GMP Atorvastatin Tablet 20 mg
Product Description
Paediatric use should only be carried out by physicians experienced in the treatment of paediatric hyperlipidaemia and patients should be re-evaluated on a regular basis to assess progress.
For patients aged 10 years and above, the recommended starting dose of atorvastatin is 10 mg per day with titration up to 20 mg per day. Titration should be conducted according to the individual response and tolerability in paediatric patients. Safety information for paediatric patients treated with doses above 20 mg, corresponding to about 0.5 mg/kg, is limited.
There is limited experience in children between 6–10 years of age (see section 5.1). Atorvastatin is not indicated in the treatment of patients below the age of 10 years.
Other pharmaceutical forms/strengths may be more appropriate for this population.
Method of administration
Atorvastatin is for oral administration. Each daily dose of atorvastatin is given all at once and may be given at any time of day with or without food.
Effect of co-administered medicinal products on atorvastatin
Atorvastatin is metabolized by cytochrome P450 3A4 (CYP3A4) and is a substrate to transport proteins e.g. the hepatic uptake transporter OATP1B1. Concomitant administration of medicinal products that are inhibitors of CYP3A4 or transport proteins may lead to increased plasma concentrations of atorvastatin and an increased risk of myopathy. The risk might also be increased at concomitant administration of atorvastatin with other medicinal products that have a potential to induce myopathy, such as fibric acid derivates and ezetimibe (see section 4.4).
CYP3A4 inhibitors
Potent CYP3A4 inhibitors have been shown to lead to markedly increased concentrations of atorvastatin (see Table 1 and specific information below). Co- administration of potent CYP3A4 inhibitors (e.g. ciclosporin, telithromycin, clarithromycin, delavirdine, stiripentol, ketoconazole, voriconazole, itraconazole, posaconazole and HIV protease inhibitors including ritonavir, lopinavir, atazanavir, indinavir, darunavir, etc.) should be avoided if possible. In cases where co- administration of these medicinal products with atorvastatin cannot be avoided lower starting and maximum doses of atorvastatin should be considered and appropriate clinical monitoring of the patient is recommended (see Table 1).
Moderate CYP3A4 inhibitors (e.g. erythromycin, diltiazem, verapamil and fluconazole) may increase plasma concentrations of atorvastatin (see Table 1). An increased risk of myopathy has been observed with the use of erythromycin in combination with statins. Interaction studies evaluating the effects of amiodarone or verapamil on atorvastatin have not been conducted. Both amiodarone and verapamil are known to inhibit CYP3A4 activity and co-administration with atorvastatin may result in increased exposure to atorvastatin. Therefore, a lower maximum dose of atorvastatin should be considered and appropriate clinical monitoring of the patient is recommended when concomitantly used with moderate CYP3A4 inhibitors. Appropriate clinical monitoring is recommended after initiation or following dose adjustments of the inhibitor.
CYP3A4 inducers
Concomitant administration of atorvastatin with inducers of cytochrome P450 3A (e.g. efavirenz, rifampin, St. John's Wort) can lead to variable reductions in plasma concentrations of atorvastatin. Due to the dual interaction mechanism of rifampin, (cytochrome P450 3A induction and inhibition of hepatocyte uptake transporter OATP1B1), 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 effect of rifampin on atorvastatin concentrations in hepatocytes is, however, unknown and if concomitant administration cannot be avoided, patients should be carefully monitored for efficacy.
Transport protein inhibitors
Inhibitors of transport proteins (e.g. ciclosporin) can increase the systemic exposure of atorvastatin (see Table 1). The effect of inhibition of hepatic uptake transporters on atorvastatin concentrations in hepatocytes is unknown. If concomitant administration cannot be avoided, a dose reduction and clinical monitoring for efficacy is recommended (see Table 1).
Gemfibrozil / fibric acid derivatives
The use of fibrates alone is occasionally associated with muscle related events, including rhabdomyolysis. The risk of these events may be increased with the concomitant use of fibric acid derivatives and atorvastatin. If concomitant administration cannot be avoided, the lowest dose of atorvastatin to achieve the therapeutic objective should be used and the patients should be appropriately monitored (see section 4.4).
