SIMVASTATIN- simvastatin tablet, film coated
1 INDICATIONS AND USAGE
Simvastatin tablets USP are indicated:
- To reduce the risk of total mortality by reducing risk of coronary heart disease death, non-fatal myocardial infarction and stroke, and the need for coronary and non-coronary revascularization procedures in adults with established coronary heart disease, cerebrovascular disease, peripheral vascular disease, and/or diabetes, who are at high risk of coronary heart disease events.
- As an adjunct to diet to reduce low-density lipoprotein cholesterol (LDL-C):
- In adults with primary hyperlipidemia.
- In adults and pediatric patients aged 10 years and older with heterozygous familial hypercholesterolemia (HeFH).
- As an adjunct to other LDL-C-lowering therapies to reduce LDL-C in adults with homozygous familial hypercholesterolemia (HoFH).
- As an adjunct to diet for the treatment of adults with:
- Primary dysbetalipoproteinemia.
2 DOSAGE AND ADMINISTRATION
2.1 Important Dosage and Administration Information
- Take simvastatin tablets USP orally once daily in the evening.
- The maximum recommended dosage is simvastatin tablets USP 40 mg once daily [see DOSAGE AND ADMINISTRATION ( 2.2, 2.3)]. The simvastatin tablets USP 80 mg daily dosage is restricted to patients who have been taking simvastatin tablets USP 80 mg daily chronically (e.g., for 12 months or more) without evidence of muscle toxicity [see WARNINGS AND PRECAUTIONS ( 5.1)].
- For patients that require a high-intensity statin or are unable to achieve their LDL-C goal receiving simvastatin tablets USP 40 mg daily, prescribe alternative LDL-C-lowering treatment.
- Assess LDL-C when clinically appropriate, as early as 4 weeks after initiating simvastatin tablets USP, and adjust the dosage if necessary.
2.2 Recommended Dosage in Adult Patients
The recommended dosage range of simvastatin tablets USP is 20 mg to 40 mg once daily
2.3 Recommended Dosage in Pediatric Patients 10 Years of Age and Older with HeFH
The recommended dosage range of simvastatin tablets USP is 10 mg to 40 mg daily.
2.4 Recommended Dosage in Patients with Renal Impairment
For patients with severe renal impairment [creatinine clearance (CLcr) 15 – 29 mL/min], the recommended starting dosage of simvastatin is 5 mg once daily [see WARNINGS AND PRECAUTIONS ( 5.1) AND USE IN SPECIFIC POPULATIONS ( 8.6)]. Simvastatin tablets USP is not available in a 5 mg strength. Use another simvastatin product to initiate dosing in such patients.
There are no dosage adjustment recommendations for patients with mild or moderate renal impairment
2.5 Dosage Modifications Due to Drug Interactions
Concomitant use of simvastatin tablets USP with the following drugs requires dosage modification of simvastatin tablets USP [see WARNINGS AND PRECAUTIONS ( 5.1) AND DRUG INTERACTIONS ( 7.1)].
Patients taking Lomitapide
Reduce the dosage of simvastatin tablets USP by 50%. Do not exceed simvastatin tablets USP 20 mg once daily (or 40 mg once daily for patients who have previously taken simvastatin tablets USP 80 mg daily chronically while taking lomitapide) [see DOSAGE AND ADMINISTRATION (2.1)].
Patients taking Verapamil, Diltiazem, or Dronedarone
Do not exceed simvastatin tablets USP 10 mg once daily.
Patients taking Amiodarone, Amlodipine, or Ranolazine
Do not exceed simvastatin tablets USP 20 mg once daily.
3 DOSAGE FORMS AND STRENGTHS
- Simvastatin tablets 5 mg are tan colored, round, biconvex, film-coated tablets debossed with ‘LL’ on one side and ‘C01’ on the other side.
- Simvastatin tablets 10 mg are peach colored, oval shaped, biconvex, film-coated tablets debossed with ‘LL’ on one side and ‘C02’ on the other side.
- Simvastatin tablets 20 mg are tan colored, oval shaped, biconvex, film-coated tablets debossed with ‘LL’ on one side and ‘C03’ on the other side.
- Simvastatin tablets 40 mg are brick red colored, round shaped, biconvex, film-coated tablets debossed with ‘LL’ on one side and ‘C04’ on the other side.
- Simvastatin tablets 80 mg are brick red colored, capsule shaped, biconvex, film-coated tablets debossed with ‘LL’ on one side and ‘C05’ on the other side.
Simvastatin is contraindicated in the following conditions:
- Concomitant use of strong CYP3A4 inhibitors (select azole anti-fungals, macrolide antibiotics, anti-viral medications, and nefazodone) [see DRUG INTERACTIONS ( 7.1)].
