Atorvastatin calcium (Lipitor)- Indications, Dose, side effects

Atorvastatin calcium is a lipid-lowering drug that acts by irreversibly inhibiting the key rate-limiting enzyme HMG CO-A reductase inhibitor. It is used for:

    • Dysbetalipoproteinemia:

      • primary dysbetalipoproteinemia (Fredrickson type III).
    • Heterozygous familial and nonfamilial hypercholesterolemia and mixed dyslipidemia:

      • To reduce elevated:
        • total cholesterol
        • low-density lipoprotein cholesterol (LDL-C),
        • apolipoprotein B (apo B), and
        • triglyceride levels,
        • and to increase HDL-C in patients with primary hypercholesterolemia (heterozygous familial and nonfamilial) and mixed dyslipidemia (Fredrickson type IIa and IIb).
    • Heterozygous familial hypercholesterolemia:

    • Total-C, LDL-C, and apo B levels reduction in:
      • pediatric patients 10 to 17 years of age with heterozygous familial hypercholesterolemia with LDL-C ≥190 mg/dL,
      • LDL-C of more than 160 mg/dL with a family history of premature cardiovascular disease (CVD), or
      • LDL-C of more than 160 mg/dL with two or more other CVD risk factors.
    • Homozygous familial hypercholesterolemia:

      • To reduce total-C and LDL-C in:
        • Homozygous familial hypercholesterolemia patients as an adjunct to other lipid-lowering treatments (eg, LDL apheresis) or if such treatments are unavailable.
    • Hypertriglyceridemia:

      • Treatment of elevated serum triglyceride levels (Fredrickson type IV).
      • Limitations of use: It has not been studied in conditions where the major lipid abnormality is the elevation of chylomicrons (Fredrickson Types I and V).
  • Prevention of cardiovascular disease (CVD):

    • Primary prevention of cardiovascular disease (high-risk for CVD):
      • To reduce the risk of MI, stroke, and revascularization procedures and angina in adult patients without clinically evident coronary heart disease who have multiple CHD risk factors (eg, age, smoking, hypertension, low high-density lipoprotein cholesterol [HDL-C], family history of early CHD)
      • to reduce the risk of MI and stroke in patients with type 2 diabetes and without clinically evident CHD but with multiple risk factors for CHD (eg, retinopathy, albuminuria, smoking, hypertension).
    • Secondary prevention of cardiovascular disease:

      • To reduce the risk of nonfatal MI, fatal and nonfatal stroke, revascularization procedures, hospitalization for decompensated heart failure, and angina in patients with clinically evident CHD.
  • Off Label Use of Atorvastatin In Adults:

    • Cardiac risk reduction for noncardiac surgery (perioperative therapy);
    • Secondary prevention of non-cardioembolic stroke and TIA.

 

Adult dose:

Note: Doses should be given according to the baseline LDL-cholesterol serum levels and patient response; adjust the doses every 2 to 4 weeks.

Atorvastatin calcium dose in the treatment of Hypercholesterolemia (heterozygous familial and nonfamilial) and mixed hyperlipidemia (Fredrickson types IIa and IIb):

    • Start with 10 or 20 mg orally once a day and if patients requiring >45% reduction in LDL-C may be started at 40 mg once a day to a range of 10 to 80 mg once a day.

Atorvastatin calcium dose in the treatment of Homozygous familial hypercholesterolemia:

    • 10 to 80 mg orally once a day.

Atorvastatin calcium dose in the Prevention of cardiovascular disease/reduce the risk of atherosclerotic cardiovascular disease:

  • ACC/AHA Blood Cholesterol Guideline recommendations (ACC/AHA [Grundy 2018]; ACC/AHA [Stone 2013]):
    • Primary Prevention: 
      • LDL-C of more than 190 mg/dL and age 20 - 75 years: High-intensity therapy:
        • 80 mg once orally a day and if the patient was unable to tolerate the dose, may reduce dose to 40 mg once a day.
      • Diabetes, age 40 - 75 years, and an estimated 10-year ASCVD risk <7.5%: Moderate- intensity therapy:
        • 10 to 20 mg once orally a day.
      • Diabetes, age 40 - 75 years, and an estimated 10-year ASCVD risk ≥7.5%:  High- intensity therapy:
        • 80 mg orally once a day and if the patient was unable to tolerate the dose, may reduce dose to 40 mg once a day.
      • LDL-C 70 - 189 mg/dL, age 40 to 75 years and an estimated 10-year ASCVD risk ≥7.5%: Moderate- to high-intensity therapy:
        • 10 to 80 mg orally once a day.
    • Secondary prevention:

      • The patient has clinical ASCVD (eg, coronary heart disease, stroke/TIA, or peripheral arterial disease presumed to be of atherosclerotic origin) or is post-CABG.
        • Age ≤75 years: High-intensity therapy:
          • 80 mg once orally once a day and if the patient was unable to tolerate the dose, may reduce dose to 40 mg once a day.
        • Age >75 years: Moderate- to high-intensity therapy:
          • 10 to 80 mg orally once a day (ACC/AHA [Grundy 2018]) and if a moderate-intensity dose of 10 to 20 mg orally once a day is started and tolerated, increase to a high-intensity dose of 40 to 80 mg once a day within 3 months.
        • Not a candidate for high-intensity therapy: Moderate-intensity therapy:
          • 10 to 20 mg orally once a day.

US Preventive Services Task Force Recommendations:

    • Age 40 - 75 years, no history of CVD, with 1 or more CVD risk factor (dyslipidemia, diabetes, hypertension, or smoking), and calculated 10-year CVD event risk of 10% or more:
      • Primary prevention:
        • Moderate-intensity therapy: 10 to 20 mg orally once a day.

Note: Use clinical judgment in patients with very high CVD risk factors.


Atorvastatin calcium dose in the treatment of Cardiac risk reduction for non-cardiac surgery (off-label):

    • 20 mg orally once a day for 45 days; surgical intervention (vascular surgery) was performed during this period but not earlier than 2 weeks after therapy initiation.

Atorvastatin calcium dose in the treatment of Non-cardioembolic stroke/TIA (off-label):

    • Initial: 80 mg orally once a day and adjust the dose based on patient tolerability.
    • Also, consider the ACC/AHA Blood Cholesterol Guideline recommendations.

