Which statin is the ideal statin for polymedicated patients?

Statins are used widely for the treatment of cardiovascular (CV) disease because they improve the lipid profile and reduce the rate of coronary and cerebrovascular diseases. During the past 15 years, the overall risk profile of patients treated with statins has changed considerably, becoming more complex due to a progressive increase in the proportion of subjects with several concomitant diseases. Indeed, the presence of dyslipidemia is frequently associated with arterial hypertension, diabetes and the metabolic syndrome, as well as with CV and renal disease. In this patient population, the ideal statin should bear some properties that allow for both a substantial improvement in the lipid profile and a reduction in global CV risk. In particular, the ideal statin should provide both a reduction in total and LDL-C and an increase in HDL-C, effects that have been described for statins such as pitavastatin. The clinical efficacy of the ideal statin should be confirmed in a large population of patients and across a wide range of CV risk profiles, ranging from primary to secondary prevention. The ideal statin should be effective in patients in whom dyslipidemia and additional metabolic risk factors (e.g., abnormal glycemic control and metabolic syndrome) coexist. In such patients, a detrimental activation of tissue renin–angiotensin occurs that can be down-regulated with statin treatment. From the safety perspective, the ideal statin should be characterized by a low risk of drug–drug interactions, the incidence of which is significantly increased in polymedicated patients. Unlike other statins, pitavastatin does not undergo cytochrome P450 3A4 metabolism and, therefore, demonstrates a low potential for drug–drug interactions. Recently, treatment with pitavastatin has been associated with an improvement in cardio-renal function (improvement of diastolic function and reduced proteinuria). This might contribute to reduce the CV risk in addition to lipid control, the actual target for modern, effective lipid-lowering treatments.