Atorvastatin Nursing Implications
Atorvastatin Nurse Teaching
Atorvastatin is a type of antilipemic or antihyperlipidemic agent, a medication that lowers cholesterol and lipid serum levels.
Elevated levels of cholesterol and lipids (i.e. hypercholesterolemia) put patients at higher risk for coronary artery disease (CAD), which can lead to life-threatening health conditions, primarily myocardial infarction (MI) or heart attack.
Drug therapy for elevated cholesterol and lipid levels is meant to be used alongside lifestyle modifications such as dietary modifications, regular exercise, weight and stress management, and smoking cessation for the best results.
Medication-wise, there are several classes of lipid-lowering agents available, and the class to which atorvastatin is part of has its own mechanism of action, indications, contraindications, and other considerations to be taken note of when a patient is a candidate for or is already taking this particular antihyperlipidemic drug.
Indications of Atorvastatin
Cholesterol is a fatty substance used by the body to produce hormones and certain vitamins. While it is a necessary chemical for the body to function normally, if there is an excess amount present, cholesterol can form plaques, causing buildups of these plaques known as atherosclerosis.
These plaques can eventually break off and block arteries, putting patients at risk for other, potentially more fatal conditions like myocardial infarction and stroke.
Atorvastatin is primarily prescribed for its cholesterol-lowering effects to reduce the risk for coronary artery disease in patients with abnormal lipid profile (elevated LDL, total cholesterol) results, with or without additional risk factors, in combination with dietary and other lifestyle modifications.
Use of atorvastatin as a preventive drug can either be considered primary (for patients without previous history of coronary artery disease but with multiple risk factors, such as abnormal lipid profile or having diabetes mellitus type 2), or secondary (for patients who already have a previous history of coronary artery disease, to reduce the risk for diseases such as stroke or myocardial infarction).
It is of note that, as of now, atorvastatin has not yet been studied in, and therefore not prescribed in the management of Fredrickson dyslipidemia types I and V.
The available forms for atorvastatin are as follows:
- Tablets: 10 mg, 20, mg, 40 mg, 80 mg
The prescribed dosage for atorvastatin will depend on the indication the medication is prescribed for:
- Adjunct to diet to control cholesterol (LDL, total cholesterol), triglyceride levels (for Fredrickson type IV), apolipoprotein B, and to elevate HDL levels for patients with hypercholesterolemia, mixed dyslipidemia (Fredrickson types IIa and IIb) , primary dysbetaliporoteinemia (Fredrickson type III): Start with 10 or 20 mg tablet once daily. If a patient needs to lower LDL levels by more than 45%, dosage may start at 40 mg tablet once daily. Increase dosage as needed, up to a maximum dose of 80 mg daily as single dose. Continuing dosage should be based on lipid levels taken within 2 to 4 weeks after starting the drug.
- For homozygous familial hypocholesterolemia patients: May be taken alone or in conjunction with treatments to lower total and LDL cholesterol such as LDL apheresis. Start at 10 mg tablet once daily, up to a maximum of 80 mg tablet once daily as single dose.
- For pediatric patients with heterozygous familial hypercholesterolemia (ages 10 to 17 years old): Give initial dose of 10 mg tablet once daily, with adjustment intervals being at least 4 weeks. Maximum dosage should only be up to 20 mg daily. Female pediatric patients should be at least one year post menarche before being prescribed this medication.
Actions of Atorvastatin
Atorvastatin is a type of HMG-CoA reductase inhibitor anti-hyperlipidemic. HMG-CoA reductase is an enzyme that converts HMG-CoA into mevalonate acid, a conversion process that is an important step in the biosynthesis of cholesterol.
Atorvastatin acts by competitively binding to HMG-CoA, preventing the latter from being converted to mevalonate acid by HMG-COA reductase.
Through this, atorvastatin is able to decrease cholesterol production in the liver, as more LDLs end up being absorbed by the cells to turn into cholesterol, and the number of LDL receptors in hepatic cells are also increased. Conversely, this causes HDL levels to slightly increase due to this metabolic change.
