduction of myocardial infarction;
• - the risk reduction of stroke;
• - the risk reduction of revascularization procedures and stenocardia.

For patients with type II diabetes and without clinically significant ischemic heart disease but with several risk factors for ischemic heart disease such as retinopathy, albuminuria, smoking or hypertension, the medicinal product indicated for:

• - the risk reduction of myocardial infarction;
• - the risk reduction of stroke.

For patients with clinical ischemic heart disease, the medicinal product is indicated for:

• - the risk reduction of non-fatal myocardial infarction;
• - the risk reduction of non-fatal and fatal stroke;
• - the risk reduction of revascularization procedures;
• - the risk reduction of hospitalization due to congestive heart failure;
• - the risk reduction of stenocardia.

Hyperlipidaemia

      Adults

• - As an adjunct to diet to reduce increased levels of total cholesterol, LDL cholesterol, apolipoprotein B and triglycerides and to increase the level of HDL cholesterol in patients with primary hypercholesterolemia (heterozygous familial and non-family) and mixed dyslipidemia (Types IIa and IIb on the classification of Fredrickson) .
• - As an adjunct to diet for the treatment of patients with increased levels of triglycerides in the blood serum (type IV on the classification of Fredrickson).
• - For the treatment of patients with primary dysbetalipoproteinemia (type III on the classification of Fredrickson) in case when the diet is not effective.
• - For reduction of total cholesterol and LDL cholesterol in patients with homozygous familial hypercholesterolemia as an adjunct to other lipid-lowering treatments (e.g. LDL apheresis) or if such methods of treatment are unavailable.

Children

• - As an adjunct to diet to reduce levels of total cholesterol, LDL cholesterol and apolipoprotein B in boys and girls after the start of menstruation aged 10 to 17 years old with heterozygous familial hypercholesterolemia if after proper diet the test results are:

1. a) LDL cholesterol ³ 190 mg/dL or
2. b) LDL cholesterol ³ 160 mg/dL and:

• a family history has early cardiovascular disease or
• paediatric patients have two or more other risk factors for cardiovascular disease.

 

Contraindications.

Active liver disease, which may include a persistent increase of hepatic transaminase levels of unknown etiology.

Hypersensitivity to the active substance or to any of the excipients of this medicinal product.

Pregnancy.

Breastfeeding.

 

Interaction with other medicinal products and other forms of interaction.

During the treatment with statins the risk of myopathy is increased in case of concomitant use of derivatives of fibric acid, lipidomodified doses of niacin, ciclosporin or potent CYP3A4 inhibitors (e.g. clarithromycin, HIV protease inhibitors and itraconazole) (see sections "Precautions for use" and "Pharmacological properties").

CYP3A4 inhibitors. Atorvastatin is metabolized by cytochrome P450 3A4. Concomitant administration of atorvastatin with potent inhibitors of CYP 3A4 can lead to increased concentrations of atorvastatin in plasma (see Table 3 and details below). The extent of interaction and potentiation depend on variability of effect on CYP 3A4. Co-administration of potent CYP3A4 inhibitors (e.g. ciclosporin, telithromycin, clarithromycin, delavirdine, stiripentol, ketoconazole, voriconazole, itraconazole, posaconazole and HIV protease inhibitors including ritonavir, lopinavir, atazanavir, indinavir, darunavir, etc.) should be avoided if possible.In cases where co- administration of these medicinal products with atorvastatin cannot be avoided lower starting and maximum doses of atorvastatin should be considered and appropriate clinical monitoring of the patient is recommended (see Table 3).

Moderate CYP3A4 inhibitors (e.g. erythromycin, diltiazem, verapamil and fluconazole) may increase plasma concentrations of atorvastatin (see Table 1). An increased risk of myopathy has been observed with the use of erythromycin in combination with statins. Interaction studies evaluating the effects of amiodarone or verapamil on atorvastatin have not been conducted. Both amiodarone and verapamil are known to inhibit CYP3A4 activity and co-administration with atorvastatin may result in increased exposure to atorvastatin. Therefore, a lower maximum dose of atorvastatin should be considered and appropriate clinical monitoring of the patient is recommended when concomitantly used with moderate CYP3A4 inhibitors. Appropriate clinical monitoring is recommended after initiation or following dose adjustments of the inhibitor.

Grapefruit juice. Contains one or more components that inhibit CYP3A4 and may increase plasma concentrations of atorvastatin, especially with excessive grapefruit juice consumption (1.2 litres per day).

Clarithromycin. Atorvastatin AUC values are significantly increased in co-administration of atorvastatin 80 mg and clarithromycin (500 mg twice daily) compared with the use of atorvastatin alone (see section "Pharmacological properties"). Therefore, atorvastatin at the doses above 20 mg should be used with caution in patients treated with clarithromycin (see sections "Precautions for use" and "Method of administration and dosage").

