Intended for healthcare professionals


Effectiveness and efficiency of different guidelines on statin treatment for preventing deaths from coronary heart disease: modelling study

BMJ 2006; 332 doi: (Published 15 June 2006) Cite this as: BMJ 2006;332:1419

Guidelines on statin treatment should focus on high risk patients and show the optimal choice of statins.

Though Manuel DG et al have shown that guidelines on statin treatment
should focus on people with the highest risk of coronary heart disease 1,
we agree with their conclusions.

However, the concerns about the optimal choice of statins are still
remain. A recent meta-analysis (n=71,108) of randomized controlled trials
have shown that the occurrence of myalgia is less frequent with
fluvastatin, pravastatin and simvastatin than atrovastatin (OR= 0.28; 95%
CI: 0.18-0.44, OR=0.43; 95% CI: 0.36-0.51, OR= 0.23; 95% CI: 0.19-0.28,
respectively) 2. This observation could also be supported by Japanese post
-marketing surveys for both atorvastatin and pitavastatin 3, 4. For
example, atorvastatin had an increased risk of musculoskeletal adverse
events including the elevations of serum creatine phosphokinase (CK) as an
important indicator of rhabdomyolysis compared with pitavastatin in
Japanese common clinical practice (atorvastatin: 144/4805, pitavastatin:
154/7930, risk ratio, 1.54; 95% CI: 1.23-1.93; p=0.0001 by using Mann-
Whitneys U test) 3, 4. This difference was shown between atorvastatin and
pitavastatin, though pitavastatin at 1, 2, 4 mg appears to be as
efficacious as atrovastatin at 10, 20, 40 mg in the rate of LDL (low-
density lipoprotein)-C (cholesterol) reduction 5. Thus, the rate of muscle
-related adverse events differs among statins 2. The common shared belief
is that the cause of myotoxity with statins is dose-dependent 5.
Therefore, we think that lower doses of statin can be tolerated without
the risk of muscle-related adverse events.

Considering the same efficacy for the rate of LDL-C reduction are
shown in atrovastatin at 20 mg, 40 mg, pitavastatin at 2 mg, 4 mg,
rosuvastatin at 2.5 mg, 10 mg and simvastatin at 40 mg, 80 mg,
respectively 2, 5, lower doses of statins should be chosen in terms of
optimal disease management.


1 Manuel DG, Kwong K, Tanuseputro P, Lim J, Mustard CA, Anderson GM,
et al. Effectiveness and efficiency of different guidelines on statin
treatment for preventing deaths from coronary heart disease: modelling
study. BMJ 2006;332: 1419-22.

2 Silva MA, Swanson AC, Gandhi PJ, Tataronis GR. Statin-related
adverse events: a meta-analysis. Clin Ther 2006;28: 26-35.

3 Kurihara Y, Douzono S, Fujita S, Kakuda T, Nachi S, Uematsu H.
Interim Report, 8083 Patients on the Drug Use Investigation of
Pitavastatin (LIVALO Tablet), Jpn Pharmacol Ther 2006;34: 317-26. (in

4 Komano N, Masaki M, Kawai H, Kubota Y, Kajiura T. The safety and
efficacy in post-marketing surveys of atorvastatin. Prog. Med 2005;25: 131
-42. (in Japanese)

5 Mukhtar RY, Reid J, Reckless JP. Pitavastatin. Int J Clin Pract
2005;59: 239-52.

Competing interests:
None declared

Competing interests: No competing interests

16 June 2006
Hisashi Moriguchi
Professor, Laboratory for Systems Biology and Medicine, RCAST, The University of Tokyo.
Takamoto Uemura and Chifumi Sato
4-6-1, Komaba, Meguro-ku, Tokyo, Japan., 153-8904