Atorvastatin is rapidly absorbed in the bloodstream after oral intake and undergoes extensive first-pass effect in the liver. Because of this marked metabolism, the bioavailability of the drug only reaches up to 14%. Peak plasma levels are reached within 2 hours after intake, and peak effects of the medication can be seen after about 2 to 4 weeks of continued intake.
The half-life for atorvastatin can be as long as 14 hours, while its metabolites can have a half-life ranging from 20 to 30 hours. Excretion of atorvastatin and its metabolites is done through the liver and eliminated through the bile, which is then excreted in the urine and feces.
For patients with impaired hepatic function, such as those with chronic liver disease, increased plasma levels of the drug are known to occur.
Since most of the metabolism and elimination is done by the liver, renal function is not as important in determining patient compatibility with the drug compared to hepatic function. Thus, dose adjustment is typically not required for these types of patients.
Nevertheless, patients with considerable renal impairment may still need to be observed, especially if they are taking other drugs with similar mechanisms of action, metabolism, and elimination as atorvastatin.
The drug can cross the placental barrier and has been associated with causing fetal defects and malformations. Atorvastatin can also be widely distributed in breast milk.
Side Effects of Atorvastatin
Most common side effects associated with atorvastatin and other HMG-CoA inhibitors usually involve the gastrointestinal system, although symptoms from other systems have been recorded as well:
- Gastrointestinal: dyspepsia, cramps, abdominal pain, nausea, vomiting, flatulence, constipation
- CNS: headache, insomnia
- EENT: Hoarseness of voice, rhinitis, sinusitis
- Musculoskeletal: Back pain
- Genitourinary: difficulty urinating, urinary tract infection
- Diagnostic tests: Increased ALT and AST, blood bilirubin, blood alkaline phosphate, abnormal liver function tests. Lately found to also increase glycosylated hemoglobin and fasting blood sugar levels.
- Others: flu-like symptoms (i.e. cough, runny nose)
Adverse Reactions to Atorvastatin
One of the noteworthy adverse reactions to atorvastatin is the risk of developing rhabdomyolysis and acute renal failure, especially for patients with impaired kidney function.
Other adverse reactions to atorvastatin include:
- Myopathy – muscle pain or weakness
- Edema – swelling of limbs, face, and/or eyes
- Tachycardia, chest tightness
- Arthritis, arthralgia, myalgia
- Peripheral neuropathy
- Hepatitis, cholestasis, hepatic failure
Drug Interactions with Atorvastatin
- Atorvastatin and other HMG-CoA reductase inhibitors. Atorvastatin should not be taken with other drugs of the same antilipemic type. Studies found that taking the drugs together can increase the patient’s risk for critical adverse reactions such as myopathy, peripheral neuropathy, and rhabdomyolysis.
- Atorvastatin and vitamins. Taking some vitamins in high doses while taking atorvastatin may increase the risk for adverse reactions to the latter.
- Atorvastatin and antacids. Certain antacids are made up of chemicals that decrease the drug level of atorvastatin and similar drugs when taken together.
- Atorvastatin and antimicrobials. Taking atorvastatin while undergoing treatment using certain types of antibiotics or antifungals may lead to increased drug levels and amplified side effects of the former. The patient may either take atorvastatin and the antibiotic or antifungal together but under closer monitoring, or be prescribed a different type of antilipemic.
- Atorvastatin and antiretrovirals. Atorvastatin levels may be increased when being taken with certain antiretroviral drugs.
- Atorvastatin and immunosuppressants. Using atorvastatin and certain immunosuppressants together can increase the risk for adverse reactions to atorvastatin, particularly the risk for myopathy. Such immunosuppressants should not be used with the drug.
- Atorvastatin and oncology medications. Atorvastatin has been found to increase toxicity levels of some chemotherapeutic drugs and may be considered for a different antilipemic if the patient is for chemotherapy.
