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- Atorvastatin Calcium ATORVASTATIN CALCIUM TRIHYDRATE 10 mg/1 Preferred Pharmaceuticals Inc.
Atorvastatin Calcium
- Atorvastatin Calcium ATORVASTATIN CALCIUM TRIHYDRATE 10 mg/1 A-S Medication Solutions
- Atorvastatin calcium ATORVASTATIN CALCIUM TRIHYDRATE 10 mg/1 Zydus Lifesciences Limited
- Atorvastatin Calcium ATORVASTATIN CALCIUM TRIHYDRATE 10 mg/1 Preferred Pharmaceuticals, Inc.
- Atorvastatin Calcium ATORVASTATIN CALCIUM TRIHYDRATE 10 mg/1 NuCare Pharmaceuticals,Inc.
- Atorvastatin calcium ATORVASTATIN CALCIUM TRIHYDRATE 10 mg/1 Zydus Pharmaceuticals USA Inc.
- Atorvastatin Calcium ATORVASTATIN CALCIUM TRIHYDRATE 10 mg/1 Preferred Pharmaceuticals Inc.
- Atorvastatin calcium ATORVASTATIN CALCIUM TRIHYDRATE 10 mg/1 Proficient Rx LP
- Atorvastatin Calcium ATORVASTATIN CALCIUM TRIHYDRATE 10 mg/1 Dr. Reddy's Laboratories Inc
- Atorvastatin calcium ATORVASTATIN CALCIUM TRIHYDRATE 10 mg/1 ST. MARY'S MEDICAL PARK PHARMACY
- Atorvastatin Calcium ATORVASTATIN CALCIUM TRIHYDRATE 10 mg/1 Rising Pharma Holdings, Inc.
- Atorvastatin Calcium ATORVASTATIN CALCIUM TRIHYDRATE 10 mg/1 Lupin Pharmaceuticals, Inc.
Summary of product characteristics
Adverse Reactions
6 ADVERSE REACTIONS The following serious adverse reactions are discussed in greater detail in other sections of the label: Myopathy and Rhabdomyolysis [see Warnings and Precautions (5.1) ] Liver enzyme abnormalities [see Warnings and Precautions ( 5.3 ) ] Most common adverse reactions (incidence ≥ 2%) in patients treated with atorvastatin calcium tablets in placebo-controlled trials regardless of causality were: nasopharyngitis, arthralgia, diarrhea, pain in extremity, and urinary tract infection (6.1). To report SUSPECTED ADVERSE REACTIONS, contact Dr. Reddy’s Laboratories Inc., at 1-888-375-3784or FDA at 1-800-FDA-1088 orwww.fda.gov/medwatch. 6.1 Clinical Trials Experience Because clinical trials are conducted under widely varying conditions, the adverse reaction rates observed in the clinical trials of a drug cannot be directly compared to rates in the clinical trials of another drug and may not reflect the rates observed in clinical practice. In the atorvastatin calcium tablets placebo-controlled clinical trial database of 16,066 patients (8,755 atorvastatin calcium tablets vs. 7,311 placebo; age range 10 to 93 years, 39% women, 91% Caucasians, 3% Blacks, 2% Asians, 4% other) with a median treatment duration of 53 weeks, 9.7% of patients on atorvastatin calcium tablets and 9.5% of the patients on placebo discontinued due to adverse reactions regardless of causality. The five most common adverse reactions in patients treated with atorvastatin calcium tablets that led to treatment discontinuation and occurred at a rate greater than placebo were: myalgia (0.7%), diarrhea (0.5%), nausea (0.4%), alanine aminotransferase increase (0.4%), and hepatic enzyme increase (0.4%). The most commonly reported adverse reactions (incidence ≥ 2% and greater than placebo) regardless of causality, in patients treated with atorvastatin calcium tablets in placebo controlled trials (n=8755) were: nasopharyngitis (8.3%), arthralgia (6.9%), diarrhea (6.8%), pain in extremity (6%), and urinary tract infection (5.7%). Table 2 summarizes the frequency of clinical adverse reactions, regardless of causality, reported in ≥ 2% and at a rate greater than placebo in patients treated with atorvastatin calcium tablets (n=8755), from seventeen placebo-controlled trials. 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 7.0 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 extremity 6.0 8.5 3.7 9.3 3.1 5.9 Urinary tract infection 5.7 6.9 6.4 8.0 4.1 5.6 Dyspepsia 4.7 5.9 3.2 6.0 3.3 4.3 Nausea 4.0 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 3.0 Myalgia 3.5 3.6 5.9 8.4 2.7 3.1 Insomnia 3.0 2.8 1.1 5.3 2.8 2.9 Pharyngolaryngeal pain 2.3 3.9 1.6 2.8 0.7 2.1 Other adverse reactions reported in placebo-controlled studies include: Body as a whole: malaise, pyrexia; Digestive system: abdominal discomfort, eructation, flatulence, hepatitis, cholestasis; Musculoskeletal system: musculoskeletal pain, muscle fatigue, neck pain, joint swelling; Metabolic and nutritional system: transaminases increase, liver function test abnormal, blood alkaline phosphatase increase, creatine phosphokinase increase, hyperglycemia; Nervous system: nightmare; Respiratory system: epistaxis; Skin and appendages: urticaria; Special senses: vision blurred, tinnitus; Urogenital system: white blood cells urine positive. Anglo-Scandinavian Cardiac Outcomes Trial (ASCOT) In ASCOT [see Clinical Studies (14.1) ] involving 10,305 participants (age range 40 to 80 years, 19% women; 94.6% Caucasians, 2.6% Africans, 1.5% South Asians, 1.3% mixed/other) treated with atorvastatin calcium tablets 10 mg daily (n=5,168) or placebo (n=5,137), the safety and tolerability profile of the group treated with atorvastatin calcium tablets was comparable to that of the group treated with placebo during a median of 3.3 years of follow-up. Collaborative Atorvastatin Diabetes Study (CARDS) In CARDS [see Clinical Studies (14.1) ] involving 2,838 subjects (age range 39 to 77 years, 32% women; 94.3% Caucasians, 2.4% South Asians, 2.3% Afro-Caribbean, 1% other) with type 2 diabetes treated with atorvastatin calcium tablets 10 mg daily (n=1,428) or placebo (n=1,410), there was no difference in the overall frequency of adverse reactions or serious adverse reactions between the treatment groups during a median follow-up of 3.9 years. No cases of rhabdomyolysis were reported. Treating to New Targets Study (TNT) In TNT [see Clinical Studies (14.1) ] involving 10,001 subjects (age range 29 to 78 years, 19% women; 94.1% Caucasians, 2.9% Blacks, 1% Asians, 2% other) with clinically evident CHD treated with atorvastatin calcium tablets10 mg daily (n=5006) or atorvastatin calcium tablets 80 mg daily (n=4995), there were more serious adverse reactions and discontinuations due to adverse reactions in the high-dose atorvastatin group (92, 1.8%; 497, 9.9%, respectively) as compared to the low-dose group (69, 1.4%; 404, 8.1%, respectively) during a median follow-up of 4.9 years. Persistent transaminase elevations (≥3 x ULN twice within 4 to 10 days) occurred in 62 (1.3%) individuals with atorvastatin 80 mg and in nine (0.2%) individuals with atorvastatin 10 mg. Elevations of CK (≥ 10 x ULN) were low overall, but were higher in the high-dose atorvastatin treatment group (13, 0.3%) compared to the low-dose atorvastatin group (6, 0.1%). Incremental Decrease in Endpoints through Aggressive Lipid Lowering Study (IDEAL) In IDEAL [see Clinical Studies (14.1) ] involving 8,888 subjects (age range 26 to 80 years, 19% women; 99.3% Caucasians, 0.4% Asians, 0.3% Blacks, 0.04% other) treated with atorvastatin calcium tablets 80 mg/day (n=4439) or simvastatin 20 to 40 mg daily (n=4449), there was no difference in the overall frequency of adverse reactions or serious adverse reactions between the treatment groups during a median follow-up of 4.8 years. Stroke Prevention by Aggressive Reduction in Cholesterol Levels (SPARCL) In SPARCL involving 4,731 subjects (age range 21 to 92 years, 40% women; 93.3% Caucasians, 3% Blacks, 0.6% Asians, 3.1% other) without clinically evident CHD but with a stroke or transient ischemic attack (TIA) within the previous 6 months treated with atorvastatin calcium tablets 80 mg (n=2365) or placebo (n=2366) for a median follow-up of 4.9 years, there was a higher incidence of persistent hepatic transaminase elevations (≥ 3 x ULN twice within 4 to 10 days) in the atorvastatin group (0.9%) compared to placebo (0.1%). Elevations of CK (>10 x ULN) were rare, but were higher in the atorvastatin group (0.1%) compared to placebo (0%). Diabetes was reported as an adverse reaction in 144 subjects (6.1%) in the atorvastatin group and 89 subjects (3.8%) in the placebo group [see Warnings and Precautions (5.6) ]. In a post-hoc analysis, atorvastatin calcium tablets 80 mg reduced the incidence of ischemic stroke (218/2365, 9.2% vs. 274/2366, 11.6%) and increased the incidence of hemorrhagic stroke (55/2365, 2.3% vs. 33/2366, 1.4%) compared to placebo. The incidence of fatal hemorrhagic stroke was similar between groups (17 atorvastatin calcium tablets vs. 18 placebo). The incidence of non-fatal hemorrhagic strokes was significantly greater in the atorvastatin group (38 non-fatal hemorrhagic strokes) as compared to the placebo group (16 non-fatal hemorrhagic strokes). Subjects who entered the study with a hemorrhagic stroke appeared to be at increased risk for hemorrhagic stroke [7 (16%) atorvastatin calcium tablets vs. 2 (4%) placebo]. There were no significant differences between the treatment groups for all-cause mortality: 216 (9.1%) in the atorvastatin calcium tablets 80 mg/day group vs. 211 (8.9%) in the placebo group. The proportions of subjects who experienced cardiovascular death were numerically smaller in the atorvastatin calcium tablets 80 mg group (3.3%) than in the placebo group (4.1%). The proportions of subjects who experienced non-cardiovascular death were numerically larger in the atorvastatin calcium tablets 80 mg group (5%) than in the placebo group (4%). Adverse Reactions from Clinical Studies of Atorvastatin Calcium in Pediatric Patients In a 26-week controlled study in boys and postmenarchal girls with HeFH (ages 10 years to 17 years) (n=140, 31% female; 92% Caucasians, 1.6% Blacks, 1.6% Asians, 4.8% other), the safety and tolerability profile of atorvastatin calcium 10 to 20 mg daily, as an adjunct to diet to reduce total cholesterol, LDL-C, and apo B levels, was generally similar to that of placebo [see Use in Special Populations ( 8.4 ) and Clinical Studies ( 14.6 ) ]. 6.2 Postmarketing Experience The following adverse reactions have been identified during post-approval use of atorvastatin calcium tablets. Because these reactions are reported voluntarily from a population of uncertain size, it is not always possible to reliably estimate their frequency or establish a causal relationship to drug exposure. Adverse reactions associated with atorvastatin therapy reported since market introduction, that are not listed above, regardless of causality assessment, include the following: anaphylaxis, angioneurotic edema, bullous rashes (including erythema multiforme, Stevens-Johnson syndrome, and toxic epidermal necrolysis), rhabdomyolysis, myositis, fatigue, tendon rupture, fatal and non-fatal hepatic failure, dizziness, depression, peripheral neuropathy, pancreatitis and interstitial lung disease. There have been rare reports of immune-mediated necrotizing myopathy associated with statin use [see Warnings and Precautions ( 5.2 ) ] There have been rare postmarketing reports of cognitive impairment (e.g., memory loss, forgetfulness, amnesia, memory impairment, confusion) associated with statin use. These cognitive issues have been reported for all statins. The reports are generally nonserious, and reversible upon statin discontinuation, with variable times to symptom onset (1 day to years) and symptom resolution (median of 3 weeks).
Contraindications
4 CONTRAINDICATIONS 1. Active Liver Disease, Which May Include Unexplained Persistent Elevations in Hepatic Transaminase Levels 2. Hypersensitivity to Any Component of This Medication 3. Pregnancy [see Use in Specific Populations ( 8.1, 8.3 ) ]. 4. Lactation [see Use in Specific Populations ( 8.2 ) ]. 1. Active liver disease, which may include unexplained persistent elevations in hepatic transaminase levels ( 4 ). 2. Hypersensitivity to any component of this medication ( 4 ). 3. Pregnancy ( 4 , 8.1 , 8.3 ). 4. Lactation ( 4 , 8.2 ).
