Lipitor and Zocor

[FSU]

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I work at a free clinic and yesterday one of the nurses asked is it correct if we double the strength of zocor compared to lipitor (20 to 10, respectively). I didn't know the answer for that since those two are pretty much the same thing. Anyone knows why they put that patient on Lipitor 10mg and Zocor 20mg at the same time?

 

[BMBiology]

Doubling the dose of a statin only decreases LDL level by an additional 6%. Is the patient instructed to take zocor at night while lipitor in the morning?

If this is the case then I can see why a patient is prescribed both statins. Zocor is a short acting statin while lipitor is a long acting statin so zocor would inhibit cholesterol synthesis at its highest rate (around midnight) if it is taken in the evening while lipitor inhibits cholesterol synthesis throughout the day. That would be my guess.

 

[Caverject]

My guess is you misunderstood or the nurse misunderstood. If you are switching a patient from Lipitor to Zocor, the equivalent strengths are 1:2. So if the patient is on Lipitor 10, the patient needs to take Zocor 20

 

[Priapism321]

My guess is you misunderstood or the nurse misunderstood. If you are switching a patient from Lipitor to Zocor, the equivalent strengths are 1:2. So if the patient is on Lipitor 10, the patient needs to take Zocor 20

So if the patient was taking atorvastatin 80 mg, you would recommend 160 mg of simvastatin? Logic is a little too simplistic in my opinion.

 

[FSU]

Doubling the dose of a statin only decreases LDL level by an additional 6%. Is the patient instructed to take zocor at night while lipitor in the morning?

If this is the case then I can see why a patient is prescribed both statins. Zocor is a short acting statin while lipitor is a long acting statin so zocor would inhibit cholesterol synthesis at its highest rate (around midnight) if it is taken in the evening while lipitor inhibits cholesterol synthesis throughout the day. That would be my guess.

That makes sense to me. but if a patient has to take twice as much of zocor compared to lipitor, why don't the physician prescribe the lipitor for both day n night?

 

[Priapism321]

That makes sense to me. but if a patient has to take twice as much of zocor compared to lipitor, why don't the physician prescribe the lipitor for both day n night?

Two different statins at the same time makes absolutely no sense at all, although I haven't performed a literature search yet (not sure it warrants one). Anybody disagree?

 

[FSU]

Two different statins at the same time makes absolutely no sense at all, although I haven't performed a literature search yet (not sure it warrants one). Anybody disagree?

Maybe I misunderstood the nurse. patient is prescribed to take Lipitor 10mg (decrease LDL up to 38%) and Zocor 20mg (decreases up to 28%). these are the lowest strenght so i guess the physician wants to put them on trial to see which one achieve the best therapeutic response. I might need to double check with the nurse again. At first, I didn't know why the patient is prescribed to take both of these statins but I guess it sort of make sense now.

 

[BMBiology]

That makes sense to me. but if a patient has to take twice as much of zocor compared to lipitor, why don't the physician prescribe the lipitor for both day n night?

Taking lipitor 10 mg in the morning and lipitor 10 mg in the evening is equivalent to taking lipitor 20 mg daily. There's no benefit because lipitor is a long acting statin.

Assuming what I wrote earlier is correct, if a physician wants a stronger dose in the evening and wants the drug to be cleared out of the system within a few hours, then it makes sense giving the patient a short acting statin like zocor at bedtime and a long acting statin like lipitor in the morning. Giving both statins at the same time may be okay if the dose is low but that may increase the risk for adverse effects.

 

[BMBiology]

My guess is you misunderstood or the nurse misunderstood. If you are switching a patient from Lipitor to Zocor, the equivalent strengths are 1:2. So if the patient is on Lipitor 10, the patient needs to take Zocor 20

Actually, this may be right as well. There are reports that the potency of lipitor:zocor is 2:1, some reports 3:1.

http://www.medscape.com/viewarticle/556453_4

 

[twester]

No statin should be dosed at more than 80 mg as the incidence of myopathy and even rhabdomyolysis increases pretty dramatically - especially with the more potent statins like rosuvastatin (max dose of this one is 40 mg) and atorvastatin (max dose 80 mg).

And no patient should take more than one statin at once. There are other agents that can be added if the patient is not at her LDL-C goal.

 

[Jbuprepharm]

On the topic of strength equivilencies...

This was given to us in class a couple months ago, hopefully it helps

 

[tussionex]

my formulary substitution is 2:1

 

[AmrieRX]

I have never heard of giving 2 statins at once. Just increasing the dose if the LDL needs to be decreased and monitoring the patient. If a statin is not enough then add an agent from another class and watching out for se's. Lipitor works for 24 hours so why add zocor?

