Consumer medicine information

CHOLVASTIN

Pravastatin sodium

BRAND INFORMATION

Brand name

Cholvastin Tablets

Active ingredient

Pravastatin sodium

Schedule

S4

 

Consumer medicine information (CMI) leaflet

Please read this leaflet carefully before you start using CHOLVASTIN.

What is in this leaflet

This leaflet answers some common questions about CHOLVASTIN (Pravastatin Sodium).

It does not contain all the available information.

It does not take the place of talking to your doctor or pharmacist.

All medicines have risks and benefits. Your doctor has weighed the risks of you taking CHOLVASTIN against the benefits it is expected to have for you.

If you have any concerns about using/taking this medicine, ask your doctor or pharmacist.

Keep this leaflet with this medicine.

You may need to read it again.

What CHOLVASTIN tablets are used for

CHOLVASTIN tablets belong to a group of lipid-lowering medicines called HMG-CoA reductase inhibitors (commonly known as "statins"). They work by lowering lipids (fats) such as cholesterol and triglycerides in your blood when non-medicinal measures, such as a low-fat diet, exercise and lifestyle changes, alone have failed.

Cholesterol is a naturally occurring substance in the body necessary for normal growth. However, if there is too much cholesterol in your blood, it can get deposited along the walls of the blood vessels leading to narrowing and even blocking of these vessels (atherosclerosis). This is one of the common causes of heart problems such as chest pain (angina) and heart attack (myocardial infarction). High cholesterol levels have been shown to be associated with increased risk of heart disease. Other factors including high blood pressure, high blood sugar (diabetes), increased weight, lack of exercise and smoking further add to the risk of heart disease. High cholesterol levels in the blood can be brought down and kept down with dietary modifications, exercise and medicines.

CHOLVASTIN tablets are used for one or more of the following:

  • If you already have heart disease and raised levels of cholesterol, pravastatin will help reduce your chances of having another heart attack, or a stroke. It will reduce your chances of requiring a procedure (such as coronary artery bypass grafting and percutaneous transluminal coronary angioplasty) to increase the blood flow to your heart, and will slow down any further narrowing of your arteries.
  • If you do not have heart disease but just raised levels of cholesterol, pravastatin will help prolong your life, reduce the risk of your having a heart attack or requiring a procedure to increase the blood flow to your heart.
  • If you have a condition known as primary hypercholesterolaemia, pravastatin will help bring down the cholesterol levels in your blood.

There is no evidence that CHOLVASTIN tablets are addictive.

CHOLVASTIN tablets are not expected to affect your ability to drive a car or operate machinery.

Before you take CHOLVASTIN tablets

When you must not take it

Do not take CHOLVASTIN tablets if you have liver disease or any unexplained abnormal blood test results for liver function.

Do not take CHOLVASTIN tablets if you are allergic to pravastatin or any of the inactive ingredients listed at the end of this leaflet.

Do not take CHOLVASTIN tablets after the expiry date printed on the pack.

If you take it after the expiry date has passed, it may not work as well. Do not take CHOLVASTIN if the tablets do not look quite right.

Do not take CHOLVASTIN tablets if the packaging is torn or shows signs of tampering.

Do not give CHOLVASTIN tablets to children under eight years of age.

The safety of CHOLVASTIN tablets in children under 8 years of age has not been studied.

Before you start to take it

Tell your doctor if you have any allergies to:

  • any other medicines
  • any other substances, such as foods, preservatives or dyes

Tell your doctor if you are pregnant or intend to become pregnant.

Like many other medicines, CHOLVASTIN tablets are not recommended during pregnancy. Your doctor will discuss the risks and benefits of using CHOLVASTIN tablets if you are pregnant.

Tell your doctor if you are breast-feeding or planning to breast-feed.

A small quantity of pravastatin is known to pass into breast milk. CHOLVASTIN tablets are not recommended while breast-feeding. Your doctor will discuss the possible risks and benefits of taking/using CHOLVASTIN tablets while breast-feeding.

Tell your doctor if you have or have had any medical conditions, especially problems with your kidney(s)/liver.

Tell your doctor if you plan to have surgery.

Tell your doctor if you drink alcohol regularly.

Tell your doctor if you have had muscle pain, tenderness or weakness while taking other medicine used to treat high cholesterol.

If you have not told your doctor about any of the above, tell him/her before you use CHOLVASTIN tablets.

Taking other medicines

Tell your doctor if you are taking any other medicines, including medicines you buy without a prescription from a pharmacy, supermarket or health food shop.

Some medicines may interfere with the absorption or action of CHOLVASTIN tablets.

These include:

  • Gemfibrozil, niacin, colestipol, cholestyramine (other lipid-lowering medicines)
  • Cyclosporin (a medicine which modulates immune response)
  • Erythromycin (antibacterial medicine)
  • Ketoconazole (antifungal medicine)
  • Cimetidine (medicine used for healing peptic ulcers)
  • Spironolactone (potassium-sparing water tablets)

These medicines may be affected by CHOLVASTIN, or may affect how well it works. You may need to use different amounts of your medicine or you may need to take different medicines. Your doctor or pharmacist will be able to tell you what to do when taking/being given CHOLVASTIN tablets with other medicines.