Description
11 DESCRIPTION Atorvastatin calcium is a synthetic lipid-lowering agent. Atorvastatin is an inhibitor of 3-hydroxy-3-methylglutaryl-coenzyme A (HMG-CoA) reductase. This enzyme catalyzes the conversion of HMG-CoA to mevalonate, an early and rate-limiting step in cholesterol biosynthesis. Atorvastatin calcium is [R-(R*, R*)]-2-(4-fluorophenyl)-ß, δ-dihydroxy-5-(1-methylethyl)-3-phenyl-4-[(phenylamino) carbonyl]-1H-pyrrole-1-heptanoic acid, calcium salt (2:1) trihydrate. The molecular formula of atorvastatin calcium is C 66 H 74 CaF 2 N 4 O 13 and its molecular weight is 1206.408. Its structural formula is: Atorvastatin calcium USP is a white to off-white crystalline powder. It is freely soluble in methanol and insoluble in aqueous solutions of pH 4 and below. Atorvastatin calcium tablets USP, for oral administration contain 10, 20, 40 and 80 mg atorvastatin and the following inactive ingredients: calcium carbonate, croscarmellose sodium, hydroxyl propyl cellulose, lactose monohydrate, magnesium stearate, microcrystalline cellulose, polysorbate 80. The tablet coating contains hypromellose, polyethylene glycol, talc and titanium dioxide. Atorvastatin calcium tablets meets USP Dissolution Test 5. structure
Dosage And Administration
2 DOSAGE AND ADMINISTRATION 5. Dose range: 10 to 80 mg once daily ( 2.1 ). 6. Recommended start dose: 10 or 20 mg once daily ( 2.1 ). 7. Patients requiring large LDL-C reduction (>45%) may start at 40 mg once daily ( 2.1 ). 8. Pediatric patients with HeFH: starting dose: 10 mg once daily; dose range: 10 to 20 mg/day for patients 10 years to 17 years of age ( 2.2 ). 2.1 Hyperlipidemia and Mixed Dyslipidemia The recommended starting dose of atorvastatin calcium tablets is 10 or 20 mg once daily. Patients who require a large reduction in LDL-C (more than 45%) may be started at 40 mg once daily. The dosage range of atorvastatin calcium tablets is 10 to 80 mg once daily. Atorvastatin calcium tablets can be administered as a single dose at any time of the day, with or without food. The starting dose and maintenance doses of atorvastatin calcium tablets should be individualized according to patient characteristics such as goal of therapy and response. After initiation and/or upon titration of atorvastatin calcium tablets, lipid levels should be analyzed within 2 to 4 weeks and dosage adjusted accordingly. 2.2 Heterozygous Familial Hypercholesterolemia in Pediatric Patients (10 Years to 17 Years of Age) The recommended starting dose of atorvastatin calcium tablets is 10 mg/day; the usual dose range is 10 to 20 mg orally once daily [see Clinical Studies ( 14.6 ) ]. Doses should be individualized according to the recommended goal of therapy [see Indications and Usage ( 1.2 ) and Clinical Pharmacology ( 12 ) ]. Adjustments should be made at intervals of 4 weeks or more. 2.3 Homozygous Familial Hypercholesterolemia The dosage of atorvastatin calcium tablets in patients with HoFH is 10 to 80 mg daily. Atorvastatin calcium tablets should be used as an adjunct to other lipid-lowering treatments (e.g., LDL apheresis) in these patients or if such treatments are unavailable. 2.4 Concomitant Lipid-Lowering Therapy Atorvastatin calcium tablets may be used with bile acid resins. The combination of HMG-CoA reductase inhibitors (statins) and fibrates should generally be used with caution [see Warnings and Precautions (5.1) Drug Interactions (7) ]. 2.5 Dosage in Patients with Renal Impairment Renal disease does not affect the plasma concentrations nor LDL-C reduction of atorvastatin calcium tablets; thus, dosage adjustment in patients with renal dysfunction is not necessary [see Warnings and Precautions (5.1) and Clinical Pharmacology, Pharmacokinetics (12.3) ]. 2.6 Dosage in Patients Taking Cyclosporine, Clarithromycin, Itraconazole, Letermovir, or Certain Protease Inhibitors In patients taking cyclosporine or the HIV protease inhibitor tipranavir plus ritonavir or the hepatitis C virus (HCV) protease inhibitor glecaprevir plus pibrentasvir, therapy with atorvastatin calcium tablets should be avoided. In patients with HIV taking lopinavir plus ritonavir, use the lowest dose necessary of atorvastatin calcium tablets. In patients taking clarithromycin, itraconazole, elbasvir plus grazoprevir, or in patients with HIV taking a combination of saquinavir plus ritonavir, darunavir plus ritonavir, fosamprenavir, fosamprenavir plus ritonavir or letermovir therapy with atorvastatin calcium tablets should be limited to 20 mg, and appropriate clinical assessment is recommended to ensure that the lowest dose necessary of atorvastatin calcium tablets is used. In patients taking the HIV protease inhibitor nelfinavir therapy with atorvastatin calcium tablets should be limited to 40 mg. [see Warnings and Precautions ( 5.1 ) and Drug Interactions ( 7.1 )].
Indications And Usage
1 INDICATIONS AND USAGE Therapy with lipid-altering agents should be only one component of multiple risk factor intervention in individuals at significantly increased risk for atherosclerotic vascular disease due to hypercholesterolemia. Drug therapy is recommended as an adjunct to diet when the response to a diet restricted in saturated fat and cholesterol and other nonpharmacologic measures alone has been inadequate. In patients with CHD or multiple risk factors for CHD, atorvastatin calcium tablets can be started simultaneously with diet. Atorvastatin calcium tablet is an HMG-CoA reductase inhibitor indicated as an adjunct therapy to diet to: 1. Reduce the risk of MI, stroke, revascularization procedures, and angina in adult patients without CHD, but with multiple risk factors ( 1.1 ). 2. Reduce the risk of MI and stroke in adult patients with type 2 diabetes without CHD, but with multiple risk factors ( 1.1 ). · Reduce the risk of non-fatal MI, fatal and non-fatal stroke, revascularization procedures, hospitalization for CHF, and angina in adult patients with CHD ( 1.1 ). 3. Reduce elevated total-C, LDL-C, apo B, and TG levels and increase HDL-C in adult patients with primary hyperlipidemia (heterozygous familial and nonfamilial) and mixed dyslipidemia ( 1.2 ). 4. Reduce elevated TG in adult patients with hypertriglyceridemia and primary dysbetalipoproteinemia ( 1.2 ). 5. Reduce total-C and LDL-C in patients with homozygous familial hypercholesterolemia (HoFH) ( 1.2 ). 6. Reduce elevated total-C, LDL-C, and apo B levels in pediatric patients, 10 years to 17 years of age, with heterozygous familial hypercholesterolemia (HeFH) after failing an adequate trial of diet therapy ( 1.2 ). Limitations of Use: Atorvastatin calcium tablets have not been studied in Fredrickson Types I and V dyslipidemias ( 1.3 ). 1.1 Prevention of Cardiovascular Disease in Adults In adult patients without clinically evident coronary heart disease, but with multiple risk factors for coronary heart disease such as age, smoking, hypertension, low HDL-C, or a family history of early coronary heart disease, atorvastatin calcium tablets are indicated to: 1. Reduce the risk of myocardial infarction 2. Reduce the risk of stroke 3. Reduce the risk for revascularization procedures and angina In adult patients with type 2 diabetes, and without clinically evident coronary heart disease, but with multiple risk factors for coronary heart disease such as retinopathy, albuminuria, smoking, or hypertension, atorvastatin calcium tablets are indicated to: 1. Reduce the risk of myocardial infarction 2. Reduce the risk of stroke In adult patients with clinically evident coronary heart disease, atorvastatin calcium tablets are indicated to: 1. Reduce the risk of non-fatal myocardial infarction 2. Reduce the risk of fatal and non-fatal stroke 3. Reduce the risk for revascularization procedures 4. Reduce the risk of hospitalization for CHF 5. Reduce the risk of angina 1.2 Hyperlipidemia Atorvastatin calcium tablets are indicated: 1. As an adjunct to diet to reduce elevated total-C, LDL-C, apo B, and TG levels and to increase HDL-C in adult patients with primary hypercholesterolemia (heterozygous familial and nonfamilial) and mixed dyslipidemia ( Fredrickson Types IIa and IIb); 2. As an adjunct to diet for the treatment of adult patients with elevated serum TG levels ( Fredrickson Type IV); 3. For the treatment of adult patients with primary dysbetalipoproteinemia ( Fredrickson Type III) who do not respond adequately to diet; 4. To reduce total-C and LDL-C in patients with homozygous familial hypercholesterolemia (HoFH) as an adjunct to other lipid-lowering treatments (e.g., LDL apheresis) or if such treatments are unavailable; 5. As an adjunct to diet to reduce total-C, LDL-C, and apo B levels in pediatric patients, 10 years to 17 years of age, with heterozygous familial hypercholesterolemia (HeFH) if after an adequate trial of diet therapy the following findings are present: a. LDL-C remains ≥ 190 mg/dL or b. LDL-C remains ≥ 160 mg/dL and: 1. there is a positive family history of premature cardiovascular disease or 2. two or more other CVD risk factors are present in the pediatric patient 1.3 Limitations of Use Atorvastatin calcium tablets have not been studied in conditions where the major lipoprotein abnormality is elevation of chylomicrons ( Fredrickson Types I and V).
Overdosage
10 OVERDOSAGE There is no specific treatment for atorvastatin overdosage. In the event of an overdose, the patient should be treated symptomatically, and supportive measures instituted as required. Due to extensive drug binding to plasma proteins, hemodialysis is not expected to significantly enhance atorvastatin clearance.
