Atorvastatin, Fluvastatin, Pravastatin, Rosuvastatin, Simvastatin |
Issues for Surgery |
Increased risk of myocardial infarction if omitted (see Further Information). Risk of myopathy and rhabdomyolysis if continued (see Further Information). |
Advice in the Perioperative period |
Elective Surgery Continue1 – including combination products containing fibrates or ezetimibe (see Ezetimibe monograph). Vascular Surgery Emergency Surgery Continue1 – including combination products containing fibrates or ezetimibe (see Ezetimibe monograph). Post-operative Advice A potential limitation of perioperative statin use is the lack of parenteral formulation; statins with a long half-life (e.g. atorvastatin) may be favoured to bridge therapy in the period immediately after surgery when oral intake is not feasible1. Monitor LFTs and renal function (see Further Information). |
Interaction(s) with Common Anaesthetic Agents |
Midazolam Atorvastatin is noted to reduce clearance of intravenous midazolam by 33% and increases area under curve (AUC) by 40% – monitor for midazolam adverse effects (e.g. prolonged sedation and respiratory depression)2, 3. Suxamethonium Concurrent use of statins and suxamethonium has resulted in an increase in myoglobin concentrations, but this is not considered clinically relevant2, 4. |
Interaction(s) with other Common Medicines used in the Perioperative Period |
Antimicrobials (see also under Hepatotoxicity) Macrolide antimicrobials (e.g. clarithromycin) markedly increase the exposure to simvastatin. They have a moderate effect on atorvastatin and pravastatin exposure and little effect on fluvastatin and rosuvastatin exposure2. Whilst single surgical prophylactic doses should not pose a problem, continued post-operative treatment may require adjustment of statin therapy as follows2, 5, 6, 7, 8, 9, 10:-
*Erythromycin reduces the area under the curve (AUC) of rosuvastatin by 20%. This is thought to be due to the increase in gut motility caused by erythromycin9. Hepatotoxicity Concomitant use of statins and the following medications may increase the risk of hepatotoxicity5: -
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Further Information |
Pleiotropic Effects Statins induce coronary plaque stabilisation through pleiotropic effects, which may prevent plaque rupture and subsequent myocardial infarction in the perioperative period1. Skeletal Muscle Effects A concern with perioperative statin therapy is the risk of statin-induced myopathy and rhabdomyolysis. Perioperatively, factors increasing the risk of statin-induced myopathy include impairment of renal function after major surgery, and multiple drug use during anaesthesia1 (particularly with co-administration of medicines that act as CYP3A4 inhibitors). Monitor the patient for signs and symptoms of skeletal muscle effects such as muscle pain, cramps or weakness, especially if accompanied by malaise or fever. If symptoms occur, measure creatinine kinase (CK) level – if found to be > 5 times the upper limit of normal (ULN), the statin should be stopped6, 7, 8, 9, 10. Liver Effects Patients who develop increased serum transaminase levels (alanine aminotransferase, ALT and aspartate aminotransferase, AST) should be monitored until the abnormality(ies) resolve. If serum transaminases of > 3 times ULN persist, reduction of dose or withdrawal of the statin is recommended6, 7, 8, 9, 10. |
References |
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