Your doctor or pharmacist has more information on medicines to be careful with or avoid while taking CHOLVASTIN tablets.

How CHOLVASTIN tablets are given

How much to take

Make sure you continue with your recommended diet, exercise and other lifestyle changes while on your medicine.

How to take it

Swallow the tablet whole with a full glass of water.

For Hypercholesterolaemia
Adults
The usual starting dose is one half or one CHOLVASTIN 20 mg tablet taken once daily, at bedtime. Your doctor may adjust the dosage, depending on your response to the medicine.

The recommended dose of pravastatin could vary from 10 mg to 80 mg per day, taken once daily at bedtime or taken evenly in divided doses.

Adolescents (14 to 18 years)
The usual recommended dose is pravastatin 40 mg taken once daily.

Children (8 to 13 years)
The usual recommended dose is pravastatin 20 mg taken once daily.

The action of CHOLVASTIN tablets starts gradually and it may take up to four weeks to establish control of your blood cholesterol levels. Once your blood cholesterol is controlled, your doctor may reduce your daily dose to suit your condition.

For prevention of heart disease or stroke
The usual dose is one CHOLVASTIN 40 mg tablet taken once daily.

Your doctor may initially prescribe lower doses for you if you are elderly, or if you have kidney or liver problems, or you are taking other medicines such as immune system modulators if other lipid- lowering agents.

When to take it

For achieving maximum benefits from CHOLVASTIN tablets, take them preferably at bedtime on an empty stomach.

Take your CHOLVASTIN tablets at about the same time each day. Taking your tablets at the same time each day will have the best effect. It will also help you to remember when to take the tablets.

How long to take it

Continue taking CHOLVASTIN tablets until your doctor tells you to stop. Do not stop taking CHOLVASTIN tablets suddenly.

CHOLVASTIN tablets help control high blood cholesterol levels as well as the associated long-term complications. Therefore you must take CHOLVASTIN tablets every day and for a period as long as advised by your doctor. Most people will need to take CHOLVASTIN tablets for long periods of time.

If you forget to take it

If it is almost time for your next dose, skip the dose you missed and take your next dose when you are meant to.

Otherwise, take it as soon as you remember, then go back to taking it as you would normally.

Do not double a dose to make up for the dose you have missed.

If you are not sure what to do, ask your doctor or pharmacist.

If you have trouble remembering when to take your medicine, ask your pharmacist for some hints.

If you take too much (Overdose)

Immediately telephone your doctor or the Poisons Information Centre (13 11 26), or go to Accident and Emergency at your nearest hospital, if you think that you or anyone else has taken too much of CHOLVASTIN tablets. Do this even if there are no signs of discomfort or poisoning.

You may need urgent medical attention. Keep this telephone number handy.

While you are using CHOLVASTIN tablets

Things you must remember

Take CHOLVASTIN tablets exactly as your doctor tells you to.

Try not to miss any dose and take the medicine even if you feel well.

Visit your doctor regularly for check-ups and monitor your blood cholesterol levels as instructed by your doctor.

You should monitor your blood cholesterol levels regularly to make sure that CHOLVASTIN tablets are controlling your cholesterol levels.

Tell all doctors, dentists and pharmacists who are treating you that you are taking CHOLVASTIN tablets.

If you are about to be started on any new medicine, tell your doctor or pharmacist that you are taking CHOLVASTIN tablets.

If you plan to have surgery make sure you tell your doctor, dentist or anaesthetist that you are taking CHOLVASTIN tablets.

If you become pregnant while taking CHOLVASTIN tablets, tell your doctor immediately.

Things you must not do

Do not give this medicine to anyone else, even if they have the same condition as you.

Do not use CHOLVASTIN tablets to treat any other complaints unless your doctor tells you to.

Do not stop taking CHOLVASTIN tablets, or lower the dose, without first checking with your doctor.

Things to be careful of

Be careful driving or operating machinery until you know how CHOLVASTIN tablets affect you.

CHOLVASTIN tablets are not known to affect your ability to drive or operate machinery. However, they may make you feel dizzy which could affect your ability to drive or operate machinery. Make sure you know how you react to CHOLVASTIN tablets before you drive a car, operate machinery, or do anything else that could be dangerous if you are not alert.

Thing that may help your condition

  • Diet
    Eat a healthy diet, which includes plenty of fresh vegetables, fruit, bread, cereals and fish. Also eat less fat and sugar.
  • Exercise
    Regular exercise helps reduce blood pressure and helps the heart get fitter, but it is important not to overdo it. Walking is good exercise, but try to find a route that is fairly flat. Before starting any exercise, ask your doctor about the best kind of programme for you.
  • Smoking
    Your doctor may advise you to stop or at least cut down smoking.
  • Weight
    Your doctor may suggest losing weight to help lower your blood pressure and help lessen the amount of work your heart has to do. Some patients may need to see a dietician to help lose weight.

Side effects

Tell your doctor or pharmacist as soon as possible if you do not feel well while you are taking CHOLVASTIN tablets.

Pravastatin helps most people to reduce increased blood cholesterol levels, but may have unwanted side effects in a few people.