- Atorvastatin and bile acid sequestrants. While the patient can use both medications in conjunction, taking atorvastatin and a bile acid sequestrant together can decrease the effectiveness of the former. This can be avoided by spacing the intake of these drugs apart.
- Atorvastatin and anticoagulants. Atorvastatin may cause unwanted amplification of certain anticoagulants’ therapeutic effects as well as increase atorvastatin’s drug levels in the blood.
- Atorvastatin and calcium channel blockers. Taking these two drugs together may cause an increase in atorvastatin levels in the blood and increase the likelihood of adverse reactions to atorvastatin.
- Atorvastatin and other cardiac medications. Atorvastatin may cause an increase in serum levels of certain cardiac medications, leading to toxicity and related adverse reactions.
- Atorvastatin and grapefruit juice. Patients should limit drinking grapefruit juice while taking atorvastatin, as grapefruit juice was found to increase the drug’s serum levels by inhibiting the body from metabolizing atorvastatin properly, and potentially increasing the risk for liver damage.
- Atorvastatin and oral contraceptives. Atorvastatin may have an adverse effect on hormone regulation, and by extension, contraceptives that increase hormone concentration in the body.
- Atorvastatin and herbal medication. There are some herbal medications that can decrease the effectiveness of atorvastatin and other similar antilipemic drugs.
Nursing Considerations for Patients on Atorvastatin
- Prior to being prescribed atorvastatin primarily for cholesterol level management, patients are first recommended to take a low-fat/cholesterol (LDL) diet for 3 to 6 months with foods high in HDL, such as fish, avocados, and certain nuts and nut oils. These patients are only started on drug therapy if diet and lifestyle modifications are still ineffective in lowering cholesterol levels. However, should the patient be recommended for atorvastatin therapy, the patient should be informed that some cholesterol-lowering foods, such as certain whole grains, may affect absorption and serum levels of the drug.
- That said, patients who are about to take atorvastatin should be advised that atorvastatin is best used as an adjunct, and not a sole therapeutic intervention, to lower and control lipid and cholesterol levels. The patient should still adhere to dietary and lifestyle modifications in addition to adhering to the prescribed drug regimen to achieve the best possible outcome.
- Advise the patient on the proper way to take atorvastatin. Medication should not be crushed, chewed, or cut prior to intake. The drug can be taken without meals. Should the patient miss a dose, they should omit the missed medication and take the next one as scheduled. Advise the patient on the recommended daily dosage and to avoid taking double doses to make up for any missed dose.
- Advise patient to avoid drinking grapefruit juice and alcohol while taking atorvastatin, as the former can increase atorvastatin’s serum drug levels while the latter may increase the patient’s risk for liver damage. If complete avoidance is not desired, recommend that the patient should limit their grapefruit intake to only one quart per day, and alcohol intake should be no more than two glasses a day while undergoing atorvastatin therapy.
- The patient should be advised to get the following laboratories and diagnostics in order to have established baseline data. These tests should be done prior to starting atorvastatin therapy: liver function tests such as AST and ALT, serum alkaline phosphate, serum bilirubin, serum electrolytes, and serum blood glucose monitoring tests. Patients should also have baseline data for musculoskeletal and neurological assessment since most of the atorvastatin’s most alarming adverse reactions (myopathy and rhabdomyolysis) involve these systems.
- Patients taking atorvastatin should have their lipid levels monitored within 2 to 4 weeks of continuous therapy, and their hepatic function tests, within 6 to 12 weeks after starting atorvastatin therapy. Hepatic function should then be monitored periodically thereafter if drug therapy will be continued.
- Advise the patient on the possible side effects and adverse reactions to the drug, and to take note of the important signs and symptoms of adverse reactions to watch out for, as drug therapy should be stopped in some cases of adverse reaction. Signs and symptoms patients should take note of and report to the prescribing physician right away include the following: sudden, unexplained muscle pain or weakness, fever, swelling, unusual bleeding, dark-colored urine, or yellowing of skin and eyes indicative of jaundice. The drug may be put on hold in the event of severe illness or acute injury.
