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Morning or evening statins

Review
Results
Comment

As long ago as Bandolier 88 the question was asked whether taking a statin in the evening really was better than taking a statin in the morning to produce more cholesterol lowering at the same dose. A new review [1] allows a better answer.

Review

Although not described as a systematic review [1], it tells us that a number of electronic databases were searched for clinical trials that examined morning and evening dosing of statins. Studies were not restricted by the type of subjects included, so patients with hypercholesterolaemia and healthy adults were allowed for inclusion.

Results

The review found seven trials, and reports the percentage reduction in low density lipoprotein cholesterol found with each. All but two of the studies enrolled patients with hypercholesterolaemia. One trial did not have information and another trial was missed in the search.

Table 1 shows the summary data for the percentage difference in evening minus morning statins, and includes two simvastatin trials at doses of 10-20 mg and 10-40 mg that did not have data in a form to be included in Figure 1. The largest average difference (weighted by size) was for simvastatin at 8.7%. Lovastatin had only been studied in 10 patients. For the other three statins there was no large difference in low density lipoprotein cholesterol between evening and morning dosing.



Table 1: Pooled results for individual statins



Statin
Dose
(mg)
N
Evening - morning LDL-C (%)
Simvastatin
2.5-40
254
8.7
Lovastatin
40
10
5.3
Pravastatin
40
196
3.0
Rosuvastatin
10
24
2.9
Atorvastatin
40
80
-0.4


Figure 1 shows the percentage reductions for each comparison, with the two simvastatin comparisons, where there was the largest difference as dark symbols. In both of these comparisons the dose of simvastatin was low, 2.5 mg and 5 mg respectively. Other studies used clinically more relevant doses of atorvastatin, lovastatin, pravastatin, and rosuvastatin.



Figure 1: Percentage reduction in LDL-cholesterol from baseline with evening and morning statin doses (simvastatin dark symbols)





Comment

Both simvastatin and lovastatin have relatively short half lives, while the other three statins have much longer half lives. It seems that the theory of a greater bang per dose with evening dosing for short half life statins holds up.

Is knowing that some statins are better taken at night important? The answer is probably that it is. If there is to be considerable statin switching (mainly to simvastatin) to save money (Bandolier 157), then it makes sense to emphasise to patients that evening use is better. The last thing we want is to have people switching back again, which is the way to lower adherence.

If adherence is thought to be a problem, and where most tablets are taken in the morning, one of the longer half-life statins taken in the morning may be a better option for optimum cholesterol lowering.

References:

  1. R Plakogiannis, H Cohen. Optimal low-density lipoprotein cholesterol lowering - morning versus evening statin administration. Annals of Pharmacotherapy 2007 41: DOI 10.1345/aph.1G659

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