All medicines can have side effects. Sometimes they are serious, most of the time they are not. You may need medical treatment if you get some of the side effects.

Ask your doctor or pharmacist any questions you may have.

Tell your doctor if you notice any of the following and they worry you:

  • Feeling sick (nausea) or being sick (vomiting), diarrhoea or loose stools, indigestion or heartburn, escape of wind, constipation, abdominal pain and bloating
  • Tiredness, weakness, chest pain, weight gain/loss
  • Muscle pain or cramps
  • Dizziness, headache, sleep disturbance, depressed mood, anxiety/nervousness, numbness, tingling or burning sensation or pain in the feet and/or hands, uncontrolled shaking
  • Loss of hair, any other changes in skin/nail/hair, increased sensitivity to sunlight
  • Altered taste sensation, worsening of pre-existing cloudiness in the lens of the eye
  • Persistent abnormal erection of the penis, decreased sexual performance including impaired ejaculation in males and decreased orgasm
  • Breast enlargement in male or abnormal production of breast milk
  • Cough, running nose

These are the more common side effects of CHOLVASTIN tablets. These side effects are usually mild and occur at the start of treatment.

Tell your doctor immediately if you notice any of the following:

  • Unexplained/persistent muscle aches, with or without passage of pink coloured urine
  • Unusual bleeding or increased tendency to bleed, persistent sore throat and frequent infections, and/or anaemia
  • Sudden onset of severe abdominal pain associated with feeling sick (nausea) and being sick (vomiting)
  • Yellowing of skin and whites of eyes with decreased appetite, abdominal pain
  • Recurrent episodes of numbness and loss of muscle strength (pressure palsies)
  • Buzzing or ringing in the ears

Tell your doctor immediately or go to Accident and Emergency at your nearest hospital if you notice any of the following:

  • Symptoms of an allergic reaction may include rashes, hives, itching, chest constriction, shortness of breath or swelling of face, lips, tongue, hands/feet, fainting, fever.

These are very serious side effects. You may need urgent medical attention or hospitalisation. All these side effects are very rare.

Statins may very rarely be associated with a type of lung disease. You should see your doctor if you experience breathlessness or difficulty breathing, a cough and deterioration in your general health (e.g. weight loss, fever, fatigue) while taking this medicine.

Other side effects not listed above may also occur in some patients. Tell you doctor if you notice anything else that is making you feel unwell.

Do not be alarmed by this list of possible side effects. You may not experience any of them.

After using it

Storage

Keep your tablets in the blister pack until it is time to take them.

If you take the tablets out of the box or the blister pack they may not keep well.

Keep your CHOLVASTIN tablets in a cool, dry place where it stays below 25°C.

Do not store it in the bathroom or near a sink.

Do not leave it in the car on hot days.

Heat or exposure to light and dampness can destroy medicines.

Keep this medicine where young children cannot reach it.

Disposal

If your doctor tells you to stop taking or you find that the tablets have passed their expiry date, ask your pharmacist what to do with any tablets that are left over.

Product description

What it looks like

  • CHOLVASTIN 20 mg are dark yellow to yellow coloured mottled, circular, biconvex uncoated tablets debossed with ‘P2’ on one side and a breakline on the other side. Available in packs of 30 tablets.
  • CHOLVASTIN 40 mg are dark yellow to yellow coloured mottled, circular, biconvex uncoated tablets debossed with ‘P3’ on one side and a breakline on the other side. Available in packs of 30 tablets.

Ingredients

Active ingredient

  • CHOLVASTIN 20 mg tablets: 20 mg pravastatin sodium
  • CHOLVASTIN 40 mg tablets: 40 mg pravastatin sodium

Inactive ingredients

  • Lactose anhydrous
  • Sodium stearyl fumarate
  • Ferric oxide yellow

Sponsor

Ranbaxy Australia Pty Ltd.
Suite 4.02, Building D, Level 4
12 – 24 Talavera Road
North Ryde NSW 2113
Australia

CHOLVASTIN is supplied in New Zealand by:
Douglas Pharmaceuticals Ltd
Central Park Drive, Lincoln
Auckland 0610
New Zealand

Australian Registration Numbers

  • CHOLVASTIN 20 mg Tablets: AUST R 140038
  • CHOLVASTIN 40 mg Tablets: AUST R 140042

This leaflet was prepared in May 2011.

BRAND INFORMATION

Brand name

Cholvastin Tablets

Active ingredient

Pravastatin sodium

Schedule

S4

 

Name of the medicine

Pravastatin sodium.

Excipients

Anhydrous lactose, sodium stearyl fumarate, ferric oxide yellow.

Description

Chemical name: sodium (3R,5R)-3,5-dihydroxy- 7-[(1S,2S,6S,8S,8aR)-6-hydroxy-2-methyl- 8-[[(2S)-2-methylbutanoyl]oxy]- 1,2,6,7,8,8a-hexahydronaphthalen-1-yl]heptanoate. Molecular formula: C23H35NaO7. MW: 446.52.
Pravastatin is one of a new class of lipid lowering compounds, the HMG-CoA reductase inhibitors, that reduce cholesterol biosynthesis. These agents are competitive inhibitors of 3-hydroxy-3-methylglutaryl-coenzyme A (HMG-CoA) reductase, the enzyme catalysing the early rate limiting step in cholesterol biosynthesis, conversion of HMG-CoA to mevalonate.
Pravastatin sodium is a white to yellowish white powder or crystalline powder, hygroscopic. It is freely soluble in water and in methanol, soluble in ethanol.