- Advise patients to be cautious when taking over the counter or herbal drugs, as atorvastatin has been known to have adverse drug interactions with different types of medications. They should also be advised to inform their prescribing physician if they are advised to take medications that are known to have potentially severe interactions with atorvastatin, in which case closer monitoring or potentially changing antilipemic medication may be considered.
- Patients complaining of musculoskeletal involvement may need to have their CPK levels examined. If a patient’s CPK levels are at least ten times higher than the upper limit, myopathy as an adverse reaction to atorvastatin should be considered. Prompt discontinuation of the medication should be done, followed by close monitoring for worsening symptoms even after discontinuation of the drug that could be indicative of possible immune necrotizing myopathy (IMNM), such as facial muscle weakness, elevated serum creatine kinase, and muscle biopsy results showing necrosis. Should myopathy escalate to IMNM, patients should be prescribed immunosuppressive medications. If antilipemic drug therapy is still necessary for the patient, the current atorvastatin dose can either be resumed but in a reduced dosage or replaced by a different type of antilipemic drug.
- Atorvastatin is contraindicated in the following patients: hypersensitivity to atorvastatin or similar drugs, patients with active liver disease (e.g. hepatitis) or history of alcoholic liver disease, and patients with persistently elevated transaminase levels. Use with caution in patients with a history of heavy alcohol consumption, liver disease if the benefits outweigh the risks.
- Use cautiously in patients with impaired endocrine function due to the drug regimen possibly altering steroid hormone formation.
- Since the risk for myopathy and rhabdomyolysis is reportedly higher in renal impairment patients who are using atorvastatin, patients with kidney impairments should be closely monitored for signs of any musculoskeletal disorders.
- Patients over 65 years old reportedly have higher plasma levels of the medication and are at higher risk for developing moderate to severe adverse effects to atorvastatin.
- Do not use atorvastatin in patients who are suspected or confirmed to be pregnant, as use of the drug has been connected to musculoskeletal malformations in the fetus. The risk for fetal defect is especially pronounced in the first trimester.
- The drug should also be avoided by women of childbearing age, especially those who are planning to have children. Should potential benefits outweigh the risk in this situation, the patient should receive adequate counseling to help them understand the risks to the fetus should they continue taking atorvastatin while possibly being pregnant. Atorvastatin use should be put on hold at least three months before the female patient is planning to conceive.
- Lactating mothers are advised not to take atorvastatin while actively breastfeeding. If taking the drug is necessary, the mother should be advised to discontinue nursing and use alternative means (like donated breastmilk) to feed their babies.
Nursing Diagnosis for Atorvastatin
Possible Nursing Diagnoses
- Acute Pain (Abdominal)
- Risk for Sleep Deprivation related to side effect of drug therapy
- Risk for Liver Impairment
- Deficient Knowledge related to drug action and side effects
|Nursing Interventions for Atorvastatin||Rationales|
|Check the patient’s blood test results, particularly the LDL and HDL levels. Assess the patient for signs and symptoms of hypercholesterolemia.||To confirm the indication for administering atorvastatin.|
|Check the patient’s allergy status.||Previous allergic reaction to atorvastatin or any of its contents may render the patient unable to take them. Alternatives to atorvastatin should therefore be considered in case of allergy.|
|Assess if the patient is pregnant or lactating.||Contraindication: atorvastatin should not be prescribed to a pregnant woman or lactating mother as these drugs can potentially harm the fetus or newborn, as there can be a disruption in infant lipid metabolism. If the patient really requires statin treatment, breastfeeding should be avoided.|
|If administering oral atorvastatin, assess the patient’s mucous membranes and his/her ability to swallow.||To check for any potential problems with administration, hydration, and absorption.|
To ensure that the right form of atorvastatin is given through the right route.