Adverse Reactions Table
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 | 7.0 | 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 extremity | 6.0 | 8.5 | 3.7 | 9.3 | 3.1 | 5.9 |
Urinary tract infection | 5.7 | 6.9 | 6.4 | 8.0 | 4.1 | 5.6 |
Dyspepsia | 4.7 | 5.9 | 3.2 | 6.0 | 3.3 | 4.3 |
Nausea | 4.0 | 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 | 3.0 |
Myalgia | 3.5 | 3.6 | 5.9 | 8.4 | 2.7 | 3.1 |
Insomnia | 3.0 | 2.8 | 1.1 | 5.3 | 2.8 | 2.9 |
Pharyngolaryngeal pain | 2.3 | 3.9 | 1.6 | 2.8 | 0.7 | 2.1 |
Drug Interactions
7 DRUG INTERACTIONS Drug Interactions that may Increase the Risk of Myopathy and Rhabdomyolysis with atorvastatin calcium( 2.6 , 5.1 , 7 .1, 12.3 ) Drug Interactions that may Increase the Risk of Myopathy and Rhabdomyolysis with atorvastatin ( 2.6 , 5.1 , 7.1 , 12.3 ) Interacting Agents Prescribing Recommendations Cyclosporine, tipranavir plus ritonavir, glecaprevir plus pibrentasvir Avoid atorvastatin Clarithromycin, itraconazole, saquinavir plus ritonavir, darunavir plus ritonavir, fosamprenavir, fosamprenavir plus ritonavir, elbasvir plus grazoprevir, letermovir Do not exceed 20 mg atorvastatin daily Nelfinavir Do not exceed 40 mg atorvastatin daily Lopinavir plus ritonavir, simeprevir, fibric acid derivatives, erythromycin, azole antifungals, lipid-modifying doses of niacin, colchicine Consider the risk/benefit of concomitant use with atorvastatin • Other Lipid-Lowering Medications: Use with fibrate products or lipid-modifying doses (≥1 g/day) of niacin increases the risk of adverse skeletal muscle effects. Caution should be used when prescribing with atorvastatin calcium ( 7 ). • Rifampin should be simultaneously co-administered with atorvastatin ( 7.2 ). • Oral Contraceptives: Values for norethindrone and ethinyl estradiol may be increased ( 7.3 ). • Digoxin: Patients should be monitored appropriately ( 7.3 ). 7.1 Drug Interactions that may Increase the Risk of Myopathy and Rhabdomyolysis with Atorvastatin Calcium Atorvastatin calcium is a substrate of CYP3A4 and transporters (e.g., OATP1B1/1B3, P-gp, or BCRP). Atorvastatin plasma levels can be significantly increased with concomitant administration of inhibitors of CYP3A4 and transporters. Table 3 includes a list of drugs that may increase exposure to atorvastatin and may increase the risk of myopathy and rhabdomyolysis when used concomitantly and instructions for preventing or managing them [see Warnings and Precautions ( 5.1 ) and Clinical Pharmacology ( 12.3) ]. Table 3: Drug Interactions that may Increase the Risk of Myopathy and Rhabdomyolysis with Atorvastatin Calcium Cyclosporine or Gemfibrozil Clinical Impact: Atorvastatin plasma levels were significantly increased with concomitant administration of atorvastatin and cyclosporine, an inhibitor of CYP3A4 and OATP1B1 [ see Error! Hyperlink reference not valid. ]. Gemfibrozil may cause myopathy when given alone. The risk of myopathy and rhabdomyolysis is increased with concomitant use of cyclosporine or gemfibrozil with atorvastatin. Intervention: Concomitant use of cyclosporine or gemfibrozil with atorvastatin is not recommended. Anti-Viral Medications Clinical Impact: Atorvastatin plasma levels were significantly increased with concomitant administration of atorvastatin with many anti-viral medications, which are inhibitors of CYP3A4 and/or transporters (e.g., BCRP, OATP1B1/1B3, P-gp, MRP2, and/or OAT2) [ see Error! Hyperlink reference not valid. ]. Cases of myopathy and rhabdomyolysis have been reported with concomitant use of ledipasvir plus sofosbuvir with atorvastatin. Intervention: • Concomitant use of tipranavir plus ritonavir or glecaprevir plus pibrentasvir with atorvastatin is not recommended. • In patients taking lopinavir plus ritonavir, or simeprevir, consider the risk/benefit of concomitant use with atorvastatin. • In patients taking saquinavir plus ritonavir, darunavir plus ritonavir, fosamprenavir, fosamprenavir plus ritonavir, elbasvir plus grazoprevir or letermovir, do not exceed atorvastatin 20 mg. • In patients taking nelfinavir, do not exceed atorvastatin 40 mg [ see Error! Hyperlink reference not valid. ]. • Consider the risk/benefit of concomitant use of ledipasvir plus sofosbuvir with atorvastatin. • Monitor all patients for signs and symptoms of myopathy particularly during initiation of therapy and during upward dose titration of either drug. Examples: Tipranavir plus ritonavir, glecaprevir plus pibrentasvir, lopinavir plus ritonavir, simeprevir, saquinavir plus ritonavir, darunavir plus ritonavir, fosamprenavir, fosamprenavir plus ritonavir, elbasvir plus grazoprevir, letermovir, nelfinavir, and ledipasvir plus sofosbuvir. Select Azole Antifungals or Macrolide Antibiotics Clinical Impact: Atorvastatin plasma levels were significantly increased with concomitant administration of atorvastatin with select azole antifungals or macrolide antibiotics, due to inhibition of CYP3A4 and/or transporters [ see Error! Hyperlink reference not valid. ]. Intervention: In patients taking clarithromycin or itraconazole, do not exceed atorvastatin 20 mg [ see Error! Hyperlink reference not valid. ]. Consider the risk/benefit of concomitant use of other azole antifungals or macrolide antibiotics with atorvastatin. Monitor all patients for signs and symptoms of myopathy particularly during initiation of therapy and during upward dose titration of either drug. Examples: Erythromycin, clarithromycin, itraconazole, ketoconazole, posaconazole, and voriconazole. Niacin Clinical Impact: Cases of myopathy and rhabdomyolysis have been observed with concomitant use of lipid modifying dosages of niacin (>1 gram/day niacin) with atorvastatin. Intervention: Consider if the benefit of using lipid modifying dosages of niacin concomitantly with atorvastatin outweighs the increased risk of myopathy and rhabdomyolysis. If concomitant use is decided, monitor patients for signs and symptoms of myopathy particularly during initiation of therapy and during upward dose titration of either drug. Fibrates (other than Gemfibrozil) Clinical Impact: Fibrates may cause myopathy when given alone. The risk of myopathy and rhabdomyolysis is increased with concomitant use of fibrates with atorvastatin. Intervention: Consider if the benefit of using fibrates concomitantly with atorvastatin outweighs the increased risk of myopathy and rhabdomyolysis. If concomitant use is decided, monitor patients for signs and symptoms of myopathy particularly during initiation of therapy and during upward dose titration of either drug. Colchicine Clinical Impact: Cases of myopathy and rhabdomyolysis have been reported with concomitant use of colchicine with atorvastatin. Intervention: Consider the risk/benefit of concomitant use of colchicine with atorvastatin. If concomitant use is decided, monitor patients for signs and symptoms of myopathy particularly during initiation of therapy and during upward dose titration of either drug. Grapefruit Juice Clinical Impact: Grapefruit juice consumption, especially excessive consumption, more than 1.2 liters/daily, can raise the plasma levels of atorvastatin and may increase the risk of myopathy and rhabdomyolysis. Intervention: Avoid intake of large quantities of grapefruit juice, more than 1.2 liters daily, when taking atorvastatin. 7.2 Drug Interactions that may Decrease Exposure to Atorvastatin Calcium Table 4 presents drug interactions that may decrease exposure to atorvastatin calcium and instructions for preventing or managing them. Table 4: Drug Interactions that may Decrease Exposure to Atorvastatin Calcium Rifampin Clinical Impact: Concomitant administration of atorvastatin calcium tablets with rifampin, an inducer of cytochrome P450 3A4 and inhibitor of OATP1B1, can lead to variable reductions in plasma concentrations of atorvastatin. Due to the dual interaction mechanism of rifampin, delayed administration of atorvastatin calcium tablets after administration of rifampin has been associated with a significant reduction in atorvastatin plasma concentrations. Intervention : Administer atorvastatin calcium tablets and rifampin simultaneously. 7.3 Atorvastatin Calcium Effects on Other Drugs Table 5 presents atorvastatin calcium effect on other drugs and instructions for preventing or managing them. Table 5: Atorvastatin Calcium Effects on Other Drugs Oral Contraceptives Clinical Impact: Co-administration of atorvastatin calcium tablets and an oral contraceptive increased plasma concentrations of norethindrone and ethinyl estradiol [see Clinical Pharmacology ( 12.3 )]. Intervention : Consider this when selecting an oral contraceptive for patients taking atorvastatin calcium tablets. Digoxin Clinical Impact: When multiple doses of atorvastatin calcium tablets and digoxin were co-administered, steady state plasma digoxin concentrations increased [see Clinical Pharmacology ( 12.3 )] . Intervention : Monitor patients taking digoxin appropriately.
Drug Interactions Table
Drug Interactions that may Increase the Risk of Myopathy and Rhabdomyolysis with atorvastatin ( | |
Interacting Agents | Prescribing Recommendations |
Cyclosporine, tipranavir plus ritonavir, glecaprevir plus pibrentasvir | Avoid atorvastatin |
Do not exceed 20 mg atorvastatin daily | |
Nelfinavir | Do not exceed 40 mg atorvastatin daily |
Lopinavir plus ritonavir, simeprevir, fibric acid derivatives, erythromycin, azole antifungals, lipid-modifying doses of niacin, colchicine | Consider the risk/benefit of concomitant use with atorvastatin |
Clinical Pharmacology
12 CLINICAL PHARMACOLOGY 12.1 Mechanism of Action Atorvastatin calcium is a selective, competitive inhibitor of HMG-CoA reductase, the rate-limiting enzyme that converts 3-hydroxy-3-methylglutaryl-coenzyme A to mevalonate, a precursor of sterols, including cholesterol. In animal models, atorvastatin lowers plasma cholesterol and lipoprotein levels by inhibiting HMG-CoA reductase and cholesterol synthesis in the liver and by increasing the number of hepatic LDL receptors on the cell surface to enhance uptake and catabolism of LDL; atorvastatin also reduces LDL production and the number of LDL particles. 12.2 Pharmacodynamics Atorvastatin calcium, as well as some of its metabolites, are pharmacologically active in humans. The liver is the primary site of action and the principal site of cholesterol synthesis and LDL clearance. Drug dosage, rather than systemic drug concentration, correlates better with LDL-C reduction. Individualization of drug dosage should be based on therapeutic response [see Dosage and Administration (2) ]. 12.3 Pharmacokinetics Absorption:Atorvastatin calcium tablets are rapidly absorbed after oral administration; maximum plasma concentrations occur within 1 to 2 hours. Extent of absorption increases in proportion to atorvastatin calcium dose. The absolute bioavailability of atorvastatin (parent drug) is approximately 14% 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. Although food decreases the rate and extent of drug absorption by approximately 25% and 9%, respectively, as assessed by Cmax and AUC, LDL-C reduction is similar whether atorvastatin calcium tablets are given with or without food. Plasma atorvastatin concentrations are lower (approximately 30% for Cmax and AUC) following evening drug administration compared with morning. However, LDL-C reduction is the same regardless of the time of day of drug administration [see Dosage and Administration (2) ]. Distribution:Mean volume of distribution of atorvastatin is approximately 381 liters. Atorvastatin is ≥98% bound to plasma proteins. A blood/plasma ratio of approximately 0.25 indicates poor drug penetration into red blood cells. Based on observations in rats, atorvastatin is likely to be secreted in human milk [see Contraindications, Nursing Mothers Error! Hyperlink reference not valid. and Use in Specific Populations (8.2 ) ]. Metabolism:Atorvastatin is extensively 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 suggest the importance of atorvastatin metabolism by cytochrome P450 3A4, consistent with increased plasma concentrations of atorvastatin in humans following co-administration with erythromycin, a known inhibitor of this isozyme [see Drug Interactions (7.1) ]. In animals, the ortho-hydroxy metabolite undergoes further glucuronidation. Excretion:Atorvastatin and its metabolites are eliminated primarily in bile following hepatic and/or extra-hepatic metabolism; however, the drug does not appear to undergo enterohepatic recirculation. Mean plasma elimination half-life of atorvastatin in humans is approximately 14 hours, but the half-life of inhibitory activity for HMG-CoA reductase is 20 to 30 hours due to the contribution of active metabolites. Less than 2% of a dose of atorvastatin calcium tablets are recovered in urine following oral administration. Specific Populations Geriatric:Plasma concentrations of atorvastatin are higher (approximately 40% for Cmax and 30% for AUC) in healthy elderly subjects (age ≥65 years) than in young adults. Clinical data suggest a greater degree of LDL-lowering at any dose of drug in the elderly patient population compared to younger adults [see Use in Specific Populations (8.5) ]. Pediatric:Apparent oral clearance of atorvastatin in pediatric subjects appeared similar to that of adults when scaled allometrically by body weight as the body weight was the only significant covariate in atorvastatin population PK model with data including pediatric HeFH patients (ages 10 years to 17 years of age, n=29) in an open-label, 8-week study. Gender : Plasma concentrations of atorvastatin in women differ from those in men (approximately 20% higher for Cmax and 10% lower for AUC); however, there is no clinically significant difference in LDL-C reduction with atorvastatin between men and women. Renal Impairment:Renal disease has no influence on the plasma concentrations or LDL-C reduction of atorvastatin; thus, dose adjustment in patients with renal dysfunction is not necessary [see Dosage and Administration (2.5) and Warnings and Precautions (5.1) ]. Hemodialysis:While studies have not been conducted in patients with end-stage renal disease, hemodialysis is not expected to significantly enhance clearance of atorvastatin since the drug is extensively bound to plasma proteins. Hepatic Impairment:In patients with chronic alcoholic liver disease, plasma concentrations of atorvastatin are markedly increased. Cmax and AUC are each 4-fold greater in patients with Childs-Pugh A disease. Cmax and AUC are approximately 16-fold and 11-fold increased, respectively, in patients with Childs-Pugh B disease [see Contraindications ( 4 ) ]. Drug Interaction Studies Atorvastatin is a substrate of the hepatic transporters, OATP1B1 and OATP1B3 transporter. Metabolites of atorvastatin are substrates of OATP1B1. Atorvastatin is also identified as a substrate of the efflux transporter BCRP, which may limit the intestinal absorption and biliary clearance of atorvastatin. TABLE 6. Effect of Co-administered Drugs on the Pharmacokinetics of Atorvastatin Co-administered drug and dosing regimen Atorvastatin Dose (mg) Ratio of AUC & Ratio of C max & # Cyclosporine 5.2 mg/kg/day, stable dose 10 mg QD a for 28 days 8.69 10.66 # Tipranavir 500 mg BID b /ritonavir 200 mg BID b , 7 days 10 mg, SD c 9.36 8.58 # Glecaprevir 400 mg QD a /pibrentasvir 120 mg QD a , 7 days 10 mg QD a for 7 days 8.28 22.00 # Telaprevir 750 mg q8h f , 10 days 20 mg, SD c 7.88 10.60 #, ‡ Saquinavir 400 mg BID b / ritonavir 400 mg BID b , 15 days 40 mg QD a for 4 days 3.93 4.31 # Elbasvir 50 mg QD a /grazoprevir 200 mg QD a , 13 days 10 mg SD c 1.94 4.34 # Simeprevir 150 mg QD a , 10 days 40 mg SD c 2.12 1.70 # Clarithromycin 500 mg BID b , 9 days 80 mg QD for 8 days 4.54 5.38 # Darunavir 300 mg BID b /ritonavir 100 mg BID b , 9 days 10 mg QD a for 4 days 3.45 2.25 # Itraconazole 200 mg QD a , 4 days 40 mg SD c 3.32 1.20 # Letermovir 480 mg QD a , 10 days 20 mg SD c 3.29 2.17 # Fosamprenavir 700 mg BID b /ritonavir 100 mg BID b , 14 days 10 mg QD a for 4 days 2.53 2.84 # Fosamprenavir 1400 mg BID b , 14 days 10 mg QD a for 4 days 2.30 4.04 # Nelfinavir 1250 mg BID b , 14 days 10 mg QD a for 28 days 1.74 2.22 # Grapefruit Juice, 240 mL QD a,* 40 mg, SD c 1.37 1.16 Diltiazem 240 mg QD a , 28 days 40 mg, SD c 1.51 1.00 Erythromycin 500 mg QID e , 7 days 10 mg, SD c 1.33 1.38 Amlodipine 10 mg, single dose 80 mg, SD c 1.18 0.91 Cimetidine 300 mg QID e , 2 weeks 10 mg QD a for 2 weeks 1.00 0.89 Colestipol 10 g BID b , 24 weeks 40 mg QD a for 8 weeks NA 0.74 ** Maalox TC ® 30 mL QID e , 17 days 10 mg QD a for 15 days 0.66 0.67 Efavirenz 600 mg QD a , 14 days 10 mg for 3 days 0.59 1.01 # Rifampin 600 mg QD a , 7 days (co-administered) † 40 mg SD c 1.12 2.90 # Rifampin 600 mg QD a , 5 days (doses separated) † 40 mg SD c 0.20 0.60 # Gemfibrozil 600 mg BID b , 7 days 40 mg SD c 1.35 1.00 # Fenofibrate 160 mg QD a , 7 days 40 mg SD c 1.03 1.02 Boceprevir 800 mg TID d , 7 days 40 mg SD c 2.32 2.66 & Represents ratio of treatments (co-administered drug plus atorvastatin vs. atorvastatin alone). # See Sections 5.1 and 7 for clinical significance. * Greater increases in AUC (ratio of AUC up to 2.5) and/or C max (ratio of C max up to1.71) have been reported with excessive grapefruit consumption (≥ 750 mL to 1.2 liters per day). ** Ratio based on a single sample taken 8 to 16 h post dose. † Due to the dual interaction mechanism of rifampin, simultaneous co-administration of atorvastatin with rifampin is recommended, as delayed administration of atorvastatin after administration of rifampin has been associated with a significant reduction in atorvastatin plasma concentrations. ‡ The dose of saquinavir plus ritonavir in this study is not the clinically used dose. The increase in atorvastatin exposure when used clinically is likely to be higher than what was observed in this study. Therefore, caution should be applied and the lowest dose necessary should be used. a Once daily b Twice daily c Single dose d Three times daily e Four times daily f Every 8 hours TABLE 7. Effect of Atorvastatin on the Pharmacokinetics of Co-administered Drugs Atorvastatin Co-administered drug and dosing regimen Drug/Dose (mg) Ratio of AUC Ratio of C max 80 mg QD a for 15 days Antipyrine, 600 mg SD c 1.03 0.89 80 mg QD a for 10 days # Digoxin 0.25 mg QD a , 20 days 1.15 1.20 40 mg QD a for 22 days Oral contraceptive QD a , 2 months -norethindrone 1 mg -ethinyl estradiol 35 μg 1.28 1.19 1.23 1.30 10 mg, SD c Tipranavir 500 mg BID b /ritonavir 200 mg BID b , 7 days 1.08 0.96 10 mg QD a for 4 days Fosamprenavir 1400 mg BID b , 14 days 0.73 0.82 10 mg QD a for 4 days Fosamprenavir 700 mg BID b /ritonavir 100 mg BID b , 14 days 0.99 0.94 # See Section 7 for clinical significance. a Once daily b Twice daily c Single dose Atorvastatin calcium had no clinically significant effect on prothrombin time when administered to patients receiving chronic warfarin treatment.