Pharmacology

Mechanism of action.

Pravastatin produces its lipid lowering effect in two ways. First, as a consequence of its reversible inhibition of HMG-CoA reductase activity, it affects modest reductions in intracellular pools of cholesterol. This results in an increase in the number of LDL receptors on cell surfaces and enhanced receptor mediated catabolism and clearance of circulating LDL. Second, pravastatin inhibits LDL production by inhibiting hepatic synthesis of VLDL, the LDL precursor.
Clinical and pathologic studies have shown that elevated levels of total cholesterol (total-C), low density lipoprotein cholesterol (LDL-C) and apolipoprotein B (a membrane transport complex for LDL) promote human atherosclerosis. Similarly decreased levels of HDL cholesterol (HDL-C) and its transport complex, apolipoprotein A, are associated with the development of atherosclerosis. Epidemiologic investigations have established that cardiovascular morbidity and mortality vary directly with the level of total-C and LDL-C and inversely with the level of HDL-C. In multicentre clinical trials those pharmacologic and/or nonpharmacologic interventions that lowered total-C and LDL-C and increased HDL-C reduced the rate of cardiovascular events (both fatal and nonfatal myocardial infarctions) and improved survival. In both normal volunteers and patients with hypercholesterolemia, treatment with pravastatin reduced total-C, LDL-C, apolipoprotein B, VLDL-C and TG while increasing HDL-C and apolipoprotein A.
The effects of HMG-CoA reductase inhibitors on Lp(a), fibrinogen, and certain other independent biochemical risk markers for coronary heart disease are unknown.
Pravastatin is a hydrophilic HMG-CoA reductase inhibitor.

Pharmacokinetics.

Pravastatin is administered orally in the active form. It is rapidly absorbed, with peak plasma levels attained 1 to 1.5 hours following ingestion. Based on urinary recovery of radiolabelled drug, the average oral absorption of pravastatin is 34% and absolute bioavailability is 17%.
Pravastatin undergoes extensive first-pass extraction in the liver (extraction ratio 0.66), which is its primary site of action, and the primary site of cholesterol synthesis and of LDL-C clearance. Since it is excreted in the bile, plasma levels are of limited value in predicting therapeutic effectiveness. Pravastatin plasma concentrations [including: area under the concentration time curve (AUC), peak (Cmax), and steady-state minimum (Cmin)] are directly proportional to administered dose. Steady-state AUCs, Cmax and Cmin plasma concentrations showed no evidence of pravastatin accumulation following once or twice daily administration of pravastatin tablets. Approximately 50% of the circulating drug is bound to plasma proteins.
The plasma elimination half-life (t1/2) of pravastatin (oral) is between 1.5 and 2 hours. Approximately 20% of a radiolabelled oral dose is excreted in urine and 70% in the faeces. After intravenous administration of radiolabelled pravastatin to normal volunteers, approximately 47% of total body clearance was via renal excretion and 53% by nonrenal routes (i.e. biliary excretion and biotransformation). Accumulation of drug and/or metabolites may occur in patients with renal or hepatic insufficiency, although, as there are dual routes of elimination, the potential exists for compensatory excretion by the alternate route. The major metabolite of pravastatin is the 3a-hydroxy isomer. This metabolite has one-tenth to one-fortieth the HMG-CoA reductase inhibitory activity of the parent compound.
After 2 weeks of once daily 20 mg oral pravastatin administration, the geometric means of AUC were 80.7 (CV 44%) and 44.8 (CV 89%) ng.hr/mL for children (8-11 years, n = 14) and adolescents (12-16 years, n = 10), respectively. The corresponding values for Cmax were 42.4 (CV 54%) and 18.6 ng/mL (CV 100%) for children and adolescents, respectively. No conclusion can be made based on these findings due to the small number of samples and large variability.

Clinical Trials

Hypercholestrolemia.