Protease inhibitor combination. Atorvastatin AUC values are ​​significantly increased in the co-administration of atorvastatin with several combinations of HIV protease inhibitors, as well as protease inhibitor hepatitis C virus telaprevir, compared with the use of atorvastatin alone. Therefore, the patients, treated with HIV protease inhibitor ritonavir + typranavir or protease inhibitor of hepatitis C virus telaprevir, should avoid the co-administration of atorvastatin. The preparation should be prescribed with caution in patients treated with HIV protease inhibitor lopinavir + ritonavir and used in the lowest necessary dose. For the patients treated with protease inhibitors HIV saquinavir + ritonavir, darunavir + ritonavir, fosamprenavir, or fosamprenavir + ritonavir, the dose of atorvastatin should not exceed 20 mg and to be used with caution (see sections "Precautions for use" and "Method of administration and dosage"). For the patients treated with HIV protease inhibitor nelfinavir or protease inhibitor of hepatitis C virus boceprevir, the dose of atorvastatin should not exceed 40 mg, and the close clinical monitoring of patients is recommended.

Itraconazole. Atorvastatin AUC values are increased in the co-administration of atorvastatin 40 mg and itraconazole 200 mg. Therefore, the patients, treated with itraconazole, should be careful if the dose of atorvastatin exceeds 20 mg (see sections "Precautions for use" and "Method of administration and dosage").

Ciclosporin. Atorvastatin and its metabolites are substrates of OATP1B1 transporter. OATP1B1 inhibitors (e.g. ciclosporin) may increase the bioavailability of atorvastatin. Atorvastatin AUC values are significantly increased in the co-administration of atorvastatin 10 mg and ciclosporin in the dose of 5.2 mg/kg/day compared with the use of atorvastatin alone (see section "Pharmacological properties"). You should avoid the co-administration of atorvastatin and ciclosporin (see section "Precautions for use").

Medical recommendations for the interactions of medical products are summarized in Table 3 (see sections "Precautions for use" and "Method of administration and dosage").

Table 3

Interactions of medical products associated with increased risk of myopathy/rhabdomyolysis

Interacting medical products	Medical recommendations for use
Ciclosporin, HIV protease inhibitors (typranavir + ritonavir),  protease inhibitor of hepatitis C virus  (telaprevir)	Avoid the use of atorvastatin
HIV protease inhibitor (lopinavir + ritonavir)	Use with caution and in the smallest  necessary dose
Clarithromycin, itraconazole, HIV protease inhibitors (saquinavir + ritonavir*, darunavir + ritonavir, fosamprenavir, fosamprenavir + ritonavir)	Do not exceed the daily dose of  atorvastatin 20 mg
HIV protease inhibitor (nelfinavir) Protease inhibitors of hepatitis C virus (boceprevir)	Do not exceed the  daily dose of  atorvastatin 40 mg

* Use with caution and in the lowest necessary dose.

 

Gemfibrozil. The co-administration of Atorvastatin Ananta with gemfibrozil should be avoided due to the increased risk of myopathy/rhabdomyolysis in the co-administration of HMG-CoA reductase inhibitors and gemfibrozil (see section "Precautions for use").

Other fibrates. Since it is known that during the treatment with HMG-CoA reductase inhibitors, in concomitant use of other fibrates, the risk of myopathy is increased, so atorvastatin should be used with caution in concomitant use with other fibrates (see section "Precautions for use").

Niacin. The risk of adverse reactions of the skeletal muscles could be increased in co-administration of niacin. Therefore, in such circumstances the possibility of atorvastatin dose reduction should be considered (see section "Precautions for use").

Rifampin or other inducers of P450 3A4 cytochrome. Co-administration with inducers of P450 3A4 cytochrome (e.g. efavirenz, rifampin) can lead to unstable reduction of the plasma concentration of atorvastatin. Because of dual mechanism of interaction of rifampin, the concomitant administration of atorvastatin with rifampin is recommended. It was shown that after rifampin introduction, the delayed use of the preparation is associated with a significant decrease in plasma atorvastatin concentrations.

Diltiazem hydrochloride

Co-administration of atorvastatin (40 mg) and diltiazem (240 mg) is accompanied by increased plasma atorvastatin concentrations.

Cimetidine

No features of interaction of atorvastatin and cimetidine have been found.

Antacids

Oral co-administration of atorvastatin and antacid suspension containing magnesium and aluminum hydroxide are accompanied by a decrease of plasma atorvastatin concentrations approximately by 35%. The hypolipidemic effect of atorvastatin was unchanged.

Colestipol

Plasma concentrations of atorvastatin and its active metabolites were lower (atorvastatin concentration ratio 0.74) when colestipol was co-administered with atorvastatin. However, lipid effects were greater when Atorvastatin and colestipol were co-administered than when either medicinal product was given alone.

