Lipitor: what it is used for, dosage and side effects

What Lipitor is and which active substance it contains

Lipitor contains atorvastatin, an active substance from the group of HMG-CoA reductase inhibitors, which everybody calls statins. In the Maltese register of medicines it is recorded with atorvastatin as its active substance and the oral route of administration. It is a tablet taken once a day.

The same substance is on that register under several other names from other companies, among them products sold simply as atorvastatin with the manufacturer's name attached, and it also appears in fixed combination with ezetimibe, a substance that works on cholesterol in a different way. The practical consequence is the usual one: two packs that look nothing alike may contain the same medicine, and a combination tablet already contains the statin, so plain atorvastatin should not be added to it without the doctor saying so.

Statins differ from one another in strength for a given quantity, in how they are broken down by the liver and therefore in which medicines they interact with. That is why a switch from one statin to another is not a simple substitution of one tablet for another, and why the doctor rather than the pharmacy shelf decides which one and how much.

Read the leaflet supplied with your own pack before you start it, because wording on warnings and interactions is revised from time to time. Authorised products in Malta and their product information are listed by the Medicines Authority. What raised cholesterol means and which blood tests belong to it is described at /health-guide/high-cholesterol/, and the wider picture at /heart-and-cholesterol/.

What it is used for

The medicine is used to lower raised levels of cholesterol carried by low-density lipoprotein, the fraction usually shortened to LDL, and to lower cardiovascular risk in people in whom that risk is judged to be high. The second of those is the real target: the point of the treatment is not a tidier laboratory report but fewer heart attacks and strokes.

Risk is not read off a single cholesterol figure. The doctor weighs the lipid profile together with blood pressure, smoking, diabetes, kidney function, family history, age and whether you have already had a cardiovascular event. Two people with the same cholesterol result can therefore reasonably end up on different treatment, and that is not an inconsistency.

The medicine does not replace what you eat, how much you move, whether you smoke and what you weigh. Those are not an optional extra alongside the tablet; they change the size of the risk the tablet is working against.

Raised cholesterol causes no symptoms of its own. It does not hurt, it cannot be felt and it cannot be judged from how well you are, which is why the treatment is assessed on blood tests. Feeling perfectly well is the normal state of someone with a high LDL level, not evidence that treatment is unnecessary.

How atorvastatin works

Cholesterol in the blood comes partly from food and largely from the liver, which manufactures it. The key step in that manufacture is carried out by an enzyme called HMG-CoA reductase. Atorvastatin blocks that enzyme, so the liver makes less cholesterol.

The liver responds to having less cholesterol of its own by putting more receptors for LDL on its surface, and those receptors pull LDL particles out of the bloodstream. The fall in the blood level is therefore the result of two things happening together: less production and more removal. Statins also lower triglycerides to some degree and raise HDL cholesterol slightly.

There is a second effect that matters for the outcome even though it does not show up in the lipid profile. Statins make existing deposits in the artery wall more stable and less likely to rupture, and rupture is the event that sets off most heart attacks. This is part of why the benefit of treatment is larger than the change in the numbers alone would suggest.

The effect on the blood level appears over weeks, and it lasts only while the medicine is taken. Stop it and the liver returns to its previous rate of production, the level drifts back, and it does so without any symptom to signal it. Cholesterol synthesis in the liver is more active at night, which is why some statins are taken in the evening; atorvastatin acts over a long enough period for the time of day to matter less, and the instruction for your pack is in its leaflet.

How it is taken and what to watch for

The strength and the dose are set by the doctor, who starts from your lipid profile and your calculated risk and then adjusts against a repeat test. The tablet is taken once a day, swallowed whole with water, and the schedule for your pack is in the leaflet supplied with it. Regularity matters more than the exact hour.

The medicine is not used in pregnancy or while breastfeeding, and women who could become pregnant are advised to use reliable contraception while taking it. It is also not used where there is hypersensitivity to the substance, in active liver disease and where liver enzymes are persistently and unexplainedly raised. These are contraindications, not matters for extra care: if you are pregnant or planning a pregnancy, tell the doctor, because the treatment is stopped rather than reduced.

Particular care and a decision by the doctor are needed where there is a history of liver disease, in significant alcohol intake, in reduced kidney function, in an underactive thyroid, in inherited muscle disorders or where a previous statin caused muscle problems, and in older patients. The doctor usually checks liver enzymes before treatment and afterwards as they judge necessary.

Muscle symptoms deserve their own instruction. Aching, tenderness, weakness or cramp in the muscles, particularly if it is widespread or comes with dark urine, a fever or a general feeling of illness, should be reported rather than managed by quietly stopping the tablet. Most muscle aches in people on a statin turn out to have another cause, and of those that are caused by the medicine most settle on a different statin or a different dose, so stopping in silence usually means losing the treatment for no reason. Severe, unexplained muscle pain with dark urine needs urgent assessment.