Dosage adjustment for atorvastatin with concomitant medications:

    • Boceprevir, nelfinavir:
      • Use lowest effective atorvastatin dose (not to exceed 40 mg once a day)
    • Clarithromycin, fosamprenavir, itraconazole, ritonavir (plus fosamprenavir, darunavir, or saquinavir):
      • Use lowest effective atorvastatin dose (not to exceed 20 mg once a day)
    • Lomitapide:
      • Consider atorvastatin dose reduction (per lomitapide manufacturer).

 

Dose in children:

 Doses should be given according to the baseline LDL-cholesterol serum levels and patient response; adjust the doses every 2 to 4 weeks.

Dose in the treatment of Heterozygous familial and non-familial hypercholesterolemia: 

Note: Begin treatment if, after adequate trial (6 to 12 months) of intensive lifestyle modification emphasizing body weight normalization and diet, the following are present:

  • LDL-C of 190 mg/dL or more, or
  • LDL-C remains 160 mg/dL or more and 2 or more cardiovascular risk factors:
    • family history of premature atherosclerotic cardiovascular disease (<55 years of age)
    • overweight
    • obesity or
    • other elements of insulin resistance syndrome or LDL-C ≥130 mg/dL and diabetes mellitus.
  • Children 6 to 10 years of age (Tanner stage I):
    • Start with 5 mg orally once a day, may increase the dose by doubling it if target is not achieved i-e, 5 mg to 10 mg to 20 mg (max dose is 80 mg once a day)
  • Children and Adolescents 10 to 17 years:
    • Start with 10 mg once daily; may increase the dose by doubling it if target is not achieved i-e, 10 mg to 20 mg to 40 mg (max dose is 80 mg once a day)

Dose in the treatment of Hyperlipidemia: 

  • Children and Adolescents 10 to 17 years (males and postmenarchal females):
    • Start with 10 mg orally once a day if the target is not achieved in 1 to 3 months, may increase the dose. (max 80mg/day)

Dose in the Prevention of graft coronary artery disease:

  • Children and Adolescents:
    • 0.2 mg/kg/day orally rounded to nearest 2.5 mg increment; not to exceed age-appropriate doses.

Dosage adjustment for atorvastatin calcium with concomitant medications:

      • No recommendations are given for individuals less than 18 years of age.
      • In adolescents ≥18 years, the following have been suggested:
    • Boceprevir, nelfinavir:
      • Use lowest effective atorvastatin dose; maximum daily dose: 40 mg/day
    • Clarithromycin, fosamprenavir, itraconazole, ritonavir (plus fosamprenavir, darunavir, or saquinavir):
      • Use lowest effective atorvastatin dose; maximum daily dose: 20 mg/day

Dosing adjustment for toxicity:

    • Muscle symptoms (potential myopathy):
      • Children ≥10 years and Adolescents:
        • Discontinue use until symptoms can be evaluated.
        • Check the CPK level.
        • Evaluate patients for conditions that may increase the risk for muscle symptoms (eg, hypothyroidism, reduced renal or hepatic function, rheumatologic disorders such as polymyalgia rheumatica, steroid myopathy, vitamin D deficiency, or primary muscle diseases).
        • Upon resolution (symptoms and any associated CPK abnormalities), resume the original or consider a lower dose of atorvastatin and retitrate.
        • If muscle symptoms recur, discontinue atorvastatin use.
        • After muscle symptom resolution, may then reinitiate a different statin at an initial low dose.
        • Gradually increase the dose if tolerated.
        • Based on experience in adult patients, if muscle symptoms or elevated CPK persists for 2 months in the absence of continued statin use, consider other causes of muscle symptoms.
        • If determined to be due to another condition aside from statin use, may resume statin therapy at the original dose.

 

Pregnancy Risk Factor: X

    • Pregnant women and those at risk of becoming pregnant should not take Atorvastatin Calcium.
    • Congenital anomalies have been reported in some cases following the maternal use of HMG–CoA reductase inhibitors during pregnancy. However, there are not many data.
    • The role of cholesterol biosynthesis in fetal development may be significant; serum cholesterol and total triglycerides rise normally during pregnancy.
    • It is unlikely that the temporary discontinuation of lipid-lowering medication during pregnancy will have an impact on long-term outcomes for primary hypercholesterolemia treatment.
    • If an unplanned pregnancy occurs during treatment, the medication will be discontinued immediately.
    • Recommend appropriate contraception for females who are taking statins.
    • Stop using the plan pregnancy 1 to 2 months before you are due.

Atorvastatin calcium use during Breast-Feeding:

    • Breastfeeding women should not use this product.
    • It is unknown if atorvastatin can be found in breast milk.

 

Renal dose:

No dosage adjustment necessary. Dialysis: Due to the high protein binding, atorvastatin calcium is not expected to be cleared by dialysis.

Dose in liver disease :

Contraindicated in active liver disease or in patients with unexplained persistent elevations of serum transaminases.

 

Common Side Effects of Atorvastatin calcium Include:

  • Gastrointestinal:
    • Diarrhea
  • Neuromuscular & skeletal:
    • Arthralgia
  • Respiratory:
    • Nasopharyngitis

Less Common Side Effects of Atorvastatin calcium Include:

  • Cardiovascular:
    • Hemorrhagic Stroke
  • Central Nervous System:
    • Insomnia
    • Malaise
    • Nightmares
  • Dermatologic:
    • Urticaria
  • Endocrine & Metabolic:
    • Diabetes Mellitus
    • Hyperglycemia
  • Gastrointestinal:
    • Nausea
    • Dyspepsia
    • Abdominal Distress
    • Cholestasis
    • Eructation
    • Flatulence
  • Genitourinary:
    • Urinary Tract Infection
    • Urine Abnormality
  • Hepatic:
    • Increased Serum Transaminases
    • Abnormal Hepatic Function Tests
    • Hepatitis
    • Increased Serum Alkaline Phosphatase
  • Neuromuscular & Skeletal:
    • Limb Pain
    • Myalgia
    • Musculoskeletal Pain
    • Muscle Spasm
    • Increased Creatine Phosphokinase
    • Joint Swelling
    • Muscle Fatigue
    • Neck Pain
  • Ophthalmic:
    • Blurred Vision
  • Otic:
    • Tinnitus
  • Respiratory:
    • Pharyngolaryngeal Pain
    • Epistaxis
  • Miscellaneous:
    • Fever

Frequency not defined:

  • Central nervous system:
    • Myasthenia

 

Contraindication to Atorvastatin calcium Include:

  • Allergy reactions to atorvastatin and any component of the formulation
  • Active liver disease
  • Unexplained persistent increases in serum transaminases
  • pregnancy;
  • Breastfeeding
  • Concurrent therapy with glecaprevir/pibrentasvir

Warnings and precautions

  • Diabetes mellitus:
    • Reports have indicated an increase in fasting blood glucose and glycated hemoglobin.
  • Hepatotoxicity:
    • It has been associated with persistent transaminitis (elevation of liver function tests)
    • Usually, the liver functions return to normal after a reduction in dose, discontinuation or interruption of drug therapy.
    • Both fatal and nonfatal liver diseases have been reported, but they are rare.
    • If serious hepatotoxicity occurs (with symptoms, hyperbilirubinemia, or jaundice), interrupt therapy immediately.
    • Do not restart atorvastatin if an alternative cause is not found.
    • At baseline, and as indicated by the physician, liver enzyme tests should be performed. If there are signs or symptoms of liver injury, they should also be taken.
    • Ethanol could increase the risk of adverse hepatic reactions.
    • Encourage patients to limit their ethanol intake.
  • Myopathy and rhabdomyolysis
    • It has been reported that muscle necrosis (rhabdomyolysis), secondary to myoglobinuria or myopathy, can be caused by its use. If myopathy is diagnosed, patients should be closely monitored.
    • This is a dose-dependent risk and can be increased by concurrent use of strong CYP3A4 inhibitors (eg clarithromycin. Itraconazole. protease inhibitors), cyclosporine. Fibromic acid derivatives (eg gemfibrozil) or niacin (doses >=1 g/day).
    • If concurrent use is necessary, consider lowering the starting and maintenance doses.
    • Patients with hypothyroidism that has not been properly treated and patients who are taking colchicine (eg, for myopathy) should be cautious. These patients are more likely to develop myopathy.
    • HMG-CoA reductase inhibits have been linked to immune-mediated necrotizing myopathy.
    • Patients should be taught to report any unexplained pain, tenderness, weakness or brown urine, especially if it is accompanied by malaise, fever, or other symptoms.
    • If CPK levels are elevated or myopathy is suspected or diagnosed, therapy should be stopped.
  • Hepatic impairment, ethanol and/or ethanol abuse:
    • Patients who have had liver disease, or who have consumed large amounts of alcohol in the past should be cautious. It is not recommended for patients with active liver disease or persistent elevated serum transaminases.
  • Renal impairment
    • Patients with kidney impairment should be cautious; they are more likely to develop myopathy.
  • Stroke
    • Patients who have had a stroke or TIA in the past may be at greater risk of hemorhagic stroke if they are receiving long-term treatment with high-dose (80 mg/day) atorvastatin.
    • The post-hoc analysis revealed that patients suffering from hemorhagic stroke or lacunar may be at greater risk. However, this finding was deemed hypothesis generating.
    • If a hemorhagic stroke is a real possibility, the overall benefits of treatment with atorvastatin (ie. reduced risk of strokes and cardiovascular events) seem to outweigh any increased risk.

 

 

Atorvastatin: Drug Interaction

Note: Drug Interaction Categories:

  • Risk Factor C: Monitor When Using Combination
  • Risk Factor D: Consider Treatment Modification
  • Risk Factor X: Avoid Concomitant Use
    •  
    Risk Factor C (Monitor therapy).
    Acipimox May increase the myopathic (rhabdomyolysis-enhancing) effect of HMGCoA Reductase Ihibitors (Statins).
    Aliskiren AtorvaSTATin could increase the serum level of Aliskiren
    Amiodarone May increase serum AtorvaSTATin concentrations.
    Aprepitant High risk of Inhibitors causing an increase in serum CYP3A4 Substrates concentrations
    Asunaprevir May increase serum concentrations of HMG-CoA Reductase Inhibitors. (Statins).
    Azithromycin (Systemic) May increase the myopathic (rhabdomyolysis-enhancing) effect of AtorvaSTATin
    Bexarotene (Systemic) May lower the serum level of AtorvaSTATin.
    Bosentan Could lower serum concentrations of CYP3A4 substrates (High Risk with Inducers).
    Cimetidine AtorvaSTATin could increase the toxic/adverse effects of Cimetidine. There is the potential to increase endogenous steroid activity by using AtorvaSTATin.
    Clofazimine High risk of Inhibitors causing an increase in serum CYP3A4 Substrates concentrations
    Moderate CYP3A4 Inducers Could lower serum concentrations of CYP3A4 substrates (High Risk with Inducers).
    Moderate CYP3A4 inhibitors Might decrease metabolism of CYP3A4 substrates (High Risk with Inhibitors).
    Dabigatran Etexilate AtorvaSTATin could lower the serum concentrations of Dabigatran Etexilate.
    Daclatasvir May increase serum concentrations of HMG-CoA Reductase Inhibitors. (Statins).
    Deferasirox Could lower serum concentrations of CYP3A4 substrates (High Risk with Inducers).
    Digoxin AtorvaSTATin could increase serum Digoxin concentrations.
    Dronedarone May increase serum AtorvaSTATin concentrations.
    Duvelisib High risk of Inhibitors causing an increase in serum CYP3A4 Substrates concentrations
    Efavirenz May lower the serum level of AtorvaSTATin.
    Eltrombopag May increase serum OATP1B1/1B3 (SLCO1B1/1B3) Substrates.
    Erythromycin (Systemic) May increase serum AtorvaSTATin concentrations.
    Etravirine May reduce serum concentrations of HMG-CoA Reductase Inhibitors. This is true for simvastatin, loveastatin, and atorvastatin. Fluvastatin levels may also be increased. Management: It may be necessary to adjust the dose of the HMG–CoA reductase inhibit. It is not possible to expect a interaction with pravastatin or pitavastatin.
    Fenofibrate, and its derivatives May increase the toxic/adverse effect of HMGCoA Reductase Inhibitors.
    Fluconazole May increase serum AtorvaSTATin concentrations.
    Fosaprepitant High risk of Inhibitors causing an increase in serum CYP3A4 Substrates concentrations
    Fosnetupitant High risk of Inhibitors causing an increase in serum CYP3A4 Substrates concentrations
    Ivosidenib: Could lower serum concentrations of CYP3A4 substrates (High Risk with Inducers).
    Larotrectinib High risk of Inhibitors causing an increase in serum CYP3A4 Substrates concentrations
    Midazolam AtorvaSTATin could increase serum Midazolam concentrations
    Netupitant High risk of Inhibitors causing an increase in serum CYP3A4 Substrates concentrations
    Niacin May increase the toxic/adverse effect of HMGCoA Reductase Inhibitors.
    Niacinamide May increase the toxic/adverse effect of HMGCoA Reductase Inhibitors.
    Palbociclib High risk of Inhibitors causing an increase in serum CYP3A4 Substrates concentrations
    P-glycoprotein/ABCB1 Inhibitors Increases serum concentration of Pglycoprotein/ABCB1 substrates. P-glycoprotein inhibitors can also increase the distribution of pglycoprotein substrates to certain cells/tissues/organs in which p-glycoprotein exists in high amounts (e.g. brain, T-lymphocytes and testes). .
    Raltegravir May increase the myopathic (rhabdomyolysis-enhancing) effect of HMGCoA Reductase Ihibitors (Statins).
    Ranolazine May increase serum AtorvaSTATin concentrations.
    Repaglinide HMG-CoA Reductase Ihibitors (Statins), may increase serum Repaglinide concentrations.
    Rupatadine Might increase the toxic/adverse effect of HMGCoA Reductase Inhibitors. In particular, there may be an increase in the risk of increased CPK and/or other toxicities to muscles.
    Sarilumab Could lower serum concentrations of CYP3A4 substrates (High Risk with Inducers).
    Siltuximab Could lower serum concentrations of CYP3A4 substrates (High Risk with Inducers).
    Spironolactone AtorvaSTATin could increase the toxic/adverse effects of Spironolactone. There is the potential to increase endogenous steroid activity by using AtorvaSTATin.
    Teriflunomide May increase serum OATP1B1/1B3 (SLCO1B1/1B3) Substrates.
    Ticagrelor May increase serum AtorvaSTATin concentrations.
    Tocilizumab Could lower serum concentrations of CYP3A4 substrates (High Risk with Inducers).
    Trabectedin HMG-CoA Reductase inhibitors (Statins), may increase the myopathic (rhabdomyolysis), effect of Trabectedin.
    Velpatasvir May increase serum AtorvaSTATin concentrations.
    Risk Factor D (Consider therapy modifications)  
    Bezafibrate May increase the myopathic (rhabdomyolysis-effect) of HMGCoA Reductase inhibitors (Statins). HMG-CoA Reductase inhibitors (Statins) may be increased by bezafibrate. Bezafibrate may cause an increase in serum fluvastatin concentrations. Management: Patients should be closely monitored for signs of myopathy when concomitantly taking bezafibrate or HMG-CoA reductase inhibitors. Patients with myopathy are not advised to use bezafibrate and HMG-CoA reductase inhibitors concurrently. Alternative therapy is recommended.
    Ciprofibrate Might increase the toxic/adverse effect of HMGCoA Reductase Inhibitors. Management: If possible, avoid the use of HMG CoA reductase inhibitors or ciprofibrate. Concomitant therapy should be carefully considered. Patients should be closely monitored for signs/symptoms and treatment options.
    Clarithromycin Increased serum levels of AtorvaSTATin may occur. Clarithromycin and atorvastatin should be used in conjunction. Monitor patients closely for signs of atorvastatin toxicities if this combination is used.
    Cobicistat It may increase serum AtorvaSTATin concentrations. Management: Avoid the combined use of atorvastatin with atazanavir/cobicistat. Atorvastatin dose should not exceed 20 mg daily when combined with other cobicistat-containing regimens.
    Colchicine May increase the myopathic (rhabdomyolysis-effect) of HMGCoA Reductase inhibitors (Statins). The serum concentrations of HMG-CoA Reductase Inhibitors may be increased by Colchicine (Statins).
    Strong CYP3A4 Inducers May increase metabolism of CYP3A4 substrates (High Risk with Inducers). Management: You may consider a different drug to replace one of the interacting drugs. Some combinations might be contraindicated. Consult appropriate manufacturer labeling.
    Strong CYP3A4 inhibitors Might decrease metabolism of CYP3A4 substrates (High Risk with Inhibitors).
    Cyproterone Increased serum concentrations of HMG-CoA Reductase Inhibitors may be a result. Management: Patients receiving high doses of cyproterone (300mg/day) should avoid statins metabolized via CYP3A4 (eg simvastatin). Fluvastatin should also be avoided. If statin therapy is required, you might consider pitavastatin, rosuvastatin or pravastatin.
    Dabrafenib High risk of Inducers causing a decrease in serum CYP3A4 substrates. Management: If possible, seek alternatives to the CYP3A4 substrate. Concomitant therapy should be avoided if possible. Monitor the clinical effects of the substrate carefully (especially therapeutic effects).
    Danazol May increase serum concentrations of HMG-CoA Reductase Inhibitors. Simvastatin and danazol are contraindicated. If you take lovastatin and danazol together, do not exceed 20mg per day. Fluvastatin, pravastatin, and rosuvastatin may pose lower risk.
    DAPTOmycin HMG-CoA Reductase Inhibitors, (Statins), may increase the toxic/adverse effect of DAPTOmycin. In particular, there may be an increase in the risk of skeletal muscles toxicity. Treatment: Before you start daptomycin, consider temporarily stopping HMGCoA reductase inhibitor treatment. Regular (at least weekly) monitoring is recommended for all CPK concentrations if they are used in combination.