In controlled trials in patients with moderate hypercholesterolemia with or without atherosclerotic cardiovascular disease, pravastatin monotherapy reduced the progression of atherosclerosis, and cardiovascular events (e.g. fatal and nonfatal MI) or death.
Pravastatin is highly effective in reducing total-C and LDL-C in patients with heterozygous familial, familial combined, and nonfamilial (non-FH) forms of hypercholesterolemia. A therapeutic response is seen within 1 week, and the maximum response usually is achieved within 4 weeks. This response is maintained during extended periods of therapy.
A single daily dose administered in the evening is as effective as the same total daily dose given twice a day. Once daily administration in the evening appears to be marginally more effective than once daily administration in the morning, perhaps because hepatic cholesterol is synthesized mainly at night.
In multicentre, double blind, placebo controlled studies of patients with primary hypercholesterolemia, treatment with pravastatin significantly decreased total-C, LDL-C, and total-C/HDL-C and LDL-C/HDL-C ratios, decreased VLDL-C and plasma TG levels, and increased HDL-C. Whether administered once or twice daily, a clear dose response relationship (i.e. lipid lowering) was seen by 1 to 2 weeks following the initiation of treatment. (See Table 1.)
In a pooled analysis of two multicenter, double blind, placebo controlled studies in patients with primary hypercholesterolemia, treatment with pravastatin at a daily dose of 80 mg increased HDL-C and significantly decreased total-C, LDL-C, and TG from baseline after 6 weeks. The efficacy results of the individual studies were consistent with the pooled data. Mean percent changes from baseline after 6 weeks of treatment were: total-C (-27%), LDL-C (-37%), HDL-C (+3%) and TG (-19%), with placebo subtracted changes for LDL-C and TG of -36% and -20%, respectively.
Pravastatin, in combination with diet has been shown to reduce the incidence of cardiovascular events (e.g. fatal and nonfatal myocardial infarction). The mechanism responsible for the beneficial effects of pravastatin in hypercholesterolaemic patients is not known.

Atherosclerosis.

In the Pravastatin Limitation of Atherosclerosis in the Coronary Arteries (PLAC I) study, the effect of pravastatin therapy on coronary atherosclerosis was assessed by coronary angiography in patients with coronary disease and moderate hypercholesterolemia (baseline LDL-C range = 3.4-4.9 mmol/L). In this double blind, multicentre, controlled clinical trial, in which 408 patients were randomized, angiograms were evaluated at baseline and at three years in 264 patients. No statistically significant difference between pravastatin and placebo was seen for the primary endpoint (per patient change in mean coronary artery diameter), or for one of two secondary endpoints (change in percent lumen diameter stenosis). For the other secondary endpoint (change in minimum lumen diameter), statistically significant slowing of disease was seen in the pravastatin treatment group (p = 0.02). Although the trial was not designed to assess clinical coronary events, for myocardial infarction (fatal and nonfatal), the event rate was reduced in the pravastatin group by a statistically significant margin (10.5% for placebo versus 4.2% for pravastatin, p = 0.0498).
In another 3 year, double blind, placebo controlled, randomized trial in patients with mild to moderate hyperlipidaemia, the Pravastatin, Lipids, and Atherosclerosis in the Carotids (PLAC II) study, the effect of pravastatin therapy on carotid atherosclerosis was assessed by B-mode ultrasound. No statistically significant differences were seen in the carotid bifurcation, internal carotid artery, or all segments combined (the primary endpoint); pravastatin did reduce the increase in wall thickness in the common carotid artery (p = 0.02). Although the study was not designed to assess cardiovascular events or mortality, the event rates were reduced in the pravastatin treatment group by statistically significant margins for two combined endpoints: nonfatal or fatal myocardial infarction (13.3% placebo versus 2.7% for pravastatin, p = 0.018): and nonfatal myocardial infarction or all deaths (17.1% for placebo versus 6.7% for pravastatin, p = 0.049).
Analysis of pooled events from PLAC I and PLAC II showed that treatment with pravastatin was associated with a 67% reduction in the event rate of fatal and nonfatal myocardial infarction (11.4% for placebo versus 3.8% for pravastatin, p = 0.003) and 55% for the combined endpoint of nonfatal myocardial infarction or death from any cause (13.8% placebo versus 6.2% pravastatin, p = 0.009). Divergence in the cumulative event rate curves began at one year and was statistically significant at 2 years.
In consideration of the results of Pravastatin Limitation of Atherosclerosis in Coronary and Carotid Arteries Trials (PLAC I and PLAC II), it is important to be aware of the limitations of angiography in defining the extent and site of atherosclerosis plaque. Acute coronary events tend to occur not at the site of severe stenosis, but at lesser stenoses which are lipid rich and more prone to rupture. In addition, angiographic changes are not properly validated end points to measure morbidity and/or mortality in patients with atherosclerotic coronary artery disease associated with hypercholesterolemia.

Prevention of coronary heart disease.

Pravastatin is effective in reducing the risk of coronary heart disease (CHD) death (fatal MI and sudden death) plus nonfatal MI and improving survival in hypercholesterolemic male patients without previous myocardial infarction.
The West of Scotland Study (WOS) was a randomised, double blind, placebo controlled trial among 6595 male patients (45-64 years) with moderate to severe hypercholesterolemia (LDL-C = 4-6.6 mmol/L), a total fasting cholesterol > 6.5 mmol/L, and without a previous MI. Patients were treated with standard care, including dietary advice, and either pravastatin 40 mg (N = 3302) or placebo (N = 3293) each evening for a median duration of 4.8 years. The study was designed to assess the effect of pravastatin on fatal and nonfatal coronary heart disease. Significant results (p < 0.05) are given in Table 2.
The effect on the combined endpoint of coronary heart disease death or nonfatal myocardial infarction was evident as early as six months after beginning pravastatin therapy.
There was no statistically significant difference between treatment groups in noncardiovascular mortality, including cancer death. (See Table 3.)

Myocardial infarction and unstable angina pectoris.