 

[WVUPharm2007]

I'm too lazy to look it up and I'm sure that one of you will do it for me.....

.....but is the rhabdo caused by statins due to the actual inhibition of HMG-CoA causing something else to go wrong elsewhere in whatever else, if anything, HMG-CoA is responsible for biochemically.....or is it a thing where the drug just so happens to have an undesirable pharmacological action via a secondary pathway?

The reason I ask is simply because it would matter as to which is responsible for the toxic side effect.....drug given in raw weight or drug given in pharmacodynamic equivalences.

 

[bananaface]

I'm too lazy to look it up and I'm sure that one of you will do it for me.....

.....but is the rhabdo caused by statins due to the actual inhibition of HMG-CoA causing something else to go wrong elsewhere in whatever else, if anything, HMG-CoA is responsible for biochemically.....or is it a thing where the drug just so happens to have an undesirable pharmacological action via a secondary pathway?

The reason I ask is simply because it would matter as to which is responsible for the toxic side effect.....drug given in raw weight or drug given in pharmacodynamic equivalences.

Effectiveness and rhabdomyolysis are not proportional when considering the statins as a whole, if that is what you are getting at. Remember Baycol?

 

[WVUPharm2007]

I wasn't even in college when that mug was removed. I had to wikipedia that ****.

So from that, it would likely be concluded that rhabdo isn't caused by a deficiency in HMG-CoA....I wonder if they have identified the mechanism yet.

 

[no-see-um]

No real practical point to giving two different brands of statin to a patient, regardless of t1/2. Just choose one and go with it. There's no evidence for better outcomes using two, and it's not in the ATP III guidelines. Must weigh risk/benefit...

Regarding the rhabdo mechanism, wasn't it supposedly some electron transport issue? Lots of Mitochondria in muscle cells...

 

[ButlerPharm.D.]

In response to WVU's question, CoQ10 depletion is slowly gaining acceptance as a cause of rhabdomyolysis in patients taking Hmg-CoA reductase inhibitors. If you're interested, I suggest reading the following article from medscape entitled, "Primary Evaluation and Management of Statin Therapy Complications", it can be found at http://www.medscape.com/viewarticle/528265_1

 

[WVUPharm2007]

...so.....then it would be indirectly due to the inhibition of HMG-CoA that leads to the rhado...? That's what I get from that article, anyway...they kinda skirt around that part....

 

[dgroulx]

...so.....then it would be indirectly due to the inhibition of HMG-CoA that leads to the rhado...? That's what I get from that article, anyway...they kinda skirt around that part....

Back when I was on rotations, I looked into this and thought that the more lipophyllic statins (like Zocor) had a higher instance of rhabdo and the more hydrophillic statins (like Crestor & Lipitor) did not. The hydrophillic drugs are less likely to be taken up into muscle tissue and are more specific for liver cells. At the VA if someone has rhabdo, they switch them to Crestor.

 

[WVUPharm2007]

See, now THIS **** is interesting.

 

[Epic]

Here is why.

Many hospitals substitute Lipitor with Zocor.. usually 1:2. Patient was probably on 10mg Lipitor daily when admitted to the hospital. But hospital pharmacy substituted it with Zocor 20mg daily. Patient got discharged and was instructed to resume home meds. On the discharge order was Zocor 20mg daily..and the patient probably got the prescription filled. And at home, the patient started to resume old home med as instructed. Now the patient is on both lipitor and zocor.

Duh.

 

[pharmacogenomic]

Here is why.

Many hospitals substitute Lipitor with Zocor.. usually 1:2. Patient was probably on 10mg Lipitor daily when admitted to the hospital. But hospital pharmacy substituted it with Zocor 20mg daily. Patient got discharged and was instructed to resume home meds. On the discharge order was Zocor 20mg daily..and the patient probably got the prescription filled. And at home, the patient started to resume old home med as instructed. Now the patient is on both lipitor and zocor.

Duh.

See what a bad thing it was to stop having pharmacists do discharge counseling???

That discharge rx was probably dropped off the the daughter-in-law & picked up by the grandson & nobody ever talked to the patient.

That part of our system is broken!

No use for 2 statins concurrently!

 

[letjin]

If you have Drug Information Handbook by Lexi-comp, it has statin % reduction chart in the appendix.
I was taught to compare % reduction and make switch accordingly.

 

[RX CARE]

I know lipitor has a way longer half-life of about 36 hours, while zocor is about 4-6...Ithink, and lipitor lowers LDL-C better than zocor does....about 15 - 20% better..I think...It will be really bfutile administering both at the same time.....It is recommended to use one statin at a time...or combine with a fibrate or a resin(side effects tho')..