- Concomitant use of cyclosporine, danazol or gemfibrozil [see DRUG INTERACTIONS ( 7.1)].
- Acute liver failure or decompensated cirrhosis [see WARNINGS AND PRECAUTIONS ( 5.3)]
- Hypersensitivity to simvastatin or any excipients in simvastatin tablets USP. Hypersensitivity reactions, including anaphylaxis, angioedema and Stevens-Johnson syndrome, have been reported [see ADVERSE REACTIONS ( 6.2)]
5 WARNINGS AND PRECAUTIONS
5.1 Myopathy and Rhabdomyolysis
Simvastatin may cause myopathy and rhabdomyolysis. Acute kidney injury secondary to myoglobinuria and rare fatalities have occurred as a result of rhabdomyolysis in patients treated with statins, including simvastatin.
In clinical studies of 24,747 simvastatin -treated patients with a median follow-up of 4 years, the incidence of myopathy, defined as unexplained muscle weakness, pain, or tenderness accompanied by creatinine kinase (CK) increases greater than ten times the upper limit of normal (10xULN), were approximately 0.03%, 0.08%, and 0.61% in patients treated with simvastatin 20 mg, 40 mg, and 80 mg daily, respectively. In another clinical study of 12,064 simvastatin -treated patients (with a history of myocardial infarction) with a mean follow-up of 6.7 years, the incidences of myopathy in patients taking simvastatin 20 mg and 80 mg daily were approximately 0.02% and 0.9%, respectively. The incidences of rhabdomyolysis (defined as myopathy with a CK >40xULN) in patients taking simvastatin 20 mg and 80 mg daily were approximately 0% and 0.4%, respectively [see ADVERSE REACTIONS ( 6.1)].
Risk Factors for Myopathy
Risk factors for myopathy include age 65 years or greater, uncontrolled hypothyroidism, renal impairment, concomitant use with certain other drugs (including other lipid-lowering therapies), and higher simvastatin dosage; Chinese patients on simvastatin may be at higher risk for myopathy [see CONTRAINDICATIONS ( 4), DRUG INTERACTIONS ( 7.1), AND USE IN SPECIFIC POPULATIONS ( 8.8)]. The risk of myopathy is increased by elevated plasma levels of simvastatin and simvastatin acid. The risk is also greater in patients taking simvastatin 80 mg daily compared with patients taking lower simvastatin dosages and compared with patients using other statins with similar or greater LDL-C-lowering efficacy [see ADVERSE REACTIONS ( 6.1)].
Steps to Prevent or Reduce the Risk of Myopathy and Rhabdomyolysis
The concomitant use of strong CYP3A4 inhibitors with simvastatin is contraindicated. If short-term treatment with strong CYP3A4 inhibitors is required, temporarily suspend simvastatin during the duration of strong CYP3A4 inhibitor treatment. The concomitant use of simvastatin with gemfibrozil, cyclosporine, or danazol is also contraindicated [see CONTRAINDICATIONS ( 4) AND DRUG INTERACTIONS ( 7.1)].
Simvastatin dosage modifications are recommended for patients taking lomitapide, verapamil, diltiazem, dronedarone, amiodarone, amlodipine or ranolazine [see DOSAGE AND ADMINISTRATION ( 2.5)]. Simvastatin use should be temporarily suspended in patients taking daptomycin. Lipid modifying doses (≥1 gram/day) of niacin, fibrates, colchicine, and grapefruit juice may also increase the risk of myopathy and rhabdomyolysis [see DRUG INTERACTIONS ( 7.1)].
Use the 80 mg daily dosage of simvastatin only in patients who have been taking simvastatin 80 mg daily chronically without evidence of muscle toxicity [see DOSAGE AND ADMINISTRATION ( 2.1)] . If patients treated with simvastatin 80 mg are prescribed an interacting drug that increases the risk for myopathy and rhabdomyolysis, switch to an alternate statin [SEE DRUG INTERACTIONS ( 7.1)].
Discontinue simvastatin if markedly elevated CK levels occur or if myopathy is either diagnosed or suspected. Muscle symptoms and CK increases may resolve if simvastatin is discontinued. Temporarily discontinue simvastatin in patients experiencing an acute or serious condition at high risk of developing renal failure secondary to rhabdomyolysis, e.g., sepsis; shock; severe hypovolemia; major surgery; trauma; severe metabolic, endocrine, or electrolyte disorders; or uncontrolled epilepsy.
Inform patients of the risk of myopathy and rhabdomyolysis when starting or increasing the simvastatin dosage and advise patients receiving simvastatin 80 mg of the increased risk of myopathy and rhabdomyolysis. Instruct patients to promptly report any unexplained muscle pain, tenderness or weakness, particularly if accompanied by malaise or fever.
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