Pravastatin is effective in reducing the risk of a fatal coronary event and nonfatal MI in patients with a previous myocardial infarction and average (normal) serum cholesterol, who are > 65 years of age and whose serum LDL-cholesterol is > 3.36 mmol/L. Pravastatin is effective in reducing the frequency of stroke in patients with a previous myocardial infarction and average (normal) serum cholesterol. Pravastatin is also effective in reducing the risk of total mortality, CHD death, and recurrent coronary events (including myocardial infarction) in patients with unstable angina pectoris.
In the Cholesterol and Recurrent Events (CARE) study the effect of pravastatin on coronary heart disease death and nonfatal MI was assessed in 4159 men and women with average (normal) serum cholesterol levels (baseline mean total-C = 209 mg/dL) (5.4 mmol/L), and who had experienced a myocardial infarction in the preceding 3-20 months. Patients in this double blind, placebo controlled study participated for an average of 4.9 years. Treatment with pravastatin significantly reduced the rate of a recurrent coronary event (either CHD death or nonfatal MI) by 24% (p = 0.003). This risk reduction was statistically significant in those patients aged 65 years of age or older and in those who demonstrated a serum LDL-cholesterol of > 3.36 mmol/L. The reduction in risk for this combined endpoint was significant for both men and women. The risk of undergoing revascularisation procedures (coronary artery bypass grafting or percutaneous transluminal coronary angioplasty) was significantly reduced by 27% (p < 0.001) in the pravastatin treated patients. Pravastatin also significantly reduced the risk for stroke by 32% (p = 0.032), and stroke or transient ischemic attack (TIA) combined by 26% (p = 0.025). At baseline, 84% of the patients were receiving aspirin and 82% were taking antihypertensive medications. The comparison of the primary, secondary and tertiary endpoints for the study are summarised in Table 4.
In the Long-Term Intervention with Pravastatin in Ischemic Disease (LIPID) study, the effect of pravastatin 40 mg daily was assessed in 9014 men and women with normal to elevated serum cholesterol levels (baseline total-C = 4.0-7.0 mmol/L; mean total-C = 5.66 mmol/L; mean total-C/HDL-C ratio = 5.9), and who had experienced either a myocardial infarction or had been hospitalised for unstable angina pectoris in the preceding 3-36 months. Patients with a wide range of baseline levels of triglycerides were included (≤ 5.0 mmol/L) and enrollment was not restricted by baseline levels of HDL cholesterol. At baseline, 82% of patients were receiving aspirin, 76% were receiving antihypertensive medication, and 41% had undergone myocardial revascularisation. Patients in this multicentre, double blind, placebo controlled study participated for a mean of 5.6 years (median = 5.9 years). Treatment with pravastatin significantly reduced the risk for CHD death by 24% (p = 0.0004). The risk for coronary events (either CHD death or nonfatal MI) was significantly reduced by 24% (p < 0.0001) in the pravastatin treated patients. The risk for fatal or nonfatal myocardial infarction was reduced by 29% (p < 0.0001). Pravastatin reduced both the risk for total mortality by 23% (p < 0.0001) and cardiovascular mortality by 25% (p < 0.0001). The risk for undergoing myocardial revascularisation procedures (coronary artery bypass grafting or percutaneous transluminal coronary angioplasty) was significantly reduced by 20% (p < 0.0001) in the pravastatin treated patients. Pravastatin also significantly reduced the risk for stroke by 19% (p = 0.0477). Treatment with pravastatin significantly reduced the number of days of hospitalisation per 100 person years of follow-up by 15% (p < 0.001). The prespecified subgroup (age, sex, hypertensives, diabetics, smokers, lipid subgroups) analyses were conducted using the combined end point of CHD and nonfatal MI. The study was not powered to examine results within each subgroup but formal testing for heterogeneity of treatment effect was undertaken across each of the subgroups and no significant heterogeneity was found (p ≥ 0.08), i.e. a consistent treatment effect was seen with pravastatin therapy across all patient subgroups and event parameters. Among patients who qualified with a history of myocardial infarction, pravastatin significantly reduced the risk for total mortality by 25% (p = 0.0016); for CHD mortality by 23% (p = 0.004); for CHD events by 22% (p = 0.002) and for fatal or nonfatal MI by 25% (p = 0.0008). Among patients who qualified with a history of hospitalisation for unstable angina pectoris, pravastatin significantly reduced the risk for total mortality by 26% (p = 0.0035; for CHD mortality by 26% (p = 0.0358); for CHD events by 29% (p = 0.0001) and for fatal or nonfatal MI by 37% (p = 0.0003). (See Table 5.)

Solid organ transplantation.

The safety and efficacy of pravastatin treatment in patients receiving immunosuppresive therapy following kidney and cardiac transplantation were assessed in two prospective randomised controlled trials. Patients were treated concurrently with either 20 mg or 40 mg pravastatin and a standard immunosuppresive regimen of cyclosporin and prednisone. Cardiac transplant patients also received azathioprine as part of their immunosuppresive regimen. Plasma lipid levels were reduced in patients who received pravastatin. In the patients who received pravastatin in these trials (n = 71) no significant increases in creatinine phosphokinase or hepatic transaminases were observed and there were no cases of myositis and rhabdomyolysis. However, there is limited data available on the incidence of these adverse events in transplant patients and physicians should consider the risk of myositis and rhabdomyolysis when prescribing pravastatin therapy for hyperlipidaemia in transplant patients.