Ezetimibe
The use of ezetimibe alone is associated with muscle related events, including rhabdomyolysis. The risk of these events may therefore be increased with concomitant use of ezetimibe and atorvastatin. Appropriate clinical monitoring of these patients is recommended.
Colestipol
Plasma concentrations of atorvastatin and its active metabolites were lower (by approx. 25%) when colestipol was co-administered with atorvastatin. However, lipid effects were greater when atorvastatin and colestipol were co-administered than when either medicinal product was given alone.
Fusidic acid
Interaction studies with atorvastatin and fusidic acid have not been conducted. As with other statins, muscle related events, including rhabdomyolysis, have been reported in post-marketing experience with atorvastatin and fusidic acid given concurrently. The mechanism of this interaction is not known. Patients should be closely monitored and temporary suspension of atorvastatin treatment may be appropriate.
Effect of atorvastatin on co-administered medicinal products
Digoxin
When multiple doses of digoxin and 10 mg atorvastatin were co-administered, steady- state digoxin concentrations increased slightly. Patients taking digoxin should be monitored appropriately.
Oral contraceptives
Co-administration of atorvastatin with an oral contraceptive produced increases in plasma concentrations of norethindrone and ethinyl oestradiol.
Warfarin
In a clinical study in patients receiving chronic warfarin therapy, co-administration of atorvastatin 80 mg daily with warfarin caused a small decrease of about 1.7 seconds in prothrombin time during the first 4 days of dosing which returned to normal within 15 days of atorvastatin treatment. Although only very rare cases of clinically significant anticoagulant interactions have been reported, prothrombin time should be determined before starting atorvastatin in patients taking coumarin anticoagulants and frequently enough during early therapy to ensure that no significant alteration of prothrombin time occurs. Once a stable prothrombin time has been documented, prothrombin times can be monitored at the intervals usually recommended for patients on coumarin anticoagulants. If the dose of atorvastatin is changed or discontinued, the same procedure should be repeated. Atorvastatin therapy has not been associated with bleeding or with changes in prothrombin time in patients not taking anticoagulants.
Table 1: Effect of co-administered medicinal products on the pharmacokinetics of atorvastatin
Co-administered medicinal product and dosing regimen |
Atorvastatin |
||
Dose (mg) |
Change in AUC& |
Clinical Recommendation# |
|
Tipranavir 500 mg BID/ Ritonavir 200 mg BID, 8 days (days 14 to 21) |
40 mg on day 1, 10 mg on day 20 |
↑ 9.4 fold |
In cases where co-administration with atorvastatin is necessary, do not exceed 10 mg atorvastatin daily. Clinical monitoring of these patients is recommended. |
Ciclosporin 5.2 mg/kg/day, stable dose |
10 mg OD for 28 days |
↑ 8.7 fold |
|
Lopinavir 400 mg BID/ Ritonavir 100 mg BID, 14 days |
20 mg OD for 4 days |
↑ 5.9 fold |
In cases where co-administration with atorvastatin is necessary, lower maintenance doses of atorvastatin are recommended. At atorvastatin doses exceeding 20 mg, clinical monitoring of these patients is recommended. |
Clarithromycin 500 mg BID, 9 days |
80 mg OD for 8 days |
↑ 4.4 fold |
|
Saquinavir 400 mg BID/ Ritonavir 300 mg BID from days 5–7, increased to 400 mg BID on day 8), days 5– 18, 30 min after atorvastatin dosing |
40 mg OD for 4 days |
↑ 3.9 fold |