Azithromycin

Concomitant administration of atorvastatin (10 mg once a day) and azithromycin (500 mg once a day) was not accompanied by changes in the plasma concentration of atorvastatin.

Inhibitors of transport proteins

Inhibitors of transport proteins (e.g. ciclosporin) can increase the level of systemic exposure of atorvastatin (see Table 1). Effect of inhibition of cumulative transport proteins on concentration of atorvastatin in liver cells is unknown. If you cannot avoid the concomitant prescription of these preparations, the reduction of the dose and clinical monitoring of the effectiveness of atorvastatin are recommended (see Table 1).

Ezetimibe

The use of ezetimibe as monotherapy is associated with the development of phenomena in the musculoskeletal system, including rhabdomyolysis. Thus, in the concomitant use of ezetimibe and atorvastatin the risk of these events is increased. It is recommended to carry out a proper clinical monitoring of these patients.

Fusidic acid

The concomitant systemic use of fusidic acid with statins may increase the risk of myopathy, including rhabdomyolysis. The mechanism of this interaction (whether pharmacodynamic or pharmacokinetic, or both) is currently unknown. There have been reports of rhabdomyolysis (including fatalities) in patients receiving a combination of these drugs.

If systemic use of fusidic acid is required, atorvastatin should be discontinued for the entire duration of fusidic acid (see section “Precautions for use”).

Digoxin. In concomitant administration of high doses of atorvastatin and digoxin, the balanced levels of plasma concentration of digoxin are increased (see section “Pharmacokinetics”). Patients taking digoxin should be monitored appropriately.

Oral contraceptives. Co-administration of atorvastatin and oral contraceptives increased AUC values for ethinylestradiol and norethisterone (see section “Pharmacological properties”). These increases should be considered when selecting an oral contraceptive for a woman who takes atorvastatin.

Warfarin. Atorvastatin had no clinically significant effect on prothrombin time in patients who had long-term warfarin treatment.

Colchicine. The cases of myopathy, including rhabdomyolysis were reported in concomitant administration of atorvastatin with colchicine, therefore atorvastatin and colchicine should be used with caution.

Other medicines. Clinical studies have shown that concomitant use of atorvastatin and antihypertensive agents and its use in the oestrogen-replacement therapy are not accompanied by clinically significant side effects. There were no studies regarding the interaction with other preparations.

 

Precautions for use.

Skeletal muscle effects

There are rare cases of rhabdomyolysis with acute renal failure as a result of myoglobinuria when using atorvastatin and other drugs of this class. The history of renal dysfunction may be a risk factor for the development of rhabdomyolysis. Such patients need closer monitoring to detect disorders of the skeletal muscles.

Sometimes atorvastatin, like other agents of statins, causes myopathy, defined as muscle pain or muscle weakness, combined with increased levels of creatine phosphokinase (CPK) more than 10 times of the upper limit of normal. Concomitant use of higher doses of atorvastatin with certain drugs such as ciclosporin and potent inhibitors of CYP3A4 (e.g. clarithromycin, itraconazole and HIV protease inhibitors) increases the risk of myopathy / rhabdomyolysis.

The use of atorvastatin may cause immunologically mediated necrotizing myopathy (IONM) - autoimmune myopathy associated with the use of statins. IONM is characterized by the following features: proximal muscle weakness and elevated levels of creatine in the blood serum which remain despite the discontinuance of statins; muscle biopsy shows necrotizing myopathy without significant inflammation; the use of immunosuppressive agents has a positive action.

The possibility of myopathy should be considered in any patient with diffuse myalgias, muscle pain or weakness, and/or a significant increase of CPK. Patients should be recommended to inform about muscle pain, muscle weakness or pain of unknown etiology, immediately, especially if it is accompanied by a feeling of malaise or fever, or if signs and symptoms remain even after discontinuance of atorvastatin therapy. Treatment should be discontinued if CPK is significantly increased or myopathy is diagnosed or suspected.

During the treatment with the agents of this class, the risk of myopathy is increased with co-administration of ciclosporin, derivatives of fibric acid, erythromycin, clarithromycin, protease inhibitors of hepatitis C virus telaprevir, combinations of HIV protease inhibitors, including saquinavir + ritonavir, lopinavir + ritonavir, typranavir + ritonavir, darunavir + ritonavir, fosamprenavir + ritonavir and fosamprenavir, as well as niacin or azole antimycotics group. Physicians, studying combined therapy of atorvastatin and derivatives of fibric acid, erythromycin, clarithromycin, combinations of saquinavir + ritonavir, lopinavir + ritonavir, darunavir + ritonavir, fosamprenavir, fosamprenavir + ritonavir, antimycotics of azoles or lipidomodified doses of niacin, should fully consider the potential benefits and risks and monitor the state of patients for any signs or symptoms of pain or weakness in muscles, especially during the initial months of therapy and any periods of dose titration towards the increase of any of the drugs. It is necessary to consider the possibility of use of low initial and maintaining doses of atorvastatin in concomitant use of the aforementioned preparations (see section "Interaction with other medicinal products and other forms of interaction"). In such cases the possibility of periodic determination of CPK may be considered. But there is no assurance that such monitoring will prevent the severe cases of myopathy.