    DilTIAZem DilTIAZem may be increased by AtorvaSTATin. DilTIAZem can increase AtorvaSTATin's serum concentration. Use diltiazem with lower doses of atorvastatin.
    Elbasvir Increased serum levels of AtorvaSTATin may occur. Use atorvastatin only when combined with elbasvir or grazoprevir. You should be aware of any statin-related toxicities, such as myalgia and myopathy.
    Enzalutamide High risk of Inducers causing a decrease in serum concentrations of CYP3A4 substrates. Management: Avoid concurrent use of enzalutamide and CYP3A4 substrates with a narrow therapeutic index. You should exercise caution when using enzalutamide or any other CYP3A4 sub-substance.
    Fosphenytoin May lower serum concentrations of HMG-CoA Reductase Inhibitors. (Statins).
    Grapefruit Juice Increased serum concentrations of HMG-CoA Reductase Inhibitors may occur (Statins). Management: Do not use GFJ concurrently with simvastatin or lovastatin. Avoid excessive GFJ when taking atorvastatin. If possible, use a lower dose of statins or a statin less likely to interact with GFJ.
    Grazoprevir Increased serum levels of AtorvaSTATin may occur. Use atorvastatin only when combined with elbasvir or grazoprevir. You should be aware of any statin-related toxicities, such as myalgia and myopathy.
    Itraconazole Increased serum levels of AtorvaSTATin may occur. Patients receiving itraconazole should be advised to limit atorvastatin intake to 20 mg/day. To ensure the best possible dose of atorvastatin, it is important to assess your clinical response. When possible, consider fluva- or rosuva - pitava-, pravastatin, or both.
    Ketoconazole (Systemic) AtorvaSTATin could increase the harmful/toxic effects of Ketoconazole Systemic. There is the potential to have additive effects on endogenous steroid levels. Systemic ketoconazole may increase serum AtorvaSTATin concentrations. Management: Take ketoconazole (Systemic) with atorvastatin carefully and monitor for any toxic effects such as myalgia or rhabdomyolysis. Fluva- and rosuva - pitava- or pravastatin may be considered when necessary.
    Lanthanum HMG-CoA Reductase inhibitors (Statins), may reduce the serum level of Lanthanum. Administration: HMG-CoA Reductase Inhibitors (Statins) should be administered at least 2 hours before or 2 hours after administration of Lanthanum.
    Letermovir Increased serum levels of AtorvaSTATin may occur. When taking atorvastatin with letermovir, limit the daily dose to 20 mg. Letermovir should not be administered with cyclosporine.
    Lorlatinib High risk of Inducers causing a decrease in serum concentrations of CYP3A4 substrates. Management: Do not use lorlatinib concurrently with any CYP3A4 Substrates. Even a slight decrease in serum concentrations could cause therapeutic failure or serious clinical consequences.
    MiFEPRIStone High risk of Inhibitors causing an increase in serum concentrations of CYP3A4 substrates. Management: Minimize doses of CYP3A4 substrates, and monitor for increased concentrations/toxicity, during and 2 weeks following treatment with mifepristone. Avoid dihydroergotamine and ergotamine.
    Mitotane High risk of Inducers causing a decrease in serum concentrations of CYP3A4 substrates. Treatment: Patients receiving mitotane may require significant adjustments in the dosage of CYP3A4 Substrates.
    Phenytoin May lower serum concentrations of HMG-CoA Reductase Inhibitors. (Statins).
    Pitolisant High risk of Inducers causing a decrease in serum concentrations of CYP3A4 substrates Management: Avoid combining pitolisant and a CYP3A4 substrat with a low therapeutic index. Pitolisant should not be combined with other CYP3A4 sub-substances.
    Protease inhibitors This may increase serum AtorvaSTATin concentrations. Management: Refer to the full monograph for dose recommendations. Avoid atorvastatin with tipranavir/ritonavir.
    QuiNINE Increased serum concentrations of HMG-CoA Reductase Inhibitors may be a result. When quinine is used with atorvastatin or simvastatin together, it may be worth using a lower starting and maintenance doses.
    Rifamycin Derivatives Could decrease serum concentrations of HMG-CoA Reductase Inhibitors. Management: Use non-interacting antilipemic drugs (note that pitavastatin concentrations can increase when rifamycin is administered). Monitoring for altered HMGCoA reductase inhibitor reactions. Lower risk may be associated with fluvastatin or rifabutin.
    Simeprevir Increase in serum AtorvaSTATin concentration. Management: A maximum daily dose of atorvastatin should not exceed 40mg/day when simeprevir is concurrently administered. It is strongly recommended that you use the lowest possible dose of atorvastatin.
    St John's Wort May increase metabolism of HMGCoA Reductase Inhibitors, (Statins). Management: Avoid concomitant administrations of St Johns Wort and interacting HMG–CoA reductase inhibitors to reduce the risk of decreased antilipemic effect. Concomitant therapy should be monitored for any decreased effects.
    St John's Wort High risk of Inducers causing a decrease in serum CYP3A4 Substrates. Management: You may consider a different drug to replace one of the interacting drugs. Some combinations might be contraindicated. Consult appropriate manufacturer labeling.
    Stiripentol High risk of Inhibitors causing an increase in serum concentrations of CYP3A4 substrates. Management: Avoid stiripentol use with CYP3A4 Substrates that have a narrow therapeutic Index. This is to avoid adverse effects and toxicities. Monitoring of any CYP3A4 substrate that is used with stiripentol should be closely done.
    Telithromycin The serum concentrations of AtorvaSTATin may be increased. Management: Limit atorvastatin to a maximum (adult) dose not exceeding 20 mg per day when taken with telithromycin. This is consistent with the dosing of other strong CYP3A4 inhibitors such as clarithromycin, although it is not a recommendation on atorvastatin labeling.
    Tolvaptan May increase serum OATP1B1/1B3 (SLCO1B1/1B3) Substrates.
    Verapamil Verapamil serum concentration may be increased by AtorvaSTATin. Verapamil can increase AtorvaSTATin's serum concentration. Management: When combined with verapamil, you may want to use lower doses of atorvastatin.
    Voriconazole Increase in serum AtorvaSTATin. Management: Monitor for toxic effects (e.g. myalgia and rhabdomyolysis) while you are receiving atorvastatin. If necessary, reduce the dose. Fluva- and rosuva - pitava- or pravastatin may be considered when necessary.
    Voxilaprevir May increase serum concentrations of HMG-CoA Reductase Inhibitors. If statin is combined with voxilaprevir, reduce the dose and monitor for statin toxicities. Limit pravastatin dosages to 40mg daily and avoid concomitant pitavastatin and rosuvastatin use.
    Risk Factor X (Avoid Combination)  
    Antihepaciviral Combination Products May increase serum AtorvaSTATin concentrations.
    Conivaptan High risk of Inhibitors causing an increase in serum CYP3A4 Substrates concentrations
    CycloSPORINE Systemic May increase serum AtorvaSTATin concentrations.
    Fusidic Acid (Systemic). Might increase the toxic/adverse effect of HMGCoA Reductase Inhibitors. The risk of muscle toxicities including rhabdomyolysis, may be significantly higher. Management: Avoid simultaneous use wherever possible. Although contraindicated in many countries, use is still listed in product characteristic summaries. However, UK labeling indicates that it could be used in exceptional circumstances and under close supervision.
    Fusidic Acid (Systemic). High risk of Inhibitors causing an increase in serum CYP3A4 Substrates concentrations
    Gemfibrozil May increase the myopathic (rhabdomyolysis-enhancing) effect of AtorvaSTATin. Gemfibrozil can increase serum AtorvaSTATin concentrations.
    Glecaprevir and Pibrentasvir May increase serum AtorvaSTATin concentrations.
    Idelalisib High risk of Inhibitors causing an increase in serum CYP3A4 Substrates concentrations
    PAZOPanib AtorvaSTATin could increase the hepatotoxic effects of PAZOPanib. AtorvaSTATin could increase serum levels of PAZOPanib.
    Posaconazole May increase serum AtorvaSTATin concentrations.
    Red Yeast Rice May increase the toxic/adverse effect of HMGCoA Reductase Inhibitors.
    Tipranavir May increase serum AtorvaSTATin concentrations.