Paediatric study.

A double blind placebo controlled study in 214 patients (100 boys and 114 girls) with heterozygous familial hypercholesterolemia (HeFH), aged 8-18 years was conducted for two years. The children (aged 8-13 years) were randomized to placebo (n = 63) or 20 mg of pravastatin daily (n = 65) and the adolescents (aged 14-18 years) were randomized to placebo (n = 45) or 40 mg of pravastatin daily (n = 41). Inclusion in the study required an LDL-C level > 95th percentile for age and sex and one parent with either a clinical or molecular diagnosis of familial hypercholesterolemia. The mean baseline LDL-C value was 239 mg/dL (6.2 mmol/L) and 237 mg/dL (6.1 mmol/L) in the pravastatin (range 151-405 mg/dL, 3.9-10.5 mmol/L) and placebo (range 154-375 mg/dL, 4.0-9.7 mmol/L) groups, respectively. The mean baseline total cholesterol and apolipoprotein B levels in pravastatin group were: 302 mg/dL (7.8 mmol/L) and 141 mg/dL (1.4 g/L), respectively; mean baseline total cholesterol and apolipoprotein B levels in the placebo group were 299 mg/dL (7.7 mmol/L) and 140 mg/dL (1.4 g/L), respectively.
The treatment criteria for heterozygous familial hypercholesterolemia in children and adolescent patients aged 8 years and older are:
LDL-C consistently greater than 95th percentile for age and gender.
An adequate trial of a lipid lowering diet.
One parent with a clinical or molecular diagnosis of familial hypercholesterolemia.
Pravastatin significantly decreased plasma levels of LDL-C, total-C, and apolipoprotein B in both children and adolescents (see Table 6). The effect of pravastatin treatment in the two age groups was similar.
The safety and efficacy of pravastatin doses above 40 mg daily have not been studied in children. The long-term efficacy of pravastatin therapy in childhood to reduce morbidity and mortality in adulthood has not been established.

Indications

1. As an adjunct to diet for the treatment of hypercholesterolemia. Prior to initiating therapy with pravastatin, secondary causes of hypercholesterolemia (e.g. poorly controlled diabetes mellitus, hypothyroidism, nephrotic syndrome, dysproteinemias, obstructive liver disease, other drug therapy, alcoholism) should be identified and treated.
2. Cholvastin is indicated in patients with previous myocardial infarction including those who have normal (4.0-5.5 mmol/L) serum cholesterol levels.
3. Cholvastin is indicated in patients with unstable angina pectoris (see Clinical Trials).
4. Cholvastin is indicated as an adjunct to diet and lifestyle modification for the treatment of heterozygous familial hypercholesterolemia in children and adolescent patients aged 8 years and older (see Clinical Trials).

Contraindications

Hypersensitivity to any component of this medication.
Active liver disease or unexplained persistent elevations in liver function tests.

Use in pregnancy.

(Category D)
Atherosclerosis is a chronic process and discontinuation of lipid lowering drugs during pregnancy should have little impact on the outcome of long-term therapy of primary hypercholesterolemia. Cholesterol and other products of cholesterol biosynthesis are essential components for foetal development (including synthesis of steroids and cell membranes). Since HMG-CoA reductase inhibitors decrease cholesterol synthesis and possibly the synthesis of other biologically active substances derived from cholesterol, they may cause foetal harm when administered to a pregnant woman. Therefore, HMG-CoA reductase inhibitors are contraindicated during pregnancy.
Safety in pregnant women has not been established. Although pravastatin was not teratogenic in rats at doses as high as 1,000 mg/kg daily nor in rabbits at doses of up to 50 mg/kg daily, pravastatin should be administered to women of childbearing potential only when such patients are highly unlikely to conceive and have been informed of the potential hazards. If the woman becomes pregnant while taking pravastatin, it should be discontinued and the patient advised again as to the potential hazards to the foetus.

Women of childbearing potential.

Pravastatin should not be administered to women of childbearing age unless on an effective contraception and are highly unlikely to conceive and have been informed of the potential hazards. If the patient becomes pregnant while taking this class of drug, therapy should be discontinued and the patient again advised of the potential hazard to the foetus.
Concomitant use of fusidic acid (see Precautions and Interactions with Other Medicines).

Precautions

General.

Pravastatin may elevate creatine phosphokinase and transminase levels (see Adverse Effects). This should be considered in the differential diagnosis of chest pain in a patient on therapy with pravastatin.

Homozygous familial hypercholesterolemia.

Pravastatin has not been evaluated in patients with rare homozygous familial hypercholesterolemia. In this group of patients, it has been reported that HMG-CoA reductase inhibitors are less effective because the patients lack functional LDL receptors.

Hypertriglyceridemia.

Pravastatin has only a moderate triglyceride lowering effect and it is not indicated where hypertriglyceridemia is the abnormality of most concern (i.e. hypertriglyceridemia types I, IV and V).

Thyroid function.

