Expert’s Opinion

Pitavastatin is the latest statin to get approval worldwide. It is the competitive inhibitor of 3-hydroxy-3-methyl-glutarylcoenzyme A (HMG-CoA) reductase enzyme. Inhibiting this (rate-limiting) enzyme impedes cholesterol synthesis in the liver, thereby increasing low-density lipoprotein cholesterol (LDL-C) receptor expression which subsequently reduces LDL-C and total cholesterol levels.¹ Pitavastatin has many unique properties which makes it different from other available statins. Some of these properties have been described hereafter:

• Pitavastatin is more effective in increasing high-density lipoprotein cholesterol (HDL-C) compared to other statins. In an Indian double blind randomised controlled trial, 100 dyslipidaemia patients were randomised to 4 mg/day pitavastatin or 20 mg/day atorvastatin and followed-up for 8 weeks. The increase in HDL-C levels was significantly higher in the pitavastatin group (11%) vs. the atorvastatin group (5.35%) (p<0.001).² In a sub-analysis of the LIVALO Effectiveness and Safety (LIVES) study in patients with low HDL-C levels who were treated with pitavastatin for 104 weeks, there was a 32% increase in HDL-C levels. Patients who were shifted from other statins to pitavastatin also showed significant increase in HDL-C levels.³

• Pitavastatin has significant pleiotropic effects including anti-inflammatory effects which might be beneficial for atherosclerosis regression. In the Kansai Investigation of Statin for Hyperlipidaemic Intervention in Metabolism and Endocrinology (KISHIMEN) trial, dyslipidaemia patients were treated with pitavastatin 1-2 mg for 12 months. Pitavastatin significantly reduced high sensitivity C-reactive protein (hs-CRP) levels by 28.6% in overall subjects and by 62.4% in the highest quartile at 12 months.⁴

• Statin therapy is known to increase blood glucose levels and increase the risk of new onset diabetes in non-diabetic patients.⁵ Pitavastatin has shown neutral or beneficial effects on blood glucose levels in both diabetic and nondiabetic patients.⁶ In the Japan Prevention Trial of Diabetes by Pitavastatin in Patients with Impaired Glucose Tolerance (J-PREDICT) study, 1269 patients with impaired glucose tolerance were treated with 1-2 mg pitavastatin or placebo for up to 5 years. There was a significant 18% reduction in the risk of developing new onset of diabetes (Figure 1).⁷

• Pitavastatin has been shown in many studies to be well tolerated in patients who are intolerant to other statins. In a study, 3 out of 4 (76%) patients who were intolerant to >2 statins were able to tolerate pitavastatin for 6 months.⁸ Better tolerability of pitavastatin is possibly due to a lower decrease in coenzyme Q10 (CoQ10) compared to other statins.⁹ Pitavastatin should be considered a preferred statin when a patient requires statin therapy but fails to tolerate other statins.

The REAL CAD is the first cardiovascular outcome study comparing different intensities of statin therapy in Asianpatients for secondary prevention. Success of this trial has opened newer horizons for management of dyslipidaemia by socalled “moderate” intensity statin (4 mg pitavastatin) in Asian patients suffering from CAD.With several studies documenting unique benefits with the use of pitavastatin, it undoubtedly is the statin with a difference.