What is considered a high dose of atorvastatin?

In this article:

• Understanding statin intensities
• Statin intensity chart
• What is considered a high atorvastatin dose?
• Risks and side effects of high-intensity atorvastatin
• Alternatives to high doses of atorvastatin

In this article

• Understanding statin intensities
• Statin intensity chart
• What is considered a high atorvastatin dose?
• Risks and side effects of high-intensity atorvastatin
• Alternatives to high doses of atorvastatin

Atorvastatin is a generic statin, a class of medications used to lower cholesterol levels and reduce the risk of heart attack and stroke. It is available in generic form and as brand-names Lipitor and Atorvaliq. Like other statins, atorvastatin comes in different doses that correspond to different levels of treatment intensity. Some people may need only a low or moderate-intensity statin prescription, while others may benefit from a higher dose.

Some statin doses are classified as “high intensity” because they are expected to lower low-density lipoprotein (LDL) cholesterol levels by 50% or more. 

In this article, we’ll explain how statin intensity is defined, why a healthcare provider might prescribe a higher dose, and what to expect if you’re taking a high dose of atorvastatin. 

Understanding statin intensities 

Statins are categorized based on how much they lower low-density lipoprotein cholesterol (LDL-C). The intensity of a statin depends on both the drug and its dosage:

• Low-intensity statins lower LDL-C by less than 30%.
• Moderate-intensity statins lower LDL-C by 30–49%.
• High-intensity statins lower LDL-C by 50% or more.

In general, a high intensity dose of atorvastatin refers to 40–80 mg taken once daily. “In general, as you increase the dose of a statin, you will have even more LDL-cholesterol lowering. However, we know that certain statins are even more effective at lowering LDL cholesterol (e.g., rosuvastatin and atorvastatin are our strongest statins),” explains Rachel Pessah-Pollack, MD, Clinical Professor at NYU Langone Health in New York City. Some statins, like fluvastatin (Lescol), lovastatin, pravastatin, and simvastatin, are only available in low to moderate-intensity doses. Others, like atorvastatin and rosuvastatin, can be used for moderate or high-intensity therapy depending on the dose. Pitavastatin is the only statin that is recommended as a moderate-intensity statin. 

With the exception of pitavastatin, the intensity of most statins depends on the dose. For example, 10 mg of simvastatin is considered low intensity, while 20–40 mg of simvastatin is considered moderate intensity. 

Below is a chart that breaks down the different statins by their intensity levels: 

Statin intensity chart
	Low-intensity dose	Moderate intensity dose	High-intensity dose
Atorvastatin (Lipitor)	5 mg	10–20 mg	40–80 mg
Rosuvastatin (Crestor)	–	5–10 mg	20–40 mg
Fluvastatin (Lescol)	20–40 mg	40 mg twice daily	–
Fluvastatin XL (Lescol XL)	–	80 mg	–
Lovastatin (Altoprev, Mevacor)	10–20 mg	40–80 mg	–
Pitavastatin (Livalo)	–	1–4 mg	–
Pravastatin (Pravachol)	10–20 mg	40–80 mg	–
Simvastatin (Zocor, FloLipid)	10 mg	20–40 mg	–

 

What is considered a high atorvastatin dose?

A daily dose of 40–80 mg of atorvastatin is considered high-intensity statin therapy. According to its drug label, patients who need to lower their LDL cholesterol by more than 45% typically start with 40 mg per day. Joyce Oen-Hsiao, MD, Associate Professor of Cardiovascular Medicine at Yale School of Medicine in New Haven, Connecticut, explains that healthcare providers choose a statin and intensity based on individual factors: “Statin choice is dependent on the patient’s risk factors and also the level of the cholesterol,” she says.

Although 80 mg is the highest dose approved by the Food and Drug Administration (FDA), the benefit from 80 mg over 40 mg isn’t much. For example, 40 mg of atorvastatin is expected to lower LDL-C by 48%, while 80 mg lowers it by 54%. One small study published in 2018 found that after six months of therapy, 40 mg reduced LDL-C by 50% and 80 mg reduced it by 52%. 