Clinical Pharmacology Table
Co-administered drug and dosing regimen | Atorvastatin | ||
Dose (mg) | Ratio of AUC & | Ratio of Cmax& | |
#Cyclosporine 5.2 mg/kg/day, stable dose | 10 mg QD a for 28 days | 8.69 | 10.66 |
#Tipranavir 500 mg BID b/ritonavir 200 mg BID b, 7 days | 10 mg, SD c | 9.36 | 8.58 |
#Glecaprevir 400 mg QD a/pibrentasvir 120 mg QD a, 7 days | 10 mg QD a for 7 days | 8.28 | 22.00 |
#Telaprevir 750 mg q8h f, 10 days | 20 mg, SD c | 7.88 | 10.60 |
#, ‡Saquinavir 400 mg BID b/ ritonavir 400 mg BID b, 15 days | 40 mg QD a for 4 days | 3.93 | 4.31 |
#Elbasvir 50 mg QD a/grazoprevir 200 mg QD a, 13 days | 10 mg SD c | 1.94 | 4.34 |
#Simeprevir 150 mg QD a, 10 days | 40 mg SD c | 2.12 | 1.70 |
#Clarithromycin 500 mg BID b, 9 days | 80 mg QD for 8 days | 4.54 | 5.38 |
#Darunavir 300 mg BID b/ritonavir 100 mg BID b, 9 days | 10 mg QD a for 4 days | 3.45 | 2.25 |
#Itraconazole 200 mg QD a, 4 days | 40 mg SD c | 3.32 | 1.20 |
#Letermovir 480 mg QD a, 10 days | 20 mg SD c | 3.29 | 2.17 |
#Fosamprenavir 700 mg BID b/ritonavir 100 mg BID b, 14 days | 10 mg QD a for 4 days | 2.53 | 2.84 |
#Fosamprenavir 1400 mg BID b, 14 days | 10 mg QD a for 4 days | 2.30 | 4.04 |
#Nelfinavir 1250 mg BID b, 14 days | 10 mg QD a for 28 days | 1.74 | 2.22 |
#Grapefruit Juice, 240 mL QD a,* | 40 mg, SD c | 1.37 | 1.16 |
Diltiazem 240 mg QD a, 28 days | 40 mg, SD c | 1.51 | 1.00 |
Erythromycin 500 mg QID e, 7 days | 10 mg, SD c | 1.33 | 1.38 |
Amlodipine 10 mg, single dose | 80 mg, SD c | 1.18 | 0.91 |
Cimetidine 300 mg QID e, 2 weeks | 10 mg QD a for 2 weeks | 1.00 | 0.89 |
Colestipol 10 g BID b, 24 weeks | 40 mg QD a for 8 weeks | NA | 0.74 ** |
Maalox TC ® 30 mL QID e, 17 days | 10 mg QD a for 15 days | 0.66 | 0.67 |
Efavirenz 600 mg QD a, 14 days | 10 mg for 3 days | 0.59 | 1.01 |
#Rifampin 600 mg QD a, 7 days (co-administered) † | 40 mg SD c | 1.12 | 2.90 |
#Rifampin 600 mg QD a, 5 days (doses separated) † | 40 mg SD c | 0.20 | 0.60 |
#Gemfibrozil 600 mg BID b, 7 days | 40 mg SD c | 1.35 | 1.00 |
#Fenofibrate 160 mg QD a, 7 days | 40 mg SD c | 1.03 | 1.02 |
Boceprevir 800 mg TID d, 7 days | 40 mg SD c | 2.32 | 2.66 |
Mechanism Of Action
12.1 Mechanism of Action Atorvastatin calcium is a selective, competitive inhibitor of HMG-CoA reductase, the rate-limiting enzyme that converts 3-hydroxy-3-methylglutaryl-coenzyme A to mevalonate, a precursor of sterols, including cholesterol. In animal models, atorvastatin lowers plasma cholesterol and lipoprotein levels by inhibiting HMG-CoA reductase and cholesterol synthesis in the liver and by increasing the number of hepatic LDL receptors on the cell surface to enhance uptake and catabolism of LDL; atorvastatin also reduces LDL production and the number of LDL particles.
Pharmacodynamics
12.2 Pharmacodynamics Atorvastatin calcium, as well as some of its metabolites, are pharmacologically active in humans. The liver is the primary site of action and the principal site of cholesterol synthesis and LDL clearance. Drug dosage, rather than systemic drug concentration, correlates better with LDL-C reduction. Individualization of drug dosage should be based on therapeutic response [see Dosage and Administration (2) ].
Pharmacokinetics
12.3 Pharmacokinetics Absorption:Atorvastatin calcium tablets are rapidly absorbed after oral administration; maximum plasma concentrations occur within 1 to 2 hours. Extent of absorption increases in proportion to atorvastatin calcium dose. The absolute bioavailability of atorvastatin (parent drug) is approximately 14% 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. Although food decreases the rate and extent of drug absorption by approximately 25% and 9%, respectively, as assessed by Cmax and AUC, LDL-C reduction is similar whether atorvastatin calcium tablets are given with or without food. Plasma atorvastatin concentrations are lower (approximately 30% for Cmax and AUC) following evening drug administration compared with morning. However, LDL-C reduction is the same regardless of the time of day of drug administration [see Dosage and Administration (2) ]. Distribution:Mean volume of distribution of atorvastatin is approximately 381 liters. Atorvastatin is ≥98% bound to plasma proteins. A blood/plasma ratio of approximately 0.25 indicates poor drug penetration into red blood cells. Based on observations in rats, atorvastatin is likely to be secreted in human milk [see Contraindications, Nursing Mothers Error! Hyperlink reference not valid. and Use in Specific Populations (8.2 ) ]. Metabolism:Atorvastatin is extensively 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 suggest the importance of atorvastatin metabolism by cytochrome P450 3A4, consistent with increased plasma concentrations of atorvastatin in humans following co-administration with erythromycin, a known inhibitor of this isozyme [see Drug Interactions (7.1) ]. In animals, the ortho-hydroxy metabolite undergoes further glucuronidation. Excretion:Atorvastatin and its metabolites are eliminated primarily in bile following hepatic and/or extra-hepatic metabolism; however, the drug does not appear to undergo enterohepatic recirculation. Mean plasma elimination half-life of atorvastatin in humans is approximately 14 hours, but the half-life of inhibitory activity for HMG-CoA reductase is 20 to 30 hours due to the contribution of active metabolites. Less than 2% of a dose of atorvastatin calcium tablets are recovered in urine following oral administration. Specific Populations Geriatric:Plasma concentrations of atorvastatin are higher (approximately 40% for Cmax and 30% for AUC) in healthy elderly subjects (age ≥65 years) than in young adults. Clinical data suggest a greater degree of LDL-lowering at any dose of drug in the elderly patient population compared to younger adults [see Use in Specific Populations (8.5) ]. Pediatric:Apparent oral clearance of atorvastatin in pediatric subjects appeared similar to that of adults when scaled allometrically by body weight as the body weight was the only significant covariate in atorvastatin population PK model with data including pediatric HeFH patients (ages 10 years to 17 years of age, n=29) in an open-label, 8-week study. Gender : Plasma concentrations of atorvastatin in women differ from those in men (approximately 20% higher for Cmax and 10% lower for AUC); however, there is no clinically significant difference in LDL-C reduction with atorvastatin between men and women. Renal Impairment:Renal disease has no influence on the plasma concentrations or LDL-C reduction of atorvastatin; thus, dose adjustment in patients with renal dysfunction is not necessary [see Dosage and Administration (2.5) and Warnings and Precautions (5.1) ]. Hemodialysis:While studies have not been conducted in patients with end-stage renal disease, hemodialysis is not expected to significantly enhance clearance of atorvastatin since the drug is extensively bound to plasma proteins. Hepatic Impairment:In patients with chronic alcoholic liver disease, plasma concentrations of atorvastatin are markedly increased. Cmax and AUC are each 4-fold greater in patients with Childs-Pugh A disease. Cmax and AUC are approximately 16-fold and 11-fold increased, respectively, in patients with Childs-Pugh B disease [see Contraindications ( 4 ) ]. Drug Interaction Studies Atorvastatin is a substrate of the hepatic transporters, OATP1B1 and OATP1B3 transporter. Metabolites of atorvastatin are substrates of OATP1B1. Atorvastatin is also identified as a substrate of the efflux transporter BCRP, which may limit the intestinal absorption and biliary clearance of atorvastatin. TABLE 6. Effect of Co-administered Drugs on the Pharmacokinetics of Atorvastatin Co-administered drug and dosing regimen Atorvastatin Dose (mg) Ratio of AUC & Ratio of C max & # Cyclosporine 5.2 mg/kg/day, stable dose 10 mg QD a for 28 days 8.69 10.66 # Tipranavir 500 mg BID b /ritonavir 200 mg BID b , 7 days 10 mg, SD c 9.36 8.58 # Glecaprevir 400 mg QD a /pibrentasvir 120 mg QD a , 7 days 10 mg QD a for 7 days 8.28 22.00 # Telaprevir 750 mg q8h f , 10 days 20 mg, SD c 7.88 10.60 #, ‡ Saquinavir 400 mg BID b / ritonavir 400 mg BID b , 15 days 40 mg QD a for 4 days 3.93 4.31 # Elbasvir 50 mg QD a /grazoprevir 200 mg QD a , 13 days 10 mg SD c 1.94 4.34 # Simeprevir 150 mg QD a , 10 days 40 mg SD c 2.12 1.70 # Clarithromycin 500 mg BID b , 9 days 80 mg QD for 8 days 4.54 5.38 # Darunavir 300 mg BID b /ritonavir 100 mg BID b , 9 days 10 mg QD a for 4 days 3.45 2.25 # Itraconazole 200 mg QD a , 4 days 40 mg SD c 3.32 1.20 # Letermovir 480 mg QD a , 10 days 20 mg SD c 3.29 2.17 # Fosamprenavir 700 mg BID b /ritonavir 100 mg BID b , 14 days 10 mg QD a for 4 days 2.53 2.84 # Fosamprenavir 1400 mg BID b , 14 days 10 mg QD a for 4 days 2.30 4.04 # Nelfinavir 1250 mg BID b , 14 days 10 mg QD a for 28 days 1.74 2.22 # Grapefruit Juice, 240 mL QD a,* 40 mg, SD c 1.37 1.16 Diltiazem 240 mg QD a , 28 days 40 mg, SD c 1.51 1.00 Erythromycin 500 mg QID e , 7 days 10 mg, SD c 1.33 1.38 Amlodipine 10 mg, single dose 80 mg, SD c 1.18 0.91 Cimetidine 300 mg QID e , 2 weeks 10 mg QD a for 2 weeks 1.00 0.89 Colestipol 10 g BID b , 24 weeks 40 mg QD a for 8 weeks NA 0.74 ** Maalox TC ® 30 mL QID e , 17 days 10 mg QD a for 15 days 0.66 0.67 Efavirenz 600 mg QD a , 14 days 10 mg for 3 days 0.59 1.01 # Rifampin 600 mg QD a , 7 days (co-administered) † 40 mg SD c 1.12 2.90 # Rifampin 600 mg QD a , 5 days (doses separated) † 40 mg SD c 0.20 0.60 # Gemfibrozil 600 mg BID b , 7 days 40 mg SD c 1.35 1.00 # Fenofibrate 160 mg QD a , 7 days 40 mg SD c 1.03 1.02 Boceprevir 800 mg TID d , 7 days 40 mg SD c 2.32 2.66 & Represents ratio of treatments (co-administered drug plus atorvastatin vs. atorvastatin alone). # See Sections 5.1 and 7 for clinical significance. * Greater increases in AUC (ratio of AUC up to 2.5) and/or C max (ratio of C max up to1.71) have been reported with excessive grapefruit consumption (≥ 750 mL to 1.2 liters per day). ** Ratio based on a single sample taken 8 to 16 h post dose. † Due to the dual interaction mechanism of rifampin, simultaneous co-administration of atorvastatin with rifampin is recommended, as delayed administration of atorvastatin after administration of rifampin has been associated with a significant reduction in atorvastatin plasma concentrations. ‡ The dose of saquinavir plus ritonavir in this study is not the clinically used dose. The increase in atorvastatin exposure when used clinically is likely to be higher than what was observed in this study. Therefore, caution should be applied and the lowest dose necessary should be used. a Once daily b Twice daily c Single dose d Three times daily e Four times daily f Every 8 hours TABLE 7. Effect of Atorvastatin on the Pharmacokinetics of Co-administered Drugs Atorvastatin Co-administered drug and dosing regimen Drug/Dose (mg) Ratio of AUC Ratio of C max 80 mg QD a for 15 days Antipyrine, 600 mg SD c 1.03 0.89 80 mg QD a for 10 days # Digoxin 0.25 mg QD a , 20 days 1.15 1.20 40 mg QD a for 22 days Oral contraceptive QD a , 2 months -norethindrone 1 mg -ethinyl estradiol 35 μg 1.28 1.19 1.23 1.30 10 mg, SD c Tipranavir 500 mg BID b /ritonavir 200 mg BID b , 7 days 1.08 0.96 10 mg QD a for 4 days Fosamprenavir 1400 mg BID b , 14 days 0.73 0.82 10 mg QD a for 4 days Fosamprenavir 700 mg BID b /ritonavir 100 mg BID b , 14 days 0.99 0.94 # See Section 7 for clinical significance. a Once daily b Twice daily c Single dose Atorvastatin calcium had no clinically significant effect on prothrombin time when administered to patients receiving chronic warfarin treatment.
Pharmacokinetics Table
Co-administered drug and dosing regimen | Atorvastatin | ||
Dose (mg) | Ratio of AUC & | Ratio of Cmax& | |
#Cyclosporine 5.2 mg/kg/day, stable dose | 10 mg QD a for 28 days | 8.69 | 10.66 |
#Tipranavir 500 mg BID b/ritonavir 200 mg BID b, 7 days | 10 mg, SD c | 9.36 | 8.58 |
#Glecaprevir 400 mg QD a/pibrentasvir 120 mg QD a, 7 days | 10 mg QD a for 7 days | 8.28 | 22.00 |
#Telaprevir 750 mg q8h f, 10 days | 20 mg, SD c | 7.88 | 10.60 |
#, ‡Saquinavir 400 mg BID b/ ritonavir 400 mg BID b, 15 days | 40 mg QD a for 4 days | 3.93 | 4.31 |
#Elbasvir 50 mg QD a/grazoprevir 200 mg QD a, 13 days | 10 mg SD c | 1.94 | 4.34 |
#Simeprevir 150 mg QD a, 10 days | 40 mg SD c | 2.12 | 1.70 |
#Clarithromycin 500 mg BID b, 9 days | 80 mg QD for 8 days | 4.54 | 5.38 |
#Darunavir 300 mg BID b/ritonavir 100 mg BID b, 9 days | 10 mg QD a for 4 days | 3.45 | 2.25 |
#Itraconazole 200 mg QD a, 4 days | 40 mg SD c | 3.32 | 1.20 |
#Letermovir 480 mg QD a, 10 days | 20 mg SD c | 3.29 | 2.17 |
#Fosamprenavir 700 mg BID b/ritonavir 100 mg BID b, 14 days | 10 mg QD a for 4 days | 2.53 | 2.84 |
#Fosamprenavir 1400 mg BID b, 14 days | 10 mg QD a for 4 days | 2.30 | 4.04 |
#Nelfinavir 1250 mg BID b, 14 days | 10 mg QD a for 28 days | 1.74 | 2.22 |
#Grapefruit Juice, 240 mL QD a,* | 40 mg, SD c | 1.37 | 1.16 |
Diltiazem 240 mg QD a, 28 days | 40 mg, SD c | 1.51 | 1.00 |
Erythromycin 500 mg QID e, 7 days | 10 mg, SD c | 1.33 | 1.38 |
Amlodipine 10 mg, single dose | 80 mg, SD c | 1.18 | 0.91 |
Cimetidine 300 mg QID e, 2 weeks | 10 mg QD a for 2 weeks | 1.00 | 0.89 |
Colestipol 10 g BID b, 24 weeks | 40 mg QD a for 8 weeks | NA | 0.74 ** |
Maalox TC ® 30 mL QID e, 17 days | 10 mg QD a for 15 days | 0.66 | 0.67 |
Efavirenz 600 mg QD a, 14 days | 10 mg for 3 days | 0.59 | 1.01 |
#Rifampin 600 mg QD a, 7 days (co-administered) † | 40 mg SD c | 1.12 | 2.90 |
#Rifampin 600 mg QD a, 5 days (doses separated) † | 40 mg SD c | 0.20 | 0.60 |
#Gemfibrozil 600 mg BID b, 7 days | 40 mg SD c | 1.35 | 1.00 |
#Fenofibrate 160 mg QD a, 7 days | 40 mg SD c | 1.03 | 1.02 |
Boceprevir 800 mg TID d, 7 days | 40 mg SD c | 2.32 | 2.66 |
Effective Time
20230322
Version
1
Dosage Forms And Strengths
3 DOSAGE FORMS AND STRENGTHS Atorvastatin calcium tablets USP, 10 mg are white to off-white oval shaped, film-coated tablets with ‘C1’ on one side and plain on other side and free from physical defects. Atorvastatin calcium tablets USP, 20 mg are white to off-white oval shaped, film-coated tablets with ‘C2’ on one side and plain on other side and free from physical defects. Atorvastatin calcium tablets USP, 40 mg are white to off-white oval shaped, film-coated tablets with ‘C3’ on one side and plain on other side and free from physical defects. Atorvastatin calcium tablets USP, 80 mg are white to off-white oval shaped, film-coated tablets with ‘C4’ on one side and plain on other side and free from physical defects. Tablets: 10, 20, 40 and 80 mg of atorvastatin (3) .
Spl Product Data Elements
Atorvastatin Calcium Atorvastatin Calcium Atorvastatin Calcium Trihydrate atorvastatin CALCIUM CARBONATE Croscarmellose Sodium Hydroxypropyl Cellulose, Unspecified lactose monohydrate magnesium stearate Microcrystalline Cellulose Polysorbate 80 HYPROMELLOSE, UNSPECIFIED Polyethylene Glycol, Unspecified titanium dioxide Talc white to off white C1
Carcinogenesis And Mutagenesis And Impairment Of Fertility
13.1 Carcinogenesis, Mutagenesis, Impairment of Fertility In a 2-year carcinogenicity study in rats at dose levels of 10, 30, and 100 mg/kg/day, 2 rare tumors were found in muscle in high-dose females: in one, there was a rhabdomyosarcoma and, in another, there was a fibrosarcoma. This dose represents a plasma AUC (0 to 24) value of approximately 16 times the mean human plasma drug exposure after an 80 mg oral dose. A 2-year carcinogenicity study in mice given 100, 200, or 400 mg/kg/day resulted in a significant increase in liver adenomas in high-dose males and liver carcinomas in high-dose females. These findings occurred at plasma AUC (0 to 24) values of approximately 6 times the mean human plasma drug exposure after an 80 mg oral dose. In vitro, atorvastatin was not mutagenic or clastogenic in the following tests with and without metabolic activation: the Ames test with Salmonella typhimurium and Escherichia coli , the HGPRT forward mutation assay in Chinese hamster lung cells, and the chromosomal aberration assay in Chinese hamster lung cells. Atorvastatin was negative in the in vivo mouse micronucleus test. In female rats, atorvastatin at doses up to 225 mg/kg (56 times the human exposure) did not cause adverse effects on fertility. Studies in male rats performed at doses up to 175 mg/kg (15 times the human exposure) produced no changes in fertility. There was aplasia and aspermia in the epididymis of 2 of 10 rats treated with 100 mg/kg/day of atorvastatin for 3 months (16 times the human AUC at the 80 mg dose); testis weights were significantly lower at 30 and 100 mg/kg and epididymal weight was lower at 100 mg/kg. Male rats given 100 mg/kg/day for 11 weeks prior to mating had decreased spermmotility, spermatid head concentration, and increased abnormal sperm. Atorvastatin caused no adverse effects on semen parameters, or reproductive organ histopathology in dogs given doses of 10, 40, or 120 mg/kg for two years.
Nonclinical Toxicology
13 NONCLINICAL TOXICOLOGY 13.1 Carcinogenesis, Mutagenesis, Impairment of Fertility In a 2-year carcinogenicity study in rats at dose levels of 10, 30, and 100 mg/kg/day, 2 rare tumors were found in muscle in high-dose females: in one, there was a rhabdomyosarcoma and, in another, there was a fibrosarcoma. This dose represents a plasma AUC (0 to 24) value of approximately 16 times the mean human plasma drug exposure after an 80 mg oral dose. A 2-year carcinogenicity study in mice given 100, 200, or 400 mg/kg/day resulted in a significant increase in liver adenomas in high-dose males and liver carcinomas in high-dose females. These findings occurred at plasma AUC (0 to 24) values of approximately 6 times the mean human plasma drug exposure after an 80 mg oral dose. In vitro, atorvastatin was not mutagenic or clastogenic in the following tests with and without metabolic activation: the Ames test with Salmonella typhimurium and Escherichia coli , the HGPRT forward mutation assay in Chinese hamster lung cells, and the chromosomal aberration assay in Chinese hamster lung cells. Atorvastatin was negative in the in vivo mouse micronucleus test. In female rats, atorvastatin at doses up to 225 mg/kg (56 times the human exposure) did not cause adverse effects on fertility. Studies in male rats performed at doses up to 175 mg/kg (15 times the human exposure) produced no changes in fertility. There was aplasia and aspermia in the epididymis of 2 of 10 rats treated with 100 mg/kg/day of atorvastatin for 3 months (16 times the human AUC at the 80 mg dose); testis weights were significantly lower at 30 and 100 mg/kg and epididymal weight was lower at 100 mg/kg. Male rats given 100 mg/kg/day for 11 weeks prior to mating had decreased spermmotility, spermatid head concentration, and increased abnormal sperm. Atorvastatin caused no adverse effects on semen parameters, or reproductive organ histopathology in dogs given doses of 10, 40, or 120 mg/kg for two years.