In the course of atorvastatin treatment, rare cases of myopathy, including rhabdomyolysis, in concomitant use of atorvastatin with colchicine were reported. That is why colchicine and atorvastatin should be prescribed with caution to patients (see section "Interaction with other medicinal products and other forms of interaction").

Atorvastatin therapy should be discontinued temporarily or completely stopped in any patient with acute serious condition that indicates the development of myopathy, or the presence of risk factors for renal failure due to rhabdomyolysis (e.g. severe acute infection, hypotension, surgery, trauma, severe metabolic, endocrine, and electrolyte disorders, and uncontrolled seizures).

In isolated cases, statins have been reported to induce “de novo” or exacerbate existing myasthenia gravis or ocular myasthenia gravis (see section “Adverse reactions”). In case of exacerbation of symptoms, atorvastatin should be discontinued. Relapses with repeated use of the same or another statin have been reported.

Liver effect

It has been shown that statins, like some other lipid-lowering therapeutic agents, were associated with deviation from the normal biochemical parameters of liver function. Steady increase (more than 3 times the upper limit of the normal range, which is occurred 2 times or more) of the levels of serum transaminases was observed in 0.7% of patients treated with atorvastatin. The incidence of these abnormalities was 0.2%, 0.2%, 0.6% and 2.3% for doses of 10, 20, 40 and 80 mg, respectively.

There is data that jaundice has been developed in one patient treated with the preparation. In the other patients the increased indicators of liver function tests were not associated with jaundice or other clinical signs and symptoms. After a dose reduction of stop when this preparation is used or termination of its use, the transaminase levels were returned to pre-treatment levels or about those without residual effects. 18 of 30 patients with persistent increase of indicators of liver function tests continued the treatment with atorvastatin in lower doses.

Before starting therapy with atorvastatin, it is recommended to get the test results of liver enzymes indicators and to do tests again if there is a clinical necessity. There were rare post-registration reports of lethal and non-lethal liver failure in patients treated with preparations of statins, including atorvastatin. The treatment should be stopped immediately in case of severe liver injury with clinical symptoms and/or hyperbilirubinemia or jaundice during atorvastatin therapy. If there is no alternative etiology, the drug treatment should not be re-started.

Atorvastatin should be used with caution in patients who have alcohol abuse and/or have a history of liver disease. Atorvastatin is contraindicated when active liver disease or stable elevation of liver transaminases of unknown etiology (see section "Contraindications").

Endocrine function

There was reported the increase of HbA1c level and glucose concentration in blood serum when inhibitors of HMG-CoA reductase inhibitors, including atorvastatin.

Statins prevent cholesterol synthesis and theoretically might reduce the secretion of adrenals and/or gonadal steroids. Clinical studies have shown that atorvastatin does not reduce basal plasma cortisol concentration and does not damage the adrenal reserve. Effect of statins on the ability of sperm fertilization was not studied in the sufficient number of patients. It is unknown how the preparation effects on the system of "sex glands-hypophysis-hypothalamus" in women in premenopausal period. Be careful in co-administration of the preparation of statin group with other medical products that can reduce the level or activity of endogenous steroid hormones, such as ketoconazole, spironolactone and cimetidine.

The use in patients with recent cases of stroke or transient ischemic attack.

During the therapy with atorvastatin 80 mg in patients without ischemic heart disease who had a history of stroke or transient ischemic attack within the previous 6 months, a higher incidence rate of haemorrhagic stroke compared to placebo group was reported.

The incidence of lethal haemorrhagic stroke was similar in all treatment groups. The incidence of non-lethal haemorrhagic stroke was significantly higher in atorvastatin group compared to placebo group. Some initial characteristics, including the presence of haemorrhagic and lacunar stroke at the time of study enrolment, were associated with a higher incidence of haemorrhagic stroke in atorvastatin group.

Among patients treated with atorvastatin, aged 65-75 years, there were not observed any general difference in safety and efficacy of this preparation between these patients and younger patients. There were also no differences in response to treatment between elderly and younger patients but we cannot exclude a more sensitivity of some older patients. Since the elderly age (65 years) is the factor of predisposition to myopathy, atorvastatin should be prescribed with caution for elderly people.

Liver failure

Atorvastatin is contraindicated for patients with active liver disease, including persistent increase of liver transaminases of unknown aetiology (see sections "Contraindications" and “Pharmacological properties”).