Risks and side effects of high-intensity atorvastatin

Higher doses of atorvastatin can increase the risk of side effects. In the aforementioned 2018 study, people taking 80 mg daily were more likely to report muscle pain (myalgia) compared to those taking 40 mg. “One of the most common side effects is muscle aches. A severe muscle pain that does not go away requires medical attention and, in extreme form, can lead to muscle damage and kidney issues,” Dr. Pessah-Pollack says.

A 2005 study comparing moderate-intensity simvastatin (20 mg per day) to high-intensity atorvastatin (80 mg per day) found that more people on the higher-dose atorvastatin discontinued treatment due to side effects.

Common side effects of high-intensity atorvastatin include:

• Joint pain
• Diarrhea
• Pain in extremities
• Muscle pain
• Urinary tract infections
• Runny nose or sore throat

Serious side effects are less common but can occur. One is elevated liver enzymes, which are more likely at higher doses and may result in liver injury, though this is rare. According to the drug label, people who took higher doses of atorvastatin were more likely to see high liver enzymes after starting the drug.

Another serious side effect of atorvastatin is myopathy, which involves muscle aches or weakness and can progress to a serious condition called rhabdomyolysis, where muscle tissue breaks down and can damage the kidneys. The risk of myopathy increases when atorvastatin is taken alongside drugs or substances that interact with it, including:

• Fibric acid derivatives or fibrates (e.g., fenofibric acid, Fibricor, Antara)
• Strong cytochrome P450 (CYP) 3A4 inhibitors (e.g., grapefruit juice, clarithromycin, ritonavir, itraconazole)

Although statins have been shown to be generally safe in older adults, certain factors can raise the risk of myopathy. Factors that increase the risk of statin-induced myopathy include:

• Taking multiple medications at once (polypharmacy), which increases the risk of drug interactions
• Liver and kidney disease
• Hypothyroidism
• Heavy alcohol use
• Regular heavy exercise 

RELATED: What are the side effects of atorvastatin for older adults?

“Some studies have shown an increased risk for developing Type 2 diabetes with higher glucose levels on statins. While we know that the benefit for the heart outweighs this small increased risk, your doctor will monitor your blood glucose level while on statin treatment,” Dr. Pessah-Pollack says. 

As with any medication, there are risks and benefits to taking statins. That’s why regular check-ins with your healthcare provider are key to getting the most out of your treatment. “Being monitored by a health care professional is important for this class of medications to ensure side effects and potential laboratory abnormalities are monitored and addressed if present,” Dr. Pessah-Pollack explains.

Alternatives to high doses of atorvastatin

If you’re concerned about taking a high dose of atorvastatin, there may be alternative options your healthcare provider can consider. Rosuvastatin at 20–40 mg is another high-intensity statin that may be recommended in place of atorvastatin. “If a patient has tried a statin and had issues tolerating previously, switching to a different statin can be helpful, or lowering the dose of the current statin may be beneficial. In some patients, taking a low dose of statin a few times per week may be sufficient,” Dr. Pessah-Pollack says.

“Statins are first-line agents for lowering cholesterol. However, there are other non-statin medications that can be used in the event that a patient cannot tolerate the statins,” Dr. Oen-Hsiao says. In some cases, a healthcare provider may recommend switching to another statin or combining a lower dose of atorvastatin with a non-statin medication like ezetimibe to reduce LDL cholesterol without increasing side effect risks. 

RELATED: Alternatives to atorvastatin

Lifestyle changes can also help manage cholesterol levels. Healthcare providers may recommend starting with your diet: “First and foremost, patients should try to control the cholesterol that they eat. Try to eat more vegetables and lean meats, such as fish and chicken. Avoid cakes, cookies (most baked goods), fried foods, red meat, dairy, and processed meats (e.g., sausage, bacon, and hot dogs). Try to avoid coconut oil and palm oil,” Dr. Oen-Hsiao advises. 

In addition, regular exercise, managing your weight, quitting tobacco, and limiting alcohol can also help some people control their cholesterol levels. 

Bottom line

While high-intensity statins like atorvastatin can be effective for lowering your risk of heart disease and stroke, they aren’t the only option. Talk with your healthcare provider about what makes the most sense for your specific health goals, risk factors, and whether you experience side effects. With the right combination of medication and lifestyle changes, many people can manage their cholesterol safely and effectively.