Application Number
ANDA214659
Brand Name
Atorvastatin Calcium
Generic Name
Atorvastatin Calcium
Product Ndc
68788-8409
Product Type
HUMAN PRESCRIPTION DRUG
Route
ORAL
Package Label Principal Display Panel
PACKAGE LABEL.PRINCIPAL DISPLAY PANEL SECTION Atorvastatin Calcium Tablets, 10 mg - Container Label Atorvastatin Calcium Tablets 10mg
Information For Patients
17 PATIENT COUNSELING INFORMATION Advise the patient to read the FDA-approved patient labeling (Patient Information). Patients taking atorvastatin calcium tablets should be advised that cholesterol is a chronic condition and they should adhere to their medication along with their National Cholesterol Education Program (NCEP)-recommended diet, a regular exercise program as appropriate, and periodic testing of a fasting lipid panel to determine goal attainment. Patients should be advised about substances they should not take concomitantly with atorvastatin [see Warnings and Precautions ( 5.1) ]. Patients should also be advised to inform other healthcare professionals prescribing a new medication that they are taking atorvastatin calcium tablets. 17.1 Muscle Pain All patients starting therapy with atorvastatin calcium tablets should be advised of the risk of myopathy and told to report promptly any unexplained muscle pain, tenderness, or weakness particularly if accompanied by malaise or fever or if these muscle signs or symptoms persist after discontinuing atorvastatin calcium tablets. The risk of this occurring is increased when taking certain types of medication or consuming larger quantities (>1 liter) of grapefruit juice. They should discuss all medication, both prescription and over the counter, with their healthcare professional. 17.2 Liver Enzymes It is recommended that liver enzyme tests be performed before the initiation of atorvastatin calcium tablets and if signs or symptoms of liver injury occur. All patients treated with atorvastatin calcium tablets should be advised to report promptly any symptoms that may indicate liver injury, including fatigue, anorexia, right upper abdominal discomfort, dark urine, or jaundice. 17.3 Embryofetal Toxicity Advise females of reproductive potential of the risk to a fetus, to use effective contraception during treatment and to inform their healthcare provider of a known or suspected pregnancy [see Contraindications ( 4 ) and Use in Specific Populations ( 8.1 , 8.3 ) ]. 17.4 Lactation Advise women not to breastfeed during treatment with atorvastatin calcium [see Contraindications ( 4 ) and Use in Specific Populations ( 8.2 ) ]. Rx only Distributor: Dr. Reddy’s Laboratories Inc., Princeton, NJ 08540 Made in India Issued:07/2022 Repackaged By: Preferred Pharmaceuticals Inc.
Clinical Studies
14 CLINICAL STUDIES 14.1 Prevention of Cardiovascular Disease In the Anglo-Scandinavian Cardiac Outcomes Trial (ASCOT), the effect of atorvastatin calcium on fatal and non-fatal coronary heart disease was assessed in 10,305 hypertensive patients 40 to 80 years of age (mean of 63 years), without a previous myocardial infarction and with TC levels ≤251 mg/dL (6.5 mmol/L). Additionally, all patients had at least 3 of the following cardiovascular risk factors: male gender (81.1%), age >55 years (84.5%), smoking (33.2%), diabetes (24.3%), history of CHD in a first-degree relative (26%), TC:HDL >6 (14.3%), peripheral vascular disease (5.1%), left ventricular hypertrophy (14.4%), prior cerebrovascular event (9.8%), specific ECG abnormality (14.3%), proteinuria/albuminuria (62.4%). In this double-blind, placebo-controlled study, patients were treated with anti-hypertensive therapy (Goal BP <140/90 mm Hg for non-diabetic patients; <130/80 mm Hg for diabetic patients) and allocated to either atorvastatin calcium tablets 10 mg daily (n=5168) or placebo (n=5137), using a covariate adaptive method which took into account the distribution of nine baseline characteristics of patients already enrolled and minimized the imbalance of those characteristics across the groups. Patients were followed for a median duration of 3.3 years. The effect of 10 mg/day of atorvastatin calcium tablets on lipid levels was similar to that seen in previous clinical trials. Atorvastatin significantly reduced the rate of coronary events [either fatal coronary heart disease (46 events in the placebo group vs. 40 events in the atorvastatin calcium tablets group) or non-fatal MI (108 events in the placebo group vs. 60 events in the atorvastatin calcium tablets group)] with a relative risk reduction of 36% [(based on incidences of 1.9% for atorvastatin calcium tablets vs. 3% for placebo), p=0.0005 (see Figure 1)]. The risk reduction was consistent regardless of age, smoking status, obesity, or presence of renal dysfunction. The effect of atorvastatin was seen regardless of baseline LDL levels. Due to the small number of events, results for women were inconclusive. Figure 1: Effect of Atorvastatin 10 mg/day on Cumulative Incidence of Non-Fatal Myocardial Infarction or Coronary Heart Disease Death (in ASCOT-LLA) Atorvastatin also significantly decreased the relative risk for revascularization procedures by 42% (incidences of 1.4% for atorvastatin calcium and 2.5% for placebo). Although the reduction of fatal and non-fatal strokes did not reach a pre-defined significance level (p=0.01), a favorable trend was observed with a 26% relative risk reduction (incidences of 1.7% for atorvastatin calcium tablets and 2.3% for placebo). There was no significant difference between the treatment groups for death due to cardiovascular causes (p=0.51) or noncardiovascular causes (p=0.17). In the Collaborative Atorvastatin Diabetes Study (CARDS), the effect of atorvastatin on cardiovascular disease (CVD) endpoints was assessed in 2,838 subjects (94% white, 68% male), ages 40 to 75 with type 2 diabetes based on WHO criteria, without prior history of cardiovascular disease and with LDL ≤ 160 mg/dL and TG ≤ 600 mg/dL. In addition to diabetes, subjects had 1 or more of the following risk factors: current smoking (23%), hypertension (80%), retinopathy (30%), or microalbuminuria (9%) or macroalbuminuria (3%). No subjects on hemodialysis were enrolled in the study. In this multicenter, placebo-controlled, double-blind clinical trial, subjects were randomly allocated to either atorvastatin calcium tablets 10 mg daily (1,429) or placebo (1,411) in a 1:1 ratio and were followed for a median duration of 3.9 years. The primary endpoint was the occurrence of any of the major cardiovascular events: myocardial infarction, acute CHD death, unstable angina, coronary revascularization, or stroke. The primary analysis was the time to first occurrence of the primary endpoint. Baseline characteristics of subjects were: mean age of 62 years, mean HbA 1c 7.7%; median LDL-C 120 mg/dL; median TC 207 mg/dL; median TG 151 mg/dL; median HDL-C 52 mg/dL. The effect of atorvastatin 10 mg/day on lipid levels was similar to that seen in previous clinical trials. Atorvastatin significantly reduced the rate of major cardiovascular events (primary endpoint events) (83 events in the atorvastatin calcium tablets group vs. 127 events in the placebo group) with a relative risk reduction of 37%, HR 0.63, 95% CI (0.48, 0.83) (p=0.001) (see Figure 2). An effect of atorvastatin calcium tablets was seen regardless of age, sex, or baseline lipid levels. Atorvastatin significantly reduced the risk of stroke by 48% (21 events in the atorvastatin calcium tablets group vs. 39 events in the placebo group), HR 0.52, 95% CI (0.31, 0.89) (p=0.016) and reduced the risk of MI by 42% (38 events in the atorvastatin calcium tablets group vs. 64 events in the placebo group), HR 0.58, 95.1% CI (0.39, 0.86) (p=0.007). There was no significant difference between the treatment groups for angina, revascularization procedures, and acute CHD death. There were 61 deaths in the atorvastatin calcium tablets group vs. 82 deaths in the placebo group (HR 0.73, p=0.059). Figure 2: Effect of Atorvastatin 10 mg/day on Time to Occurrence of Major Cardiovascular Event (myocardial infarction, acute CHD death, unstable angina, coronary revascularization, or stroke) in CARDS In the Treating to New Targets Study (TNT), the effect of atorvastatin calcium tablets 80 mg/day vs. atorvastatin calcium tablets 10 mg/day on the reduction in cardiovascular events was assessed in 10,001 subjects (94% white, 81% male, 38% ≥65 years) with clinically evident coronary heart disease who had achieved a target LDL-C level <130 mg/dL after completing an 8-week, open-label, run-in period with atorvastatin calcium tablets 10 mg/day. Subjects were randomly assigned to either 10 mg/day or 80 mg/day of atorvastatin calcium tablets and followed for a median duration of 4.9 years. The primary endpoint was the time-to-first occurrence of any of the following major cardiovascular events (MCVE): death due to CHD, non-fatal myocardial infarction, resuscitated cardiac arrest, and fatal and non-fatal stroke. The mean LDL-C, TC, TG, non-HDL, and HDL cholesterol levels at 12 weeks were 73, 145, 128, 98, and 47 mg/dL during treatment with 80 mg of atorvastatin calcium tablets and 99, 177, 152, 129, and 48 mg/dL during treatment with 10 mg of atorvastatin calcium tablets. Treatment with atorvastatin calcium tablets 80 mg/day significantly reduced the rate of MCVE (434 events in the 80 mg/day group vs. 548 events in the 10 mg/day group) with a relative risk reduction of 22%, HR 0.78, 95% CI (0.69, 0.89), p=0.0002 (see Figure 3 and Table 9). The overall risk reduction was consistent regardless of age (<65, ≥65) or gender. Figure 3: Effect of Atorvastatin 80 mg/day vs. 10 mg/day on Time to Occurrence of Major Cardiovascular Events (TNT) TABLE 8. Overview of Efficacy Results in TNT Endpoint Atorvastatin 10 mg (N=5006) Atorvastatin 80 mg (N=4995) HR (95%CI) PRIMARY ENDPOINT n (%) n (%) First major cardiovascular endpoint 548 (10.9) 434 (8.7) 0.78 (0.69, 0.89) Components of the Primary Endpoint CHD death 127 (2.5) 101 (2.0) 0.80 (0.61, 1.03) Non-fatal, non-procedure related MI 308 (6.2) 243 (4.9) 0.78 (0.66, 0.93) Resuscitated cardiac arrest 26 (0.5) 25 (0.5) 0.96 (0.56, 1.67) Stroke (fatal and non-fatal) 155 (3.1) 117 (2.3) 0.75 (0.59, 0.96) SECONDARY ENDPOINTS First CHF with hospitalization 164 (3.3) 122 (2.4) 0.74 (0.59, 0.94) First PVD endpoint 282 (5.6) 275 (5.5) 0.97 (0.83, 1.15) First CABG or other coronary revascularization procedure 904 (18.1) 667 (13.4) 0.72 (0.65, 0.80) First documented angina endpoint 615 (12.3) 545 (10.9) 0.88 (0.79, 0.99) All-cause mortality 282 (5.6) 284 (5.7) 1.01 (0.85, 1.19) Components of All-Cause Mortality Cardiovascular death 155 (3.1) 126 (2.5) 0.81 (0.64, 1.03) Noncardiovascular death 127 (2.5) 158 (3.2) 1.25 (0.99, 1.57) Cancer death 75 (1.5) 85 (1.7) 1.13 (0.83, 1.55) Other non-CV death 43 (0.9) 58 (1.2) 1.35 (0.91, 2.00) Suicide, homicide, and othertraumatic non-CV death 9 (0.2) 15 (0.3) 1.67 (0.73, 3.82) a Atorvastatin 80 mg: atorvastatin 10 mg b Component of other secondary endpoints * Secondary endpoints not included in primary endpoint HR=hazard ratio; CHD=coronary heart disease; CI=confidence interval; MI=myocardial infarction; CHF=congestive heart failure; CV=cardiovascular; PVD=peripheral vascular disease; CABG=coronary artery bypass graft Confidence intervals for the Secondary Endpoints were not adjusted for multiple comparisons Of the events that comprised the primary efficacy endpoint, treatment with atorvastatin calcium tablets 80 mg/day significantly reduced the rate of non-fatal, non-procedure related MI and fatal and non-fatal stroke, but not CHD death or resuscitated cardiac arrest (Table 8). Of the predefined secondary endpoints, treatment with atorvastatin calcium tablets 80 mg/day significantly reduced the rate of coronary revascularization, angina, and hospitalization for heart failure, but not peripheral vascular disease. The reduction in the rate of CHF with hospitalization was only observed in the 8% of patients with a prior history of CHF. There was no significant difference between the treatment groups for all-cause mortality (Table 8). The proportions of subjects who experienced cardiovascular death, including the components of CHD death and fatal stroke, were numerically smaller in the atorvastatin calcium tablets 80 mg group than in the atorvastatin calcium tablets 10 mg treatment group. The proportions of subjects who experienced noncardiovascular death were numerically larger