Simvastatin

About Simvastatin

Simvastatin blocks HMG-CoA reductase, the liver enzyme that makes cholesterol, so the liver clears more LDL cholesterol from the blood. The label covers reducing the risk of death, coronary death, nonfatal heart attack, stroke and artery procedures in adults at high risk of coronary events who have coronary, cerebrovascular or peripheral vascular disease or diabetes; with diet, lowering LDL cholesterol in adults with primary hyperlipidemia and in adults and children 10 and older with heterozygous familial hypercholesterolemia; the homozygous form in adults, alongside other treatments; and primary dysbetalipoproteinemia and high triglycerides in adults. Adults take 20 to 40 mg once in the evening, and 40 mg is the recommended maximum: someone who needs more is moved to another treatment, since 80 mg is kept for people who have taken it for a long time, such as a year or more, without muscle problems. Children with the heterozygous form take 10 to 40 mg a day, and LDL can be checked as early as four weeks after starting.

There is no boxed warning. It must not be taken with strong CYP3A4 blockers (some azole antifungals, macrolide antibiotics, HIV and hepatitis C protease inhibitors, cobicistat-containing products and nefazodone), with cyclosporine, danazol or gemfibrozil, with acute liver failure or decompensated cirrhosis, or after an allergic reaction to it. The warnings cover muscle damage (myopathy and rhabdomyolysis, which can injure the kidneys), more likely at 65 or older, with uncontrolled hypothyroidism or kidney impairment, at higher doses and with some other medicines, and Chinese patients may be at higher risk; a rare immune-mediated muscle disease; liver problems; and rises in HbA1c and fasting blood sugar. Upper respiratory infections, headache, abdominal pain, constipation and nausea are the most common side effects. The Zocor label says to stop it when pregnancy is recognized or, alternatively, to weigh the patient’s ongoing treatment needs, and breastfeeding is not recommended.

Other medicines lower the ceiling: 10 mg a day with verapamil, diltiazem or dronedarone, and 20 mg with amiodarone, amlodipine or ranolazine; with lomitapide the dose is halved and kept at or below 20 mg (40 mg for someone long settled on 80 mg). Grapefruit juice is avoided, niacin at cholesterol-lowering doses is not recommended in Chinese patients, and simvastatin may be paused during a course of daptomycin. Zocor’s current label (revised August 2023) says the 5 mg and 80 mg Zocor tablets are no longer marketed, so a 5 mg starting dose for severe kidney impairment, or an 80 mg dose, comes from another simvastatin product. FloLipid is taken in the evening on an empty stomach, and its label, last revised in 2020, still lists pregnancy and breastfeeding as contraindications. Vytorin (simvastatin with ezetimibe) carries the same simvastatin limits.

Taking Simvastatin

How to take it

Once a day in the evening. Take FloLipid on an empty stomach, shaking the bottle well for at least 20 seconds first, and measure it with an accurate measuring device, not a household spoon.

If you miss a dose

Take the missed dose as soon as you remember, but skip it if your next dose is almost due. Do not double the next dose.

Storage

Store at room temperature, out of reach of children: tablets away from moisture, heat and light, and FloLipid never refrigerated or frozen and used within 30 days of opening.

Interactions to know about

Never with strong CYP3A4 blockers such as itraconazole, ketoconazole, clarithromycin or erythromycin, or with cyclosporine, danazol or gemfibrozil. Verapamil, diltiazem and dronedarone cap it at 10 mg and amiodarone, amlodipine and ranolazine at 20 mg, and the bempedoic acid (Nexletol) label says to avoid more than 20 mg. Avoid grapefruit juice; other fibrates, niacin and colchicine add to the muscle risk, and with warfarin the INR is checked when simvastatin is started, adjusted or stopped.

This summarizes the official prescribing information. Your prescriber’s and pharmacist’s instructions, and the leaflet that comes with your medicine, take priority.

Why the cash price for Simvastatin differs from pharmacy to pharmacy

Generic simvastatin tablets come from many makers and cost pharmacies little, so a quote is mostly the dispensing fee and markup, which differ between pharmacies; a prescription that names Zocor and blocks substitution is priced as a brand.

FloLipid has one maker and no approved generic, so it is priced as a brand, and each 150 mL bottle is discarded 30 days after opening, whatever is left.

Ways to pay less for Simvastatin without insurance

• Ask for generic simvastatin, and make sure the prescription does not block substitution for Zocor.
• Ask whether simvastatin is on the pharmacy’s flat-price generic list, and compare more than one pharmacy.
• Once your dose is settled, ask for a ninety-day supply of tablets.
• If a new medicine caps your dose, or FloLipid is quoted high, ask the prescriber whether another statin or tablets would suit you.
• Upload the prescription to Script Unlock so licensed pharmacies can quote their cash price. You pay the pharmacy directly.

Questions to ask your pharmacist about Simvastatin

1. 1.Do any of my medicines, such as amlodipine, diltiazem, verapamil, amiodarone or an antibiotic, limit my dose or rule simvastatin out?
2. 2.Which muscle symptoms should I report straight away?
3. 3.How should I take and store FloLipid if I use the liquid?
4. 4.Should I avoid grapefruit juice completely?

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