 

Monitor:

  • Lipid panel (total cholesterol, HDL, LDL, triglycerides):
    • Lipid profile (fasting or nonfasting) before initiating treatment.
    • Fasting lipid profile should be rechecked 4 to 12 weeks after starting therapy and every 3 to 12 months thereafter.
    • If 2 consecutive LDL levels are <40 mg/dL, consider decreasing the dose.
  • Hepatic transaminase levels:
    • Baseline measurement of hepatic transaminase levels (AST and ALT)
    • measure AST, ALT, total bilirubin, and alkaline phosphatase if symptoms suggest hepatotoxicity (eg, unusual fatigue or weakness, loss of appetite, abdominal pain, dark-colored urine or yellowing of skin or sclera) during therapy.
  • CPK:
    • CPK should not be routinely measured.
    • Baseline CPK measurement is reasonable for some individuals (eg, family history of statin intolerance or muscle disease, clinical presentation, concomitant drug therapy that may increase risk of myopathy).
    • Measure CPK in any patient with symptoms suggestive of myopathy (pain, tenderness, stiffness, cramping, weakness, or generalized fatigue).
  • Evaluate for new-onset diabetes mellitus during therapy:
    • if diabetes develops, continue statin therapy and encourage adherence to a heart-healthy diet, physical activity, a healthy body weight, and tobacco cessation.
  • If patient develops a confusional state or memory impairment, may evaluate patient for nonstatin causes (eg, exposure to other drugs), systemic and neuropsychiatric causes, and the possibility of adverse effects associated with statin therapy.

 

How to take Atorvastatin calcium?

Oral: with or without food, at any time of the day, do not break the tablet. 

 

Mechanism of action of Atorvastatin calcium:

Inhibitor of 3-hydroxy-3-methylglutaryl coenzyme A (HMG-CoA) reductase, the rate-limiting enzyme in cholesterol synthesis (reduces the production of mevalonic acid from HMG-CoA); This results in an increase in stimulation of LDL catabolism, and in expression of LDL receptors at hepatocyte membranes. HMG-CoA inhibitors are able to lower high-sensitivity CRP (hsCRP) levels. They also have pleiotropic effects such as improved endothelial function and reduced inflammation at the site where the coronary plaque is formed.

 

The onset of action:

  • Initial changes: 3 - 5 days;
  • Maximal reduction in plasma cholesterol and triglycerides takes 2 to 4 weeks.
  • LDL reduction: 10 mg/day: 39% (for each doubling of this dose, LDL is lowered approximately 6%)

Absorption after oral administration is rapid. Extensive first-pass metabolism in Gastrointestinal mucosa and liver occurs. Distribution: V : ~381 L Protein binding: ≥98% Metabolism: Hepatic Bioavailability is about 14% (parent drug) and about 30% of the parent drug and equipotent metabolites.

Half-life elimination of the Parent drug is about fourteen hours and 20 to 30 hours of the Equipotent metabolites. Time to peak, serum: 1 to 2 hours Excretion: Bile  

 

International Brands of Atorvastatin calcium:

  • Acrovastin
  • Actalipid
  • Aditor
  • Aforsatin
  • AG-Atorvastatin
  • APO-Atorvastatin
  • Atorvastatin-10
  • Atorvastatin-20
  • Atorvastatin-40
  • Atorvastatin-80
  • Auro-Atorvastatin
  • DOM-Atorvastatin
  • GD-Atorvastatin
  • JAMP-Atorvastatin
  • Lipitor
  • M-Atorvastatin
  • Mar-Atorvastatin
  • MYLAN-Atorvastatin
  • NOVO-Atorvastatin
  • PMS-Atorvastatin
  • RAN-Atorvastatin
  • RATIO-Atorvastatin
  • REDDY-Atorvastatin
  • RIVA-Atorvastatin
  • SANDOZ Atorvastatin
  • TEVA-AtorvastatinAle
  • Alipid
  • Amicor
  • Anxolipo
  • Aspavor
  • Astatin
  • Astator
  • Atacor
  • Atarva
  • Atasin
  • Ateroz
  • Atocor
  • Atofar
  • Atolow
  • Atopitar
  • Atorasat
  • Atorcad
  • Atorcal
  • Atoris
  • Atorlip
  • Atorphil
  • Atorsan
  • Atorvaright
  • Atorvas
  • Atorvast
  • Atorwin
  • Atoty
  • Atrofit
  • Atstat
  • Atswift
  • Atvas
  • Avamax
  • Axo
  • Bestatin
  • Carditor
  • Cardyl
  • Carvastin
  • Cheklip
  • Chlovas
  • Citalor
  • Colestop
  • Covetor
  • Debostin
  • Divator
  • Enturion
  • Fastor
  • Hipolixan
  • Lipicon
  • Lipiduce
  • Lipigo
  • Lipikhan
  • Lipilou
  • Lipinon
  • Lipitas
  • Lipiterol
  • Lipitin
  • Lipitor
  • Lipiwon
  • Lipoactin
  • Lipodar
  • Lipofix
  • Lipomax
  • Lipomet
  • Liponorm
  • Lipox
  • Litorva
  • Lopamol
  • Lorstat
  • Lowlipen
  • Neustatin-A
  • Newvast
  • Olpit
  • Orvast
  • Pelearto
  • Plan
  • Rotaqor
  • Saatin
  • Safena
  • Simtor
  • Sortis
  • Statol
  • Stator
  • Storvas
  • Tahor
  • TG-Tor
  • Tolevas
  • Torid
  • Torolac
  • Torvalipin
  • Torvast
  • Torvatec
  • Torvazin
  • Tovast
  • Trovas
  • Truvaz
  • Tulip
  • Vastor
  • Vaztor
  • X-Tor
  • Xantor
  • Xelpid
  • Xentor
  • Xerova
  • You Jia
  • Zapitor
  • Zarator