in the atorvastatin calcium tablets 80 mg group than in the atorvastatin calcium tablets 10 mg treatment group. In the Incremental Decrease in Endpoints Through Aggressive Lipid Lowering Study (IDEAL), treatment with atorvastatin calcium tablets 80 mg/day was compared to treatment with simvastatin 20 to 40 mg/day in 8,888 subjects up to 80 years of age with a history of CHD to assess whether reduction in CV risk could be achieved. Patients were mainly male (81%), white (99%) with an average age of 61.7 years, and an average LDL-C of 121.5 mg/dL at randomization; 76% were on statin therapy. In this prospective, randomized, open-label, blinded endpoint (PROBE) trial with no run-in period, subjects were followed for a median duration of 4.8 years. The mean LDL-C, TC, TG, HDL, and non-HDL cholesterol levels at Week 12 were 78, 145, 115, 45, and 100 mg/dL during treatment with 80 mg of atorvastatin calcium tablets and 105, 179, 142, 47, and 132 mg/dL during treatment with 20 to 40 mg of simvastatin. There was no significant difference between the treatment groups for the primary endpoint, the rate of first major coronary event (fatal CHD, non-fatal MI, and resuscitated cardiac arrest): 411 (9.3%) in the atorvastatin calcium tablets 80 mg/day group vs. 463 (10.4%) in the simvastatin 20 to 40 mg/day group, HR 0.89, 95% CI ( 0.78, 1.01), p=0.07. There were no significant differences between the treatment groups for all-cause mortality: 366 (8.2%) in the atorvastatin calcium tablets 80 mg/day group vs. 374 (8.4%) in the simvastatin 20 to 40 mg/day group. The proportions of subjects who experienced CV or non-CV death were similar for the atorvastatin calcium tablets 80 mg group and the simvastatin 20 to 40 mg group. figure1 figure2 figure3 14.2 Hyperlipidemia and Mixed Dyslipidemia Atorvastatin reduces total-C, LDL-C, VLDL-C, apo B, and TG, and increases HDL-C in patients with hyperlipidemia (heterozygous familial and nonfamilial) and mixed dyslipidemia (Fredrickson Types IIa and IIb). Therapeutic response is seen within 2 weeks, and maximum response is usually achieved within 4 weeks and maintained during chronic therapy. Atorvastatin calcium tablets are effective in a wide variety of patient populations with hyperlipidemia, with and without hypertriglyceridemia, in men and women, and in the elderly. In two multicenter, placebo-controlled, dose-response studies in patients with hyperlipidemia, atorvastatin calcium tablets given as a single dose over 6 weeks, significantly reduced total-C, LDL-C, apo B, and TG. (Pooled results are provided in Table 9.) TABLE 9. Dose Response in Patients With Primary Hyperlipidemia (Adjusted Mean % Change From Baseline) a Dose N TC LDL-C Apo B TG HDL-C Non-HDL-C/ HDL-C Placebo 21 4 4 3 10 -3 7 10 22 -29 -39 -32 -19 6 -34 20 20 -33 -43 -35 -26 9 -41 40 21 -37 -50 -42 -29 6 -45 80 23 -45 -60 -50 -37 5 -53 a Results are pooled from 2 dose-response studies. In patients with Fredrickson Types IIa and IIb hyperlipoproteinemia pooled from 24 controlled trials, the median (25 th and 75 th percentile) percent changes from baseline in HDL-C for atorvastatin calcium tablets 10, 20, 40, and 80 mg were 6.4 (-1.4, 14), 8.7 (0, 17), 7.8 (0, 16), and 5.1 (-2.7, 15), respectively. Additionally, analysis of the pooled data demonstrated consistent and significant decreases in total-C, LDL-C, TG, total-C/HDL-C, and LDL-C/HDL-C. In three multicenter, double-blind studies in patients with hyperlipidemia, atorvastatin was compared to other statins. After randomization, patients were treated for 16 weeks with either atorvastatin calcium tablets 10 mg per day or a fixed dose of the comparative agent (Table 10). TABLE 10. Mean Percentage Change From Baseline at Endpoint (Double-Blind, Randomized, Active-Controlled Trials) Treatment (Daily Dose) N Total-C LDL-C Apo B TG HDL-C Non-HDL-C/ HDL-C Study 1 Atorvastatin Calcium 10 mg 707 -27 -36 -28 -17 +7 -37 Lovastatin 20 mg 191 -19 -27 -20 -6 +7 -28 95% CI for Diff -9.2, -6.5 -10.7, -7.1 -10.0, -6.5 -15.2, -7.1 -1.7, 2.0 -11.1, -7.1 Study 2 Atorvastatin Calcium 10 mg 222 -25 -35 -27 -17 +6 -36 Pravastatin 20 mg 77 -17 -23 -17 -9 +8 -28 95% CI for Diff -10.8, -6.1 -14.5, -8.2 -13.4, -7.4 -14.1, -0.7 -4.9, 1.6 -11.5, -4.1 Study 3 Atorvastatin Calcium 10 mg 132 -29 -37 -34 -23 +7 -39 Simvastatin 10 mg 45 -24 -30 -30 -15 +7 -33 95% CI for Diff -8.7, -2.7 -10.1, -2.6 -8.0, -1.1 -15.1, -0.7 -4.3, 3.9 -9.6, -1.9 1 A negative value for the 95% CI for the difference between treatments favors atorvastatin for all except HDL-C, for which a positive value favors atorvastatin . If the range does not include 0, this indicates a statistically significant difference. a Significantly different from lovastatin, ANCOVA, p ≤0.05 b Significantly different from pravastatin, ANCOVA, p ≤0.05 c Significantly different from simvastatin, ANCOVA, p ≤0.05 The impact on clinical outcomes of the differences in lipid-altering effects between treatments shown in Table 10 is not known. Table 10 does not contain data comparing the effects of atorvastatin 10 mg and higher doses of lovastatin, pravastatin, and simvastatin. The drugs compared in the studies summarized in the table are not necessarily interchangeable. 14.3 Hypertriglyceridemia The response to atorvastatin in 64 patients with isolated hypertriglyceridemia(Fredrickson Type IV) treated across several clinical trials is shown in the table below (Table 11). For the atorvastatin calcium tablets -treated patients, median (min, max) baseline TG level was 565 (267 to 1,502). TABLE 11. Combined Patients With Isolated Elevated TG: Median (min, max) Percentage Change From Baseline Placebo (N=12) Atorvastatin Calcium 10 mg (N=37) Atorvastatin Calcium 20 mg (N=13) Atorvastatin Calcium 80 mg (N=14) Triglycerides -12.4 (-36.6, 82.7) -41.0 (-76.2, 49.4) -38.7 (-62.7, 29.5) -51.8 (-82.8, 41.3) Total-C -2.3 (-15.5, 24.4) -28.2 (-44.9, -6.8) -34.9 (-49.6, -15.2) -44.4 (-63.5, -3.8) LDL-C 3.6 (-31.3, 31.6) -26.5 (-57.7, 9.8) -30.4 (-53.9, 0.3) -40.5 (-60.6, -13.8) HDL-C 3.8 (-18.6, 13.4) 13.8 (-9.7, 61.5) 11.0 (-3.2, 25.2) 7.5 (-10.8, 37.2) VLDL-C -1.0 (-31.9, 53.2) -48.8 (-85.8, 57.3) -44.6 (-62.2, -10.8) -62.0 (-88.2, 37.6) non-HDL-C -2.8 (-17.6, 30.0) -33.0 (-52.1, -13.3) -42.7 (-53.7, -17.4) -51.5 (-72.9, -4.3) 14.4 Dysbetalipoproteinemia The results of an open-label crossover study of 16 patients (genotypes: 14 apo E2/E2 and 2 apo E3/E2) with dysbetalipoproteinemia ( Fredrickson Type III) are shown in the table below (Table 12). TABLE 12. Open-Label Crossover Study of 16 Patients With Dysbetalipoproteinemia ( Fredrickson Type III) Median % Change (min, max) Median (min, max) at Baseline (mg/dL) Atorvastatin Calcium 10 mg Atorvastatin Calcium 80 mg Total-C 442 (225, 1320) -37 (-85, 17) -58 (-90, -31) Triglycerides 678 (273, 5990) -39 (-92, -8) -53 (-95, -30) IDL-C + VLDL-C 215 (111, 613) -32 (-76, 9) -63 (-90, -8) non-HDL-C 411 (218, 1272) -43 (-87, -19) -64 (-92, -36) 14.5 Homozygous Familial Hypercholesterolemia In a study without a concurrent control group, 29 patients ages 6 years to 37 years with HoFH received maximum daily doses of 20 to 80 mg of atorvastatin calcium tablets. The mean LDL-C reduction in this study was 18%. Twenty-five patients with a reduction in LDL-C had a mean response of 20% (range of 7% to 53%, median of 24%); the remaining 4 patients had 7% to 24% increases in LDL-C. Five of the 29 patients had absent LDL-receptor function. Of these, 2 patients also had a portacaval shunt and had no significant reduction in LDL-C. The remaining 3 receptor-negative patients had a mean LDL-C reduction of 22%. 14.6 Heterozygous Familial Hypercholesterolemia in Pediatric Patients In a double-blind, placebo-controlled study followed by an open-label phase, 187 boys and post-menarchal girls 10 years to 17 years of age (mean age 14.1 years) with heterozygous familial hypercholesterolemia (HeFH) or severe hypercholesterolemia, were randomized to atorvastatin calcium tablets (n=140) or placebo (n=47) for 26 weeks and then all received atorvastatin calcium tablets for 26 weeks. Inclusion in the study required 1) a baseline LDL-C level ≥ 190 mg/dL or 2) a baseline LDL-C level ≥ 160 mg/dL and positive family history of FH or documented premature cardiovascular disease in a first or second-degree relative. The mean baseline LDL-C value was 218.6 mg/dL (range: 138.5 to 385 mg/dL) in the atorvastatin calcium tablets group compared to 230 mg/dL (range: 160 to 324.5 mg/dL) in the placebo group. The dosage of atorvastatin calcium tablets (once daily) was 10 mg for the first 4 weeks and uptitrated to 20 mg if the LDL-C level was > 130 mg/dL. The number of atorvastatin calcium tablets-treated patients who required uptitration to 20 mg after Week 4 during the double-blind phase was 78 (55.7%). Atorvastatin significantly decreased plasma levels of total-C, LDL-C, triglycerides, and apolipoprotein B during the 26-week double-blind phase (see Table 13). TABLE 13. Lipid-altering Effects of Atorvastatin in Adolescent Boys and Girls with Heterozygous Familial Hypercholesterolemia or Severe Hypercholesterolemia (Mean Percentage Change From Baseline at Endpoint in Intention-to-Treat Population) DOSAGE N Total-C LDL-C HDL-C TG Apolipoprotein B Placebo 47 -1.5 -0.4 -1.9 1.0 0.7 Atorvastatin Calcium 140 -31.4 -39.6 2.8 -12.0 -34.0 The mean achieved LDL-C value was 130.7 mg/dL (range: 70 to 242 mg/dL) in the atorvastatin group compared to 228.5 mg/dL (range: 152 to 385 mg/dL) in the placebo group during the 26-week double-blind phase. Atorvastatin was also studied in a three year open-label, uncontrolled trial that included 163 patients with HeFH who were 10 years to 15 years old (82 boys and 81 girls). All patients had a clinical diagnosis of HeFH confirmed by genetic analysis (if not already confirmed by family history). Approximately 98% were Caucasian, and less than 1% were Black or Asian. Mean LDL-C at baseline was 232 mg/dL. The starting atorvastatin dosage was 10 mg once daily and doses were adjusted to achieve a target of < 130 mg/dL LDL-C. The reductions in LDL-C from baseline were generally consistent across age groups within the trial as well as with previous clinical studies in both adult and pediatric placebo-controlled trials. The long-term efficacy of atorvastatin therapy in childhood to reduce morbidity and mortality in adulthood has not been established.
Clinical Studies Table
Endpoint | Atorvastatin 10 mg (N=5006) | Atorvastatin 80 mg (N=4995) | HR (95%CI) | ||
---|---|---|---|---|---|
PRIMARY ENDPOINT | n | (%) | n | (%) | |
First major cardiovascular endpoint | 548 | (10.9) | 434 | (8.7) | 0.78 (0.69, 0.89) |
Components of the Primary Endpoint | |||||
CHD death | 127 | (2.5) | 101 | (2.0) | 0.80 (0.61, 1.03) |
Non-fatal, non-procedure related MI | 308 | (6.2) | 243 | (4.9) | 0.78 (0.66, 0.93) |
Resuscitated cardiac arrest | 26 | (0.5) | 25 | (0.5) | 0.96 (0.56, 1.67) |
Stroke (fatal and non-fatal) | 155 | (3.1) | 117 | (2.3) | 0.75 (0.59, 0.96) |
SECONDARY ENDPOINTS | |||||
First CHF with hospitalization | 164 | (3.3) | 122 | (2.4) | 0.74 (0.59, 0.94) |
First PVD endpoint | 282 | (5.6) | 275 | (5.5) | 0.97 (0.83, 1.15) |
First CABG or other coronary revascularization procedure | 904 | (18.1) | 667 | (13.4) | 0.72 (0.65, 0.80) |
First documented angina endpoint | 615 | (12.3) | 545 | (10.9) | 0.88 (0.79, 0.99) |
All-cause mortality | 282 | (5.6) | 284 | (5.7) | 1.01 (0.85, 1.19) |
Components of All-Cause Mortality | |||||
Cardiovascular death | 155 | (3.1) | 126 | (2.5) | 0.81 (0.64, 1.03) |
Noncardiovascular death | 127 | (2.5) | 158 | (3.2) | 1.25 (0.99, 1.57) |
Cancer death | 75 | (1.5) | 85 | (1.7) | 1.13 (0.83, 1.55) |
Other non-CV death | 43 | (0.9) | 58 | (1.2) | 1.35 (0.91, 2.00) |
Suicide, homicide, and othertraumatic non-CV death | 9 | (0.2) | 15 | (0.3) | 1.67 (0.73, 3.82) |
Geriatric Use
8.5 Geriatric Use Of the 39,828 patients who received atorvastatin calcium tablets in clinical studies, 15,813 (40%) were ≥65 years old and 2,800 (7%) were ≥75 years old. No overall differences in safety or effectiveness were observed between these subjects and younger subjects, and other reported clinical experience has not identified differences in responses between the elderly and younger patients, but greater sensitivity of some older adults cannot be ruled out. Since advanced age (≥65 years) is a predisposing factor for myopathy, atorvastatin should be prescribed with caution in the elderly.