In cases where co-administration with atorvastatin is necessary, lower maintenance doses of atorvastatin are recommended. At atorvastatin doses exceeding 40 mg, clinical monitoring of these patients is recommended. |
Darunavir 300 mg BID/ Ritonavir 100 mg BID, 9 days |
10 mg OD for 4 days |
↑ 3.3 fold |
|
Itraconazole 200 mg OD, 4 days |
40 mg SD |
↑ 3.3 fold |
|
Fosamprenavir 700 mg BID/ Ritonavir 100 mg BID, 14 days |
10 mg OD for 4 days |
↑ 2.5 fold |
|
Fosamprenavir 1400 mg BID, 14 days |
10 mg OD for 4 days |
↑ 2.3 fold |
|
Nelfinavir 1250 mg BID, 14 days |
10 mg OD for 28 days |
↑ 1.7 fold^ |
No specific recommendation |
Grapefruit Juice, 240 mL OD* |
40 mg, SD |
↑ 37% |
Concomitant intake of large quantities of grapefruit juice and atorvastatin is not recommended. |
Diltiazem 240 mg OD, 28 days |
40 mg, SD |
↑ 51% |
After initiation or following dose adjustments of diltiazem, appropriate clinical monitoring of these patients is recommended. |
Erythromycin 500 mg QID, 7 days |
10 mg, SD |
↑ 33%^ |
Lower maximum dose and clinical monitoring of these patients is recommended. |
Amlodipine 10 mg, single dose |
80 mg, SD |
↑ 18% |
No specific recommendation. |
Cimetidine 300 mg QID, 2 weeks |
10 mg OD for 4 weeks |
↓ less than 1%^ |
No specific recommendation. |
Antacid suspension of magnesium and aluminium hydroxides, 30 mL QID, 2 weeks |
10 mg OD for 4 weeks |
↓ 35%^ |
No specific recommendation. |
Efavirenz 600 mg OD, 14 days |
10 mg for 3 days |
↓ 41% |
No specific recommendation. |
Rifampin 600 mg OD, 7 days (co-administered) |
40 mg SD |
↑ 30% |
If co-administration cannot be avoided, simultaneous co-administration of atorvastatin with rifampin is recommended, with clinical monitoring. |
Rifampin 600 mg OD, 5 days (doses separated) |
40 mg SD |
↓ 80% |
|
Gemfibrozil 600 mg BID, 7 days |
40 mg SD |
↑ 35% |
Lower starting dose and clinical monitoring of these patients is recommended. |
Fenofibrate 160 mg OD, 7 days |
40 mg SD |
↑ 3% |
Lower starting dose and clinical monitoring of these patients is recommended. |
& Data given as x-fold change represent a simple ratio between co-administration and atorvastatin alone (i.e., 1-fold = no change). Data given as % change represent % difference relative to atorvastatin alone (i.e., 0% = no change).
# See sections 4.4 and 4.5 for clinical significance.
* Contains one or more components that inhibit CYP3A4 and can increase plasma concentrations of medicinal products metabolized by CYP3A4. Intake of one 240 ml glass of grapefruit juice also resulted in a decreased AUC of 20.4% for the active orthohydroxy metabolite. Large quantities of grapefruit juice (over 1.2 l daily for 5 days) increased AUC of atorvastatin 2.5 fold and AUC of active (atorvastatin and metabolites).
^ Total atorvastatin equivalent activity.
Increase is indicated as “↑”, decrease as “↓”
OD = once daily; SD = single dose; BID = twice daily; QID = four times daily
Table 2: Effect of atorvastatin on the pharmacokinetics of co-administered medicinal products
Atorvastatin and dosing regimen |
Co-administered medicinal product |
||
Medicinal product/Dose (mg) |
Change in AUC& |
Clinical Recommendation |
|
80 mg OD for 10 days |
Digoxin 0.25 mg OD, 20 days |
↑ 15% |
Patients taking digoxin should be monitored appropriately. |
40 mg OD for 22 days |
Oral contraceptive OD, 2 months - norethindrone 1 mg - ethinyl estradiol 35 μg |
↑ 28% ↑ 19% |
No specific recommendation. |
80 mg OD for 15 days |
Phenazone, 600 mg SD* |
↑ 3% |
No specific recommendation |
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