DRUG OF THE MONTH Cost Saving Switch

Rosuvastatin switch to Atorvastatin

Wirral data Drug Total Annual Total Average cost Spend items per item Rosuvastatin £232,074 9,548 £24.31 Atorvastatin £512,325 86,962 £5.89

S witch 25% R os uvas tatin to Atorvas tatin Save £60K for the CCG

Background Information Generic atorvastatin was launched in 2012 which means there are potential cost savings if patients prescribed rosuvastatin are switched to atorvastatin.

Comparison Chart

Cost per 28 days % reduction in Cost per 28 days % reduction in Statin and Strength (July 2013 Drug Tariff) LDL cholesterol1 Statin and Strength (July 2013 Drug Tariff) LDL cholesterol1

Rosuvastatin 5mg tablets £18.03 38% Atorvastatin 10mg tablets £1.29 37%

Rosuvastatin 10mg tablets £18.03 43% Atorvastatin 20mg tablets £1.60 43%

Rosuvastatin 20mg tablets £26.02 48% Atorvastatin 40mg tablets £1.89 49%

Rosuvastatin 40mg tablets £26.69 63%* Atorvastatin 80mg tablets £3.13 55% (61%*)

*This chart is based on figures in NICE Clinical Guideline 67, Lipid Modification. May 2008 (modified March 2010)1. However, NICE did not look at rosuvastatin 40mg so the figures stated in the chart above for this strength have been taken from the rosuvastatin SPC4. The figures for atorvastatin 80mg stated in the SPC5 have therefore, also been included so a comparison can be made.

NICE guidance NICE Clinical Guideline 67, Lipid Modification1, recommends that treatment for the primary and secondary prevention of CVD should be initiated with simvastatin 40 mg. If there are potential drug interactions or simvastatin 40 mg is contraindicated, a lower dose or alternative preparation such as pravastatin may be chosen (atorvastatin had not come off patent at the time of publication).

Rosuvastatin should not be prescribed for primary prevention unless all other statins are not tolerated.

For secondary prevention NICE advises to consider increasing to simvastatin 80 mg or a drug of similar efficacy and acquisition cost if a total cholesterol of less than 4 mmol/litre or a LDL cholesterol of less than 2 mmol/litre is not attained. However an audit level of 5mmol/L for total cholesterol should be used to assess progress in populations or groups of people with CVD. Any decision to offer a higher intensity statin should take into account informed preference, comorbidities, multiple drug therapy, and the benefit and risks of treatment. Atorvastatin provides an alternative ‘low cost’ statin escalation option with fewer concerns about increased incidence of myopathy as highlighted by the MHRA with Simvastatin 80mg2.

Rosuvastatin 40mg Rosuvastatin 40mg should only be prescribed under specialist supervision as it is contraindicated in patients with predisposing risk factors for muscle toxicity.3 Therefore, all patients prescribed rosuvastatin 40mg should have been initiated under specialist supervision. It is likely that the majority of patients on this dose would be excluded from switching to atorvastatin as they would have been initiated by the lipid clinic. If they are included in the switch to atorvastatin 80mg then the patient should be reviewed to ensure they are currently taking an appropriate dose of rosuvastatin.

References 1. NICE Clinical Guideline 67, Lipid Modification. May 2008 (modified March 2010) 2. MHRA. Drug Safety Update May 2010. http://www.mhra.gov.uk/home/groups/pl-p/documents/publication/con081866.pdf 3. MHRA. Current Problems in Pharmacovigilance. Volume 31, May 2006. http://www.mhra.gov.uk/home/groups/pl-p/documents/websiteresources/con2023860.pdf 4. Rosuvastatin Summary of Product Characteristics. Accessed at http://www.medicines.org.uk/emc/ 5. Atorvastatin Summary of Product Characteristics. Accessed at http://www.medicines.org.uk/emc/

Written by: Rachael Pugh Checked by: Victoria Vincent Medicines Management Team July 2013