Nursing Mothers
8.3 Females and Males of Reproductive Potential Contraception Atorvastatin calcium may cause fetal harm when administered to a pregnant woman. Advise females of reproductive potential to use effective contraception during treatment with atorvastatin calcium [see Use in Specific Populations ( 8.1 ) ].
Pregnancy
8.1 Pregnancy Risk Summary Atorvastatin calcium tablets are contraindicated for use in pregnant women since safety in pregnant women has not been established and there is no apparent benefit of lipid lowering drugs during pregnancy. Because HMG-CoA reductase inhibitors decrease cholesterol synthesis and possibly the synthesis of other biologically active substances derived from cholesterol, atorvastatin calcium may cause fetal harm when administered to a pregnant woman. Atorvastatin calcium should be discontinued as soon as pregnancy is recognized [see Contraindications ( 4 ) ]. Limited published data on the use of atorvastatin are insufficient to determine a drug-associated risk of major congenital malformations or miscarriage. In animal reproduction studies in rats and rabbits there was no evidence of embryo-fetal toxicity or congenital malformations at doses up to 30 and 20 times, respectively, the human exposure at the maximum recommended human dose (MRHD) of 80 mg, based on body surface area (mg/m 2 ). In rats administered atorvastatin during gestation and lactation, decreased postnatal growth and development was observed at doses ≥ 6 times the MRHD (see Data). The estimated background risk of major birth defects and miscarriage for the indicated population is unknown. In the U.S. general population, the estimated background risk of major birth defects and miscarriage in clinically recognized pregnancies is 2 to 4% and 15 to 20%, respectively. Data Human Data Limited published data on atorvastatin calcium from observational studies, meta-analyses and case reports have not shown an increased risk of major congenital malformations or miscarriage. Rare reports of congenital anomalies have been received following intrauterine exposure to other HMG-CoA reductase inhibitors. In a review of approximately 100 prospectively followed pregnancies in women exposed to simvastatin or lovastatin, the incidences of congenital anomalies, spontaneous abortions, and fetal deaths/stillbirths did not exceed what would be expected in the general population. The number of cases is adequate to exclude a ≥3 to 4-fold increase in congenital anomalies over the background incidence. In 89% of the prospectively followed pregnancies, drug treatment was initiated prior to pregnancy and was discontinued at some point in the first trimester when pregnancy was identified. Animal Data Atorvastatin crosses the rat placenta and reaches a level in fetal liver equivalent to that of maternal plasma. Atorvastatin was administered to pregnant rats and rabbits during organogenesis at oral doses up to 300 mg/kg/day and 100 mg/kg/day, respectively. Atorvastatin was not teratogenic in rats at doses up to 300 mg/kg/day or in rabbits at doses up to 100 mg/kg/day. These doses resulted in multiples of about 30 times (rat) or 20 times (rabbit) the human exposure at the MRHD based on surface area (mg/m 2 ). In rats, the maternally toxic dose of 300 mg/kg resulted in increased post-implantation loss and decreased fetal body weight. At the maternally toxic doses of 50 and 100 mg/kg/day in rabbits, there was increased post-implantation loss, and at 100 mg/kg/day fetal body weights were decreased. In a study in pregnant rats administered 20, 100, or 225 mg/kg/day from gestation day 7 through to lactation day 20 (weaning), there was decreased survival at birth, postnatal day 4, weaning, and post-weaning in pups of mothers dosed with 225 mg/kg/day, a dose at which maternal toxicity was observed. Pup body weight was decreased through postnatal day 21 at 100 mg/kg/day, and through postnatal day 91 at 225 mg/kg/day. Pup development was delayed (rotarod performance at 100 mg/kg/day and acoustic startle at 225 mg/kg/day; pinnae detachment and eye-opening at 225 mg/kg/day). These doses correspond to 6 times (100 mg/kg) and 22 times (225 mg/kg) the human exposure at the MRHD, based on AUC.
Use In Specific Populations
8 USE IN SPECIFIC POPULATIONS • Hepatic impairment: Plasma concentrations markedly increased in patients with chronic alcoholic liver disease (8.6,12.3) . • Females of reproductive potential: Advise females of reproductive potential to use effective contraception during treatment with atorvastatin calcium ( 8.3 ) 8.1 Pregnancy Risk Summary Atorvastatin calcium tablets are contraindicated for use in pregnant women since safety in pregnant women has not been established and there is no apparent benefit of lipid lowering drugs during pregnancy. Because HMG-CoA reductase inhibitors decrease cholesterol synthesis and possibly the synthesis of other biologically active substances derived from cholesterol, atorvastatin calcium may cause fetal harm when administered to a pregnant woman. Atorvastatin calcium should be discontinued as soon as pregnancy is recognized [see Contraindications ( 4 ) ]. Limited published data on the use of atorvastatin are insufficient to determine a drug-associated risk of major congenital malformations or miscarriage. In animal reproduction studies in rats and rabbits there was no evidence of embryo-fetal toxicity or congenital malformations at doses up to 30 and 20 times, respectively, the human exposure at the maximum recommended human dose (MRHD) of 80 mg, based on body surface area (mg/m 2 ). In rats administered atorvastatin during gestation and lactation, decreased postnatal growth and development was observed at doses ≥ 6 times the MRHD (see Data). The estimated background risk of major birth defects and miscarriage for the indicated population is unknown. In the U.S. general population, the estimated background risk of major birth defects and miscarriage in clinically recognized pregnancies is 2 to 4% and 15 to 20%, respectively. Data Human Data Limited published data on atorvastatin calcium from observational studies, meta-analyses and case reports have not shown an increased risk of major congenital malformations or miscarriage. Rare reports of congenital anomalies have been received following intrauterine exposure to other HMG-CoA reductase inhibitors. In a review of approximately 100 prospectively followed pregnancies in women exposed to simvastatin or lovastatin, the incidences of congenital anomalies, spontaneous abortions, and fetal deaths/stillbirths did not exceed what would be expected in the general population. The number of cases is adequate to exclude a ≥3 to 4-fold increase in congenital anomalies over the background incidence. In 89% of the prospectively followed pregnancies, drug treatment was initiated prior to pregnancy and was discontinued at some point in the first trimester when pregnancy was identified. Animal Data Atorvastatin crosses the rat placenta and reaches a level in fetal liver equivalent to that of maternal plasma. Atorvastatin was administered to pregnant rats and rabbits during organogenesis at oral doses up to 300 mg/kg/day and 100 mg/kg/day, respectively. Atorvastatin was not teratogenic in rats at doses up to 300 mg/kg/day or in rabbits at doses up to 100 mg/kg/day. These doses resulted in multiples of about 30 times (rat) or 20 times (rabbit) the human exposure at the MRHD based on surface area (mg/m 2 ). In rats, the maternally toxic dose of 300 mg/kg resulted in increased post-implantation loss and decreased fetal body weight. At the maternally toxic doses of 50 and 100 mg/kg/day in rabbits, there was increased post-implantation loss, and at 100 mg/kg/day fetal body weights were decreased. In a study in pregnant rats administered 20, 100, or 225 mg/kg/day from gestation day 7 through to lactation day 20 (weaning), there was decreased survival at birth, postnatal day 4, weaning, and post-weaning in pups of mothers dosed with 225 mg/kg/day, a dose at which maternal toxicity was observed. Pup body weight was decreased through postnatal day 21 at 100 mg/kg/day, and through postnatal day 91 at 225 mg/kg/day. Pup development was delayed (rotarod performance at 100 mg/kg/day and acoustic startle at 225 mg/kg/day; pinnae detachment and eye-opening at 225 mg/kg/day). These doses correspond to 6 times (100 mg/kg) and 22 times (225 mg/kg) the human exposure at the MRHD, based on AUC. 8.2 Lactation Risk Summary Atorvastatin calcium use is contraindicated during breastfeeding [see Contraindications ( 4 ) ]. There is no available information on the effects of the drug on the breastfed infant or the effects of the drug on milk production. It is not known whether atorvastatin is present in human milk, but it has been shown that another drug in this class passes into human milk and atorvastatin is present in rat milk. Because of the potential for serious adverse reactions in a breastfed infant, advise women that breastfeeding is not recommended during treatment with atorvastatin calcium. 8.3 Females and Males of Reproductive Potential Contraception Atorvastatin calcium may cause fetal harm when administered to a pregnant woman. Advise females of reproductive potential to use effective contraception during treatment with atorvastatin calcium [see Use in Specific Populations ( 8.1 ) ]. 8.4 Pediatric Use Heterozygous Familial Hypercholesterolemia (HeFH) The safety and effectiveness of atorvastatin calcium have been established in pediatric patients, 10 years to 17 years of age, with HeFH as an adjunct to diet to reduce total cholesterol, LDL-C, and apo B levels when, after an adequate trial of diet therapy, the following are present: • LDL-C ≥ 190 mg/dL, or • LDL-C ≥ 160 mg/dL, and o a positive family history of FH, or premature CVD in a first, or second-degreerelative, or o two or more other CVD risk factors are present. Use of atorvastatin calcium for this indication is supported by evidence from [see Dosage and Administration ( 2.2 ), Adverse Reactions ( 6.1 ), Clinical Pharmacology ( 12.3 ), and Clinical Studies ( 14.6 ) ]: • A placebo-controlled clinical trial of 6 months duration in 187 boys and postmenarchal girls, 10 years to 17 years of age. Patients treated with 10 mg or 20 mg daily atorvastatin calcium tablets had an adverse reaction profile generally similar to that of patients treated with placebo. In this limited controlled study, there was no significant effect on growth or sexual maturation in boys or on menstrual cycle length in girls. • A three year open-label uncontrolled trial that included 163 pediatric patients 10 to 15 years of age with HeFH who were titrated to achieve a target LDL-C < 130 mg/dL. The safety and efficacy of atorvastatin calcium in lowering LDL-C appeared generally consistent with that observed for adult patients, despite limitations of the uncontrolled study design. Advise postmenarchal girls of contraception recommendations, if appropriate for the patient [see Use in Specific Populations ( 8.1 ), ( 8.3 ) ]. The long-term efficacy of atorvastatin calcium therapy initiated in childhood to reduce morbidity and mortality in adulthood has not been established. The safety and efficacy of atorvastatin calcium have not been established in pediatric patients younger than 10 years of age with HeFH. Homozygous Familial Hypercholesterolemia (HoFH) Clinical efficacy of atorvastatin calcium with dosages up to 80 mg/day for 1 year was evaluated in an uncontrolled study of patients with HoFH including 8 pediatric patients [see Clinical Studies ( 14.5 ) ]. 8.5 Geriatric Use Of the 39,828 patients who received atorvastatin calcium tablets in clinical studies, 15,813 (40%) were ≥65 years old and 2,800 (7%) were ≥75 years old. No overall differences in safety or effectiveness were observed between these subjects and younger subjects, and other reported clinical experience has not identified differences in responses between the elderly and younger patients, but greater sensitivity of some older adults cannot be ruled out. Since advanced age (≥65 years) is a predisposing factor for myopathy, atorvastatin should be prescribed with caution in the elderly. 8.6 Hepatic Impairment Atorvastatin calcium tablets are contraindicated in patients with active liver disease which may include unexplained persistent elevations in hepatic transaminase levels [see Contraindications (4) andPharmacokinetics (12.3) ].
How Supplied
16 HOW SUPPLIED/STORAGE AND HANDLING Atorvastatin calcium tablets USP, 10 mg are white to off-white oval shaped, film-coated tablets with ‘C1’ on one side and plain on other side and free from physical defects. Bottles of 30 NDC 68788-8409-3 Bottles of 60 NDC 68788-8409-6 Bottles of 90 NDC 68788-8409-9 Bottles of 100 NDC 68788-8409- 1 Storage Store atorvastatin calcium tablets at 20°C to 25°C (68°F to 77°F) [see USP Controlled Room Temperature].
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