Before the treatment

Atorvastatin should be prescribed with caution in patients with pre-disposing factors for rhabdomyolysis. CK level should be measured before starting statin treatment in the following situations:

• - renal failure;
• - hypothyroidism;
• - personal or familial history of hereditary muscular disorders;
• - previous history of muscular toxicity with statins or fibrates;
• - previous history of liver disease and/or where substantial quantities of alcohol are consumed.

In elderly (age > 70 years), the necessity of such measurement should be considered, according to the presence of other predisposing factors for rhabdomyolysis.

An increase in plasma levels may occur in cases of interactions and special populations including genetic subpopulations.

In such cases, the risk of treatment should be considered in relation to possible benefit, and clinical monitoring is recommended. If CK levels are significantly elevated (> 5 times ULN) at baseline, treatment should not be initiated.

Creatine kinase measurement

Creatine kinase (CK) should not be measured following strenuous exercise or in the presence of any plausible alternative cause of CK increase as this makes value interpretation difficult. If CK levels are significantly elevated at baseline (> 5 times ULN), levels should be re-measured within 5 to 7 days later to confirm the results.

During the treatment

Patients must be asked to promptly report muscle pain, cramps, or weakness especially if accompanied by malaise or fever.

If such symptoms occur whilst a patient is receiving treatment with atorvastatin, their CK levels should be measured. If these levels are found to be significantly elevated (> 5 times ULN), treatment should be stopped.

If muscular symptoms are severe and cause daily discomfort, even if the CK levels are elevated to ≤ 5 times ULN, treatment discontinuation should be considered.

If symptoms resolve and CK levels return to normal, then re-introduction of atorvastatin or introduction of an alternative statin may be considered at the lowest dose and with close monitoring.

Atorvastatin must be discontinued if clinically significant elevation of CK levels (> 10 times ULN) occur, or if rhabdomyolysis is diagnosed or suspected.

Concomitant treatment with other medicinal products

Risk of rhabdomyolysis is increased when atorvastatin is administered concomitantly with certain medicinal products that may increase the plasma concentration of atorvastatin such as potent inhibitors of CYP3A4 or transport proteins (e.g. ciclosporine, telithromycin, clarithromycin, delavirdine, stiripentol, ketoconazole, voriconazole, itraconazole, posaconazole and HIV protease inhibitors including ritonavir, lopinavir, atazanavir, indinavir, darunavir, etc). The risk of myopathy may also be increased with the concomitant use of gemfibrozil and other fibric acid derivatives, erythromycin, niacin and ezetimibe. If possible, alternative (non-interacting) therapies should be considered instead of above medicinal products.

In cases where co-administration of these medicinal products with atorvastatin is necessary, the benefit and the risk of concurrent treatment should be carefully considered. When patients are receiving medicinal products that increase the plasma concentration of atorvastatin, a lower maximum dose of atorvastatin is recommended. In addition, in the case of potent CYP3A4 inhibitors, a lower starting dose of atorvastatin should be considered and appropriate clinical monitoring of these patients is recommended.

Atorvastatin must not be co-administered with systemic formulations of fusidic acid or within 7 days of stopping fusidic acid treatment. In patients where the use of systemic fusidic acid is considered essential, statin treatment should be discontinued throughout the duration of fusidic acid treatment. There have been reports of rhabdomyolysis (including some fatalities) in patients receiving fusidic acid and statins in combination (see section "Interaction with other medicinal products and other types of interactions"). The patient should be advised to seek medical advice immediately if they experience any symptoms of muscle weakness, pain or tenderness.

Statin therapy may be re-introduced seven days after the last dose of fusidic acid.

In exceptional circumstances, where prolonged systemic fusidic acid is needed, e.g., for the treatment of severe infections, the need for co-administration of Atorvastatin and fusidic acid should only be considered on a case by case basis and under close medical supervision.

Interstitial lung disease

Exceptional cases of interstitial lung disease have been reported with some statins, especially with long-term therapy. Presenting features can include dyspnoea, non- productive cough and deterioration in general health (fatigue, weight loss and fever). If it is suspected a patient has developed interstitial lung disease, statin therapy should be discontinued.

Excipients

The medicinal product includes lactose. This preparation should not be used in patients with rare hereditary diseases associated with intolerance to galactose, Lapp lactase deficiency or disturbance of glucose-galactose malabsorption. Lipidomodified drug therapy should be one of the components of complex therapy for patients with a significantly increased risk for atherosclerotic vascular disease due to hypercholesterolemia.

Drug therapy is recommended as an adjunct to a diet when the results of the diet, limiting consumption of saturated fats and cholesterol, as well as the use of other non-drug measures were not enough. The intake of atorvastatin may be started simultaneously along with the diet for patients with ischemic heart disease or several risk factors for ischemic heart disease.