Brands in pakistan:

Atorvastatin [Tabs 5 Mg]

Vastor Atco Laboratories Limited

Atorvastatin [Tabs 10 Mg]

A-Chole Alied Medical
Altolip Webros Pharmaceuticals
Astat Medisure Laboratories Pakistan (Pvt.) Ltd.
Astatin Pharmacare Laboratories (Pvt) Ltd.
Astra Kurative Pak (Pvt) Ltd
Atastan Rakaposhi Pharmaceutical (Pvt) Ltd.
Atopitar Geofman Pharmaceuticals
Atorex Dyson Research Laboratories
Atorin Fynk Pharmaceuticals
Atorlip Pearl Pharmaceuticals
Atorsan Novartis Pharma (Pak) Ltd
Atorscot Scotmann Pharmaceuticals
Atorva Pharmatec Pakistan (Pvt) Ltd.
Atrachol Kurative Pak (Pvt) Ltd
Atrata S.J. & G. Fazul Ellahie (Pvt) Ltd.
Atrolead Leads Pharma (Pvt) Ltd
Atronil Popular Chemical Works (Pvt) Ltd.
Av Fozan Pharmaceuticals Industriers (Pvt) Ltd
Aztor Ez Paramount Pharmaceuticals
Bvasta Goodman Laboratories
Bvasta Goodman Laboratories
Caliptrol Ferozsons Laboratoies Ltd.
Cardistatin Caylex Pharmaceuticals (Pvt) Ltd.
Cholein Jawa Pharmaceuticals(Pvt) Ltd.
Cholestor P.D.H. Pharmaceuticals (Pvt) Ltd.
Colezaf Zafa Pharmaceutical Laboratories (Pvt) Ltd.
Colistrol Zanctok Pharmaceuticals
Colstat Rasco Pharma
Delip Standpharm Pakistan (Pvt) Ltd.
Derot Healthtek (Pvt) Ltd
Descol Nabiqasim Industries (Pvt) Ltd.
E-Stat Ethical Laboratories (Pvt) Ltd.
Etar English Pharmaceuticals Industries
Etortin Lexicon Pharmaceuticals (Pvt) Ltd.
Fopsec Merck Private Ltd.
Genovax Genix Pharma (Pvt) Ltd
Kolmark Unimark Pharmaceuticals
Lastolip Wilshire Laboratories (Pvt) Ltd.
Lipam Ambrosia Pharmaceuticals
Lipica Csh Pharmaceuticals-North (Pvt) Ltd
Lipidin Schazoo Zaka
Lipidip Beste Pharma (Pvt) Ltd.
Lipifal Helicon Pharmaceutek Pakistan (Pvt) Ltd.
Lipigan A.J. & Company.
Lipiget Getz Pharma Pakistan (Pvt) Ltd.
Lipilow Searle Pakistan (Pvt.) Ltd.
Lipirex Highnoon Laboratories Ltd.
Lipistat Pulse Pharmaceuticals
Lipitor Pfizer Laboratories Ltd.
Lipivastin Mass Pharma (Private) Limited
Lipotrim Efroze Chemical Industries (Pvt) Ltd.
Lipvas Lowitt Pharmaceuticals (Pvt) Ltd
Lochol Scilife Pharma (Private) Ltd
Medilip Medicaids Pakistan (Pvt) Ltd.
Megavastin Mega Pharmaceuticals (Pvt) Ltd
Minilip Pulse Pharmaceuticals
Momentium Werrick Pharmaceuticals
Momentium-Plus Werrick Pharmaceuticals
Orva Bosch Pharmaceuticals (Pvt) Ltd.
Oscar Scotmann Pharmaceuticals
Pro-Statin Consolidated Chemical Laboratories (Pvt) Ltd.
Raytor Ray Pharma (Pvt) Ltd
Reduse Raazee Theraputics (Pvt) Ltd.
Renorm Global Pharmaceuticals
Rostinox Medipak Limited
Rovax Ferroza International Pharmaceuticals (Pvt) Ltd.
Safeheart Tg Pharma
Save Wilsons Pharmaceuticals
Semostatin Semos Pharmaceuticals (Pvt) Ltd.
Sensicon Barrett Hodgson Pakistan (Pvt) Ltd.
Snolip Indus Pharma (Pvt) Ltd.
Stat A High - Q International
Tavas Shaheen Agencies
Tavist Macter International (Pvt) Ltd.
Torlip 3h Hamaz Pharmaceutical (Pvt) Ltd.
Torstan Karachi Chemical Industries
Trovas Adamjee Pharmaceuticals (Pvt) Ltd.
Vasclear Continental Chemical Company (Pvt) Ltd.
Vasta Miracle Pharmaceuticals(Pvt) Ltd
Vastor Atco Laboratories Limited
Vozar Afta Pharma
Winstor Sanofi Aventis (Pakistan) Ltd.
Xetrol Tagma Pharma (Pvt) Ltd.
Zepitor Xenon Pharmaceuticals (Pvt) Ltd.

Atorvastatin [Tabs 20 Mg]