Serum thyroxine was studied in 661 patients who were administered pravastatin in five controlled clinical trials. From observations of up to two years in duration, no clear association was found between pravastatin use and changes in thyroxine levels.

Renal insufficiency.

A single 20 mg oral dose of pravastatin was administered to 24 patients with varying degrees of renal impairment (as determined by creatinine clearance). No effect was observed on the pharmacokinetics of pravastatin or its 3x-hydroxy isomeric metabolite (SQ 31,908). A small increase was seen in mean AUC values and half-life (1.5) for the inactive enzymatic ring hydroxylation metabolite (SQ 31,945). Given this small sample size, the dosage administered, and the degree of individual variability, patients with renal impairment who are receiving pravastatin should be closely monitored.

Hepatic.

HMG-CoA reductase inhibitors have been associated with biochemical abnormalities of liver function. As with other lipid lowering agents, marked persistent increases (greater than three times the upper limit of normal) in serum transaminases were seen in 1.3% of patients treated with pravastatin in the US for an average period of 18 months. In clinical trials these elevations were usually not associated with clinical signs and symptoms of liver disease and usually declined to pretreatment levels upon discontinuation of therapy. Only two patients had marked persistent abnormalities possibly attributable to therapy.
The significance of these changes, which usually appear during the first few months of treatment initiation, is not known. In the majority of patients treated with pravastatin in clinical trials, these increased values declined to pretreatment levels despite continuation of therapy at the same dose. These biochemical findings are usually asymptomatic although worldwide experience indicates that anorexia, weakness, and/or abdominal pain may also be present in rare patients.
As with other lipid lowering agents, liver function tests should be performed periodically. Special attention should be given to patients who develop increased transaminase levels and those on higher doses of pravastatin. Liver function tests should be repeated to confirm an elevation and subsequently monitored at more frequent intervals. If increases in alanine aminotransferase (ALT) and aspartate aminotransferase (AST) equal or exceed three times the upper limit of normal and persist, therapy should be discontinued.
Caution should be exercised when pravastatin is administered to patients with a history of liver disease or heavy alcohol ingestion. Such patients should be closely monitored, started at the lower end of the recommended dosing range, and titrated to the desired therapeutic effect.

Skeletal muscle.

Myalgia, myopathy, and rhabdomyolysis have been reported with the use of HMG-CoA reductase inhibitors. Uncomplicated myalgia has been reported in pravastatin treated patients. Myopathy, defined as muscle aching or muscle weakness in conjunction with increases in creatine phosphokinase (CPK) values to greater than 10 times the upper limit of normal, was reported to be possibly due to pravastatin in < 0.1% of patients in clinical trials. Rhabdomyolysis with renal dysfunction secondary to myoglobinuria has also very rarely been reported with pravastatin. However, myopathy should be considered in any patients with diffuse myalgia, muscle tenderness or weakness, and/or marked elevation of CPK. Patients should be advised to report promptly unexplained muscle pain, tenderness or weakness. Pravastatin therapy should be discontinued if markedly elevated CPK levels occur or myopathy is suspected or diagnosed (pravastatin therapy should also be temporarily withheld in any patient experiencing an acute or serious condition predisposing to the development of renal failure secondary to rhabdomyolysis, e.g. sepsis, hypotension, major surgery, trauma, severe metabolic, endocrine, or electrolyte disorders, or uncontrolled epilepsy). CPK levels should be checked at 6 to 12 month intervals in paediatric patients.
The risk of myopathy during treatment with another HMG-CoA reductase inhibitor is increased with concurrent therapy with either fibrates, cyclosporin, erythromycin or niacin. The use of fibrates alone is occasionally associated with myopathy. In a limited size clinical trial of combined therapy with pravastatin (40 mg/day) and gemfibrozil (1200 mg/day) myopathy was not reported, although a trend towards CPK elevations and musculoskeletal symptoms was seen. The combined use of pravastatin and fibrates should generally be avoided.
Myopathy has not been observed in 3 post transplant clinical trials which had involved a total of 100 patients (76 cardiac and 24 renal). Some patients have been treated for up to 2 years with pravastatin (10-40 mg) and cyclosporin and either with or without other immunosuppressants. In a separate lipid lowering trial involving 158 patients, no myopathy has been reported with pravastatin in combination with niacin.
Pravastatin must not be coadministered with fusidic acid. There have been reports of rhabdomyolysis (including some fatalities) in patients receiving this combination. In patients where the use of systemic fusidic acid is considered essential, statin treatment should be discontinued throughout the duration of fusidic acid treatment. The patient should be advised to seek medical advice immediately if they experience any symptoms of muscle weakness, pain or tenderness. Pravastatin therapy may be reintroduced seven days after the last dose of fusidic acid.

Endocrine function.

HMG-CoA reductase inhibitors interfere with cholesterol synthesis and lower circulating cholesterol levels, and, as such, might theoretically blunt adrenal or gonadal steroid hormone production. Results of clinical trials with pravastatin in males and postmenopausal females were inconsistent with regard to possible effects of the drug on basal steroid hormone levels. In a study of 21 males, the mean testosterone response to human chorionic gonadotropin was significantly reduced (p < 0.004) after 16 weeks of treatment with 40 mg of pravastatin