Limitations of use

Atorvastatin was not studied in conditions where the main deviation from the norm of the lipoprotein is increase of chylomicrons (types I and V on Fredrickson classification).

 

Pregnancy and lactation.

Pregnancy

Risk assessment

Atorvastatin is contraindicated during pregnancy. Safety in pregnant women has not been established. There is no clear benefit of taking lipid-lowering drugs during pregnancy. Since HMG-CoA reductase inhibitors reduce cholesterol synthesis and possibly the synthesis of other biologically active cholesterol derivatives, atorvastatin may affect a foetus. The drug should be discontinued as soon as pregnancy is established (see section “Contraindications”).

The estimated background risk of significant birth defects and miscarriages for the specified population is unknown. In the general US population, the estimated background risk of significant birth defects and miscarriages in clinically determined pregnancies is 2‒4% and 15‒20%, respectively.

Contraception

Atorvastatin may affect a foetus when administered to a pregnant woman. Women of reproductive age should be informed of the need for effective contraception during treatment with this drug.

Clinical data

Limited data from observational studies, meta-analyses and clinical cases on the use of atorvastatin calcium have not shown an increased risk of serious birth defects or miscarriages.

There have been rare reports of congenital abnormalities following intrauterine exposure to other HMG-CoA reductase inhibitors. A prospective follow-up of approximately 100 pregnancies in women treated with simvastatin or lovastatin has shown that the incidence of congenital foetal abnormalities, miscarriages, and prenatal deaths / stillbirths did not exceed the rate expected for the general population.

The number of cases is sufficient to rule out ≥ 3‒4-fold increase in congenital anomalies of foetal development compared to the background frequency. In 89% of pregnant women who were prospectively monitored, treatment with the drug began before pregnancy and stopped during the first trimester after pregnancy.

Breast-feeding

The drug is contraindicated during breastfeeding period. There is no information on the effect of the drug on infants or lactation. It is unknown whether atorvastatin is excreted in breast milk, but it has been shown that another drug in this class is excreted in breast milk; atorvastatin excretes into the milk of rats. Because of the potential for serious adverse reactions, women taking atorvastatin should not breast-feed their infants (see section “Contraindications”).

 

Effects on ability to drive and use machines.

Atorvastatin has negligible influence on reaction rate to drive and use machines.

 

Method of administration and dosage.

Hyperlipidaemia and mixed dyslipidaemia

The recommended initial dose of the drug is 10 or 20 mg once a day. For patients requiring a significant reduction of LDL-C levels (over 45%), the therapy may be started from the dose of 40 mg once a day. Atorvastatin dose rate is between 10 to 80 mg once a day. The preparation can be taken in one-time dose any time regardless of the meal. Initial and maintenance doses of atorvastatin should be adjusted individually, according to the goals of the treatment and patient response. After starting the treatment and/or after titration of atorvastatin dose, the lipid levels should be analysed within a period of 2 to 4 weeks and the dose should be adjusted accordingly.

Heterozygous familial hypercholesterolaemia in paediatric patients (10 – 17-years of age).

It is recommended to use atorvastatin in the initial dose of 10 mg once a day. The usual dose range is 10 to 20 mg orally once a day. The doses of the drug should be individually selected for each patient according to the purpose of treatment. Dose adjustments should be made at intervals of 4 weeks or more.

Homozygous familial hypercholesterolaemia.

The dose of atorvastatin in patients with homozygous familial hypercholesterolemia is 10 to 80 mg daily. Atorvastatin should be used as an adjunct to other lipid-lowering treatments (e.g. LDL apheresis) in these patients or if such treatments are unavailable.

Concurrent lipid-lowering therapy

Atorvastatin can be used with bile acid sequestrants. The combination of inhibitors of HMG-CoA reductase inhibitors (statins) and fibrates should be used with caution (see sections "Precautions for use", "Interaction with other medicinal products and other forms of interaction").

Renal failure.

Kidney disease does not affect the concentration of atorvastatin or reduction of LDL-C in blood plasma. So, there is no need for dose adjustment (see sections "Interaction with other medicinal products and other forms of interaction", "Pharmacokinetics").

The dosage for patients treated with ciclosporin, clarithromycin, itraconazole or certain protease inhibitors

You should avoid treatment with atorvastatin in patients treated with ciclosporin or HIV protease inhibitors (typranavir + ritonavir) or protease inhibitor of hepatitis C virus (telaprevir). Atorvastatin should be used with caution in patients with HIV treated with lopinavir + ritonavir and to be used in the lowest necessary dose. In patients treated with clarithromycin, itraconazole or in patients with HIV treated in a combination with saquinavir + ritonavir, darunavir + ritonavir, fosamprenavir, or fosamprenavir + ritonavir, the therapeutic dose of atorvastatin should be limited to the dose of 20 mg, and it is recommended to conduct the proper clinical examinations to ensure the application of the lowest necessary dose of atorvastatin. In patients treated with protease inhibitor of HIV nelfinavir or protease inhibitor of HCV boceprevir, treatment with atorvastatin should be limited to the dose to 40 mg, and it is recommended to conduct the proper clinical examinations to ensure the application of the lowest necessary dose of atorvastatin (see sections "Precautions for use" and "Interaction with other medicinal products and other forms of interaction").