|Assess for signs of renal impairment.||atorvastatin can increase liver enzyme levels. They must be used with caution in people with impaired renal function.|
|Check medical history for: 70 years of age and aboveHistory of liver or renal diseaseLarge alcohol consumptionMusculoskeletal disordersDiabetes myopathy or rhabdomyolysis (or family history of such)||atorvastatin may cause myopathy, liver or renal impairment, and high blood glucose levels, and therefore should be prescribed with caution in patients included in the listed risk groups.|
|Check for history of hypothyroidism. Collect bloods for thyroid function tests as indicated.||Hypoactive thyroid can cause high cholesterol levels. Treating this condition may correct the problem without the need for taking atorvastatin.|
|Check the patient’s list of current medications for digoxin, warfarin, or oral contraceptives.||• Digoxin and warfarin – these drugs increase the serum levels of atorvastatin, causing drug toxicity. • Oral contraceptives – when taking both atorvastatin and oral contraceptives, it is important to note that serum estrogen levels may increase.|
Nursing Planning and Intervention
|Nursing Interventions for Atorvastatin||Rationales|
|Instruct the patient to minimize consumption of grapefruit juice while on atorvastatin.||Grapefruit juice can increase serum statin levels, which may lead to drug toxicity.|
|Inform the patient that he/she can take atorvastatin with or without meals, but preferably with or after meals.||To ensure optimal absorption and therapeutic action by atorvastatin. Atorvastatin works best if it is taken with meals.|
|Advise the patient to take the statin at night.||The enzyme that it needs to target is more active at night.|
|Educate the patient about the action, indication, common side effects, and adverse reactions to note when taking atorvastatin. Instruct the patient on how to self-administer oral atorvastatin.||To inform the patient on the basics of atorvastatin, as well as to empower him/her to safely self-administer the medication.|
|Perform a pregnancy test for the female patient.||Atorvastatin should not be prescribed to a pregnant woman as these drugs can potentially harm the fetus or newborn, as there can be a disruption in infant lipid metabolism|
|Collect blood for liver function tests (LFTs). Check the patient’s liver enzymes.||Atorvastatin can increase liver enzyme levels. They must be used with caution in people with impaired renal function.|
|Advise the patient to stop alcohol consumption while on atorvastatin.||This will prevent unwanted effects on the liver while on atorvastatin.|
|Check the patient’s blood glucose level.||Atorvastatin may cause increased blood glucose levels and must be used with caution in patients with impaired glucose regulation.|
|Nursing Interventions for Atorvastatin||Rationales|
|Ask the patient to repeat the information about atorvastatin.||To evaluate the effectiveness of health teaching on atorvastatin.|
|Monitor the renal and liver function of the patient through performing regular blood tests.||To ensure that the atorvastatin did not cause any adverse effects to the patient’s kidneys or liver. Patients on a long-term statin treatment should have an appointment for liver function tests at 3 months and 12 months of starting atorvastatin.|
|Monitor the patient’s response to atorvastatin.||To check if the atorvastatin is effective, the dose needs to be adjusted, or the drug should be stopped and changed to an alternative treatment.|
Ackley, B. J., Ladwig, G. B., Makic, M. B., Martinez-Kratz, M. R., & Zanotti, M. (2020). Nursing diagnoses handbook: An evidence-based guide to planning care. St. Louis, MO: Elsevier. Buy on Amazon
Gulanick, M., & Myers, J. L. (2022). Nursing care plans: Diagnoses, interventions, & outcomes. St. Louis, MO: Elsevier. Buy on Amazon
Ignatavicius, D. D., Workman, M. L., Rebar, C. R., & Heimgartner, N. M. (2018). Medical-surgical nursing: Concepts for interprofessional collaborative care. St. Louis, MO: Elsevier. Buy on Amazon
Silvestri, L. A. (2020). Saunders comprehensive review for the NCLEX-RN examination. St. Louis, MO: Elsevier. Buy on Amazon
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