Interactions with other medicines

Atorvastatin is broken down in the liver by the enzyme system CYP3A4, and that single fact drives most of its interactions. Medicines that inhibit that system raise the level of atorvastatin in the blood and with it the risk of muscle damage: they include some antifungal medicines such as itraconazole and ketoconazole, some antibiotics of the macrolide family such as clarithromycin, ciclosporin, and medicines containing ritonavir and other protease inhibitors. With part of this group the doctor caps the dose, and with part the combination is avoided altogether.

Grapefruit and grapefruit juice act on the same enzyme system through diet rather than through a prescription, so regular consumption of large amounts is not recommended while taking this medicine. It is the kind of thing a patient would never think to mention, which is exactly why it is worth saying.

Other lipid-lowering medicines, in particular gemfibrozil and other fibrates, and high doses of nicotinic acid increase the risk of muscle problems when combined with a statin. Care is also needed with digoxin, with colchicine and with oral contraceptives, whose levels can change. With anticoagulants of the coumarin type, clotting tests may need checking more often around a change of statin dose.

List for your doctor and your pharmacist everything you take, including medicines bought without a prescription, food supplements and herbal products, and mention a statin whenever any new medicine is started by anyone. A short course of an antibiotic prescribed by someone who does not know you take a statin is one of the commonest ways this interaction arises in practice.

Side effects and when to seek help

The complaints described most often are inflammation of the nose and throat, headache, nausea, constipation or diarrhoea, wind, muscle and joint pain, pain in the limbs and back pain, and a rise in liver enzymes or in blood sugar on blood tests.

Less often, dizziness, tingling or numbness in the hands and feet, difficulty sleeping, nightmares, blurred vision, ringing in the ears, rash and itching are reported. Some people describe memory problems, which have been reported with this group and which are reversible when the medicine is stopped.

Rare but serious events include inflammation of the muscles and rhabdomyolysis, a severe breakdown of muscle tissue that can damage the kidneys; inflammation of the liver with jaundice; severe skin reactions with blistering; severe hypersensitivity with swelling of the face, lips or tongue; inflammation of the pancreas; and an immune-mediated muscle disease that can persist after the medicine is stopped.

Seek medical help without delay for unexplained muscle pain, tenderness or weakness, particularly with dark urine, fever or feeling generally unwell; for yellowing of the skin or the whites of the eyes; for severe abdominal pain; for a widespread blistering rash; and for swelling of the face or tongue with difficulty breathing. In a life-threatening situation call 112 or go to Accident and Emergency.

The complete list of side effects with information on how often each occurs is in the leaflet supplied with your pack. A suspected side effect can be reported to your doctor or pharmacist, and safety of medicines on the Maltese market is monitored by the Medicines Authority.

Prescription status and what we can do

Lipitor is a prescription-only medicine in Malta, so the decision to start it and the dose belong to a doctor. We do not sell medicines and we cannot send you one. What we offer is a written medical questionnaire and a doctor review of your answers. There is no video call, no telephone consultation and no live chat.

We are not part of any Maltese state health record and we write nothing into one. The doctor issues a cross-border prescription in the format set out in the Annex to Directive 2012/52/EU, which reaches you as a PDF by e-mail. You print it or show it on screen at the pharmacy, together with a photo identity document. There is no code and no number to quote, and a pharmacy in Malta may dispense it; the decision rests with the pharmacist, who can refuse if the document is illegible or if its authenticity is in doubt. What a pharmacist looks at is described at /blog/eu-prescription-maltese-pharmacy/.

If atorvastatin has already been started for you and this is a continuation of established treatment, you can fill in the questionnaire at /repeat-prescription/. The review is carried out by lek. Damian Wojno, a doctor registered with the Polish Medical Chamber, licence no. 3211301; he is not registered with the Medical Council of Malta. A recent lipid profile and recent liver enzymes are the results the doctor asks for most often. We do not start this treatment for the first time from a questionnaire, and we do not deal this way with unexplained muscle pain or the other warning signs described above, because they call for examination.

The assessment costs 24,90 €, with an optional priority surcharge of 9,90 €. The fee covers the medical consultation, not the issuing of a document, and it is not funded by the Maltese public health system. If the doctor declines on medical or legal grounds, we refund the fee. If the doctor asks for documents, you have at least seven days to send them in, and if the consultation cannot be completed, we close the request and refund the fee in full. The medicine itself is paid for separately at the pharmacy, and whether a product is government funded in Malta is decided under the Government Formulary List and the POYC scheme, not by us.