 

children.

Patients aged 10-17 years with heterozygous familial hypercholesterolemia, in particular adolescent boys and girls after beginning of menstruation period, the significant effect of the preparation on growth or sexual maturation in boys or duration of menstrual cycle in girls has  not been revealed (see sections "Adverse reactions", "Method of administration and dosage"). Adolescent girls should be informed regarding the appropriate methods of contraception during the treatment period with atorvastatin (see section "Pregnancy and lactation").

Efficacy and safety of atorvastatin treatment of children under 10 years-old have not been studied. Therefore the use of atorvastatin in patients of this age group is not recommended.

 

Overdose.

Specific treatment is not available for atorvastatin overdose. Should an overdose occur, the patient should be treated symptomatically and supportive measures instituted, as required. Due to extensive atorvastatin binding to plasma proteins, haemodialysis is not expected to significantly enhance atorvastatin clearance.

 

Adverse reactions.

Table 4 shows the incidence of clinical adverse reactions, regardless of causality, reported in 2% of patients or more and at a frequency higher than in the placebo group in patients treated with atorvastatin (n = 8755), according to 17 placebo-controlled studies.

Clinical adverse reactions occurring in more than 2% of patients treated with any dose of atorvastatin and at a frequency higher than that in the placebo group, regardless of causation (% of patients).

Table 4

Adverse reaction*	Any dose N=8755	10 mg N=3908	20 mg N=188		40 mg N=604		80 mg N=4055	Placebo N=7311
Nasopharyngitis	8.3	12.9	5.3	7		4.2		8.2
Arthralgia	6.9	8.9	11.7	10.6		4.3		6.5
Diarrhea	6.8	7.3	6.4	14.1		5.2		6.3
Pain in extremities	6	8.5	3.7	9.3		3.1		5.9
Urinary tract infection	5.7	6.9	6.4	8		4.1		5.6
Dyspepsia	4.7	5.9	3.2	6		3.3		4.3
Nausea	4	3.7	3.7	7.1		3.8		3.5
Musculoskeletal pain	3.8	5.2	3.2	5.1		2.3		3.6
Muscle spasms	3.6	4.6	4.8	5.1		2.4		3
Myalgia	3.5	3.6	5.9	8.4		2.7		3.1
Insomnia	3	2.8	1.1	5.3		2.8		2.9
Pharyngolaryngeal pain	2.3	3.9	1.6	2.8		0.7		2.1

* Adverse reaction> 2% at any dose is more than the placebo group

 

Other adverse reactions include:

- general disorders: chest pain, swelling of the face, fever, asthenia, rigid neck, fatigue, photosensitivity reaction, generalized oedema, pyrexia, peripheral oedema;

- nervous system disorders: insomnia, dizziness, paraesthesia, drowsiness, amnesia, sleep disturbance, nightmares, decreased libido, emotional lability, incoordination, peripheral neuropathy, torticollis, facial nerve paralysis, hyperkinesia, depression, hypoesthesia, hypertension, headache, dysgeusia;

- gastrointestinal disorders: gastroenteritis, liver dysfunction, colitis, vomiting, nausea, gastritis, dry mouth, rectum haemorrhage, esophagitis, glossitis, mouth ulcers, anorexia, increased appetite, stomatitis, cheilitis, duodenal ulcer, dysphagia, enteritis, melena, bleeding gums, gastric ulcer, tenesmus, ulcerative stomatitis, hepatitis, pancreatitis, cholestatic jaundice, diarrhea, abdominal pain, dyspepsia, constipation, meteorism, epigastrium discomfort, belching, cholestasis;

- musculoskeletal and connective tissue disorders: arthritis, myopathy, myalgia, myositis, muscle cramps; bursitis, tendosynovitis, myasthenia gravis, tendon contracture, musculoskeletal pain, muscle spasms, increased muscle fatigue, neck pain, swollen joints, tendonopathy (sometimes complicated by rupture of a tendon), joint pain, back pain, rhabdomyolysis;

- metabolism and nutrition disorders: peripheral oedema, hyperglycaemia, increase of creatine phosphokinase, gout, weight gain, hypoglycaemia, anorexia, increased transaminases, abnormal liver function tests, increased alkaline phosphatase levels;

- hepatobiliary disorders: hepatic failure;