A-Chole Alied Medical
A-Tin Heal Pharmaceuticals Pvt Ltd
A-Vast Wise Pharmaceuticals (Pvt) Ltd
Altolip Webros Pharmaceuticals
Astat Medisure Laboratories Pakistan (Pvt.) Ltd.
Astra Kurative Pak (Pvt) Ltd
Atopitar Geofman Pharmaceuticals
Atorex Dyson Research Laboratories
Atorin Fynk Pharmaceuticals
Atorlip Pearl Pharmaceuticals
Atorsan Novartis Pharma (Pak) Ltd
Atorscot Scotmann Pharmaceuticals
Atorva Pharmatec Pakistan (Pvt) Ltd.
Atorvastin Orta Labs. (Pvt) Ltd.
Atostat Don Valley Pharmaceuticals (Pvt) Ltd.
Atrachol Kurative Pak (Pvt) Ltd
Atrata S.J. & G. Fazul Ellahie (Pvt) Ltd.
Atrolead Leads Pharma (Pvt) Ltd
Atronil Popular Chemical Works (Pvt) Ltd.
Av Fozan Pharmaceuticals Industriers (Pvt) Ltd
Avast Helicon Pharmaceutek Pakistan (Pvt) Ltd.
Caliptrol Ferozsons Laboratoies Ltd.
Cardistatin Caylex Pharmaceuticals (Pvt) Ltd.
Catril Macter International (Pvt) Ltd.
Cholein Jawa Pharmaceuticals(Pvt) Ltd.
Cholestor P.D.H. Pharmaceuticals (Pvt) Ltd.
Colezaf Zafa Pharmaceutical Laboratories (Pvt) Ltd.
Colistrol Zanctok Pharmaceuticals
Colstat Rasco Pharma
Delip Standpharm Pakistan (Pvt) Ltd.
Derot Healthtek (Pvt) Ltd
Descol Nabiqasim Industries (Pvt) Ltd.
E-Stat Ethical Laboratories (Pvt) Ltd.
Eravas Medera Pharmaceuticals (Pvt) Ltd.
Etar English Pharmaceuticals Industries
Fopsec Merck Private Ltd.
Genovax Genix Pharma (Pvt) Ltd
Kolmark Unimark Pharmaceuticals
Lastolip Wilshire Laboratories (Pvt) Ltd.
Lipam Ambrosia Pharmaceuticals
Lipica Csh Pharmaceuticals-North (Pvt) Ltd
Lipidin Schazoo Zaka
Lipifal Helicon Pharmaceutek Pakistan (Pvt) Ltd.
Lipigan A.J. & Company.
Lipiget Getz Pharma Pakistan (Pvt) Ltd.
Lipilow Searle Pakistan (Pvt.) Ltd.
Lipirex Highnoon Laboratories Ltd.
Lipistat Pulse Pharmaceuticals
Lipitor Pfizer Laboratories Ltd.
Lipivastin Mass Pharma (Private) Limited
Lipotrex Wns Field Pharmaceuticals
Lipotrim Efroze Chemical Industries (Pvt) Ltd.
Lipvas Lowitt Pharmaceuticals (Pvt) Ltd
Lochol Scilife Pharma (Private) Ltd
Lova Mega Pharmaceuticals (Pvt) Ltd
Megavastin Mega Pharmaceuticals (Pvt) Ltd
Minilip Pulse Pharmaceuticals
Momentium Werrick Pharmaceuticals
Orva Bosch Pharmaceuticals (Pvt) Ltd.
Oscar Scotmann Pharmaceuticals
Pro-Statin Consolidated Chemical Laboratories (Pvt) Ltd.
Raytor Ray Pharma (Pvt) Ltd
Reduse Raazee Theraputics (Pvt) Ltd.
Renorm Global Pharmaceuticals
Rostinox Medipak Limited
Rovax Ferroza International Pharmaceuticals (Pvt) Ltd.
Safeheart Tg Pharma
Save Wilsons Pharmaceuticals
Semostatin Semos Pharmaceuticals (Pvt) Ltd.
Sensicon Barrett Hodgson Pakistan (Pvt) Ltd.
Snolip Indus Pharma (Pvt) Ltd.
Stat A High - Q International
Stator Tread Pharmaceuticals Pvt Ltd
Tavas Shaheen Agencies
Torlip 3h Hamaz Pharmaceutical (Pvt) Ltd.
Trovas Adamjee Pharmaceuticals (Pvt) Ltd.
Univastin Unison Chemical Works
Vasclear Continental Chemical Company (Pvt) Ltd.
Vasta Miracle Pharmaceuticals(Pvt) Ltd
Vastor Atco Laboratories Limited
Vozar Afta Pharma
Winstor Sanofi Aventis (Pakistan) Ltd.
Xetrol Tagma Pharma (Pvt) Ltd.
Xtor Paramount Pharmaceuticals
Zepitor Xenon Pharmaceuticals (Pvt) Ltd.

Atorvastatin [Tabs 40 Mg]

Altolip Webros Pharmaceuticals
Atopitar Geofman Pharmaceuticals
Atorscot Scotmann Pharmaceuticals
Atorvastin Orta Labs. (Pvt) Ltd.
Atrolead Leads Pharma (Pvt) Ltd
Atronil Popular Chemical Works (Pvt) Ltd.
Avast Helicon Pharmaceutek Pakistan (Pvt) Ltd.
Caliptrol Ferozsons Laboratoies Ltd.
Catril Macter International (Pvt) Ltd.
Catril Macter International (Pvt) Ltd.
Cholestor P.D.H. Pharmaceuticals (Pvt) Ltd.
Colistrol Zanctok Pharmaceuticals
Derot Healthtek (Pvt) Ltd
Descol Nabiqasim Industries (Pvt) Ltd.
Fopsec Merck Private Ltd.
Genovax Genix Pharma (Pvt) Ltd
Kolmark Unimark Pharmaceuticals
Lastolip Wilshire Laboratories (Pvt) Ltd.
Lipica Csh Pharmaceuticals-North (Pvt) Ltd
Lipidin Schazoo Zaka
Lipifal Helicon Pharmaceutek Pakistan (Pvt) Ltd.
Lipiget Getz Pharma Pakistan (Pvt) Ltd.
Lipilow Searle Pakistan (Pvt.) Ltd.
Lipirex Highnoon Laboratories Ltd.
Lipitor Pfizer Laboratories Ltd.
Lipivastin Mass Pharma (Private) Limited
Lipotrim Efroze Chemical Industries (Pvt) Ltd.
Lochol Scilife Pharma (Private) Ltd
Momentium Werrick Pharmaceuticals
Orva Bosch Pharmaceuticals (Pvt) Ltd.
Oscar Scotmann Pharmaceuticals
Pro-Statin Consolidated Chemical Laboratories (Pvt) Ltd.
Raytor Ray Pharma (Pvt) Ltd
Reduse Raazee Theraputics (Pvt) Ltd.
Save Wilsons Pharmaceuticals
Semostatin Semos Pharmaceuticals (Pvt) Ltd.
Sensicon Barrett Hodgson Pakistan (Pvt) Ltd.
Tavas Shaheen Agencies
Tavist Macter International (Pvt) Ltd.
Vasta Miracle Pharmaceuticals(Pvt) Ltd
Vozar Afta Pharma
Winstor Sanofi Aventis (Pakistan) Ltd.
Xtor Paramount Pharmaceuticals

Atorvastatin [Tabs 80 Mg]

Genovax Genix Pharma (Pvt) Ltd
Lastolip Wilshire Laboratories (Pvt) Ltd.
Lipidin Schazoo Zaka

 

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