- skin and subcutaneous tissue disorders: alopecia, pruritus, contact dermatitis, dry skin, increased sweating, acne, urticaria, eczema, seborrhoea, skin ulcers, skin rash, angioedema, bullous dermatitis (including erythema multiforme), Stevens-Johnson syndrome and toxic epidermal necrolysis;

- respiratory, thoracic and mediastinal disorders: sore throat and larynx, bronchitis, rhinitis, pneumonia, dyspnoea, asthma, epistaxis, nasopharyngitis;

- blood and lymphatic system disorders: ecchymosis, anaemia, lymphadenopathy, thrombocytopenia, petechiae;

- immune system disorders: allergic reactions; anaphylaxis;

- sense organs disorders: amblyopia, parosmia, loss of taste, perverted appetite;

- eye disorders: blurred vision, visual disturbance, dry eyes, refraction disturbance, cataract, eye haemorrhage, glaucoma;

- ear and labyrinth disorders: tinnitus, hearing loss;

- reproductive and urinary system disorders: urinary tract infection, haematuria, albuminuria, frequent urinary, cystitis, dysuria, urolithiasis, nocturia, epididymitis, mastopathy, vaginal haemorrhage, uterine bleeding, increase of breast, metrorrhagia, nephritis, urinary incontinence, urinary retention, acute urinary retention, impotence, ejaculation disturbance, leukocyturia, gynaecomastia;

- cardiovascular disorders: palpitation, vasodilatation, syncope, migraine, postural hypotension, phlebitis, arrhythmia, angina, hypotension;

- laboratory disorders: common: liver function test abnormal, blood creatine kinase increased; uncommon: white blood cells urine positive.

As with other HMG-CoA reductase inhibitors elevated serum transaminases have been reported in patients receiving Atorvastatin. These changes were usually mild, transient, and did not require interruption of treatment. Clinically important (> 3 times upper normal limit) elevations in serum transaminases occurred in 0.8% patients treated with atorvastatin. These elevations were dose related and were reversible in all patients.

Elevated serum creatine kinase (CK) levels greater than 3 times upper limit of normal occurred in 2.5% of patients treated with atorvastatin, similar to other HMG-CoA reductase inhibitors in clinical trials. Levels above 10 times the normal upper range occurred in 0.4% patients treated with atorvastatin.

Paediatric population (10-17 years-old). Patients, treated with atorvastatin, have noted that adverse reactions are similar to those in patients of the placebo group. The most common adverse reaction, observed in both groups, regardless causal relationship, was infections.

Post-marketing period

In the post-marketing period the following adverse reactions have been reported. Since these reactions have been reported on a voluntary basis by a population of unknown numbers, it is not always possible to reliably estimate their frequency or to establish a cause and effect relationship with the drug.

The adverse reactions associated with atorvastatin treatment include: anaphylaxis, angioneurotic oedema, bullous rash (including exudative multiform erythema, Stevens-Johnson syndrome, epidermal necrolysis), rhabdomyolysis, myositis, fatigue, tendon rupture, lethal and non-lethal liver failure, dizziness, depression, peripheral neuropathy, pancreatitis and interstitial lung disease.

There have been rare reports of immunologically mediated necrotizing myopathy associated with statin use (see section “Precautions for use”).

There have been rare post-registration reports of cognitive disorders (such as memory loss, forgetfulness, amnesia, memory disorders, confusion) associated with statins. These cognitive disorders have been reported with the use of all statins. In general, they did not belong to the category of serious adverse reactions and were reversible after discontinuation of statins, had different times before onset (1 day to several years) and disappearance (median duration was 3 weeks).

The following adverse reactions have been reported with the use of some statins: sexual function disorder; exceptional cases of interstitial lung disease, especially during long-term treatment.

The following adverse reactions have been reported in post-marketing period.

Blood and lymphatic system disorders: thrombocytopenia.

Immune system disorders: allergic reactions, anaphylaxis (including anaphylactic shock).

Metabolism and nutrition disorders: weight gain.

Nervous system disorders: headache, hypaesthesia, dysgeusia; myasthenia gravis (the incidence of this disorder is unknown).

Gastrointestinal tract disorders: abdominal pain.

Ear and labyrinth disorders: tinnitus.

Eye disorders: ocular myasthenia gravis (the incidence of this disorder is unknown).

Skin and subcutaneous tissue disorders: urticaria.

Musculoskeletal and connective tissue: arthralgia, back pain.

General disorders: chest pain, peripheral oedema, malaise, fatigue.

Laboratory disorders: increase in alanine aminotransferase activity, increase in blood creatine phosphokinase activity.

 

Shelf life. 3 years.

 

Storage conditions.

Store in the original package at a temperature not exceeding 30 °С.

Keep out of the reach of children.

 

Packaging.  10 tablets in a blister, 3 blisters in a box.

 

Terms of dispensing. On prescription.

 

 

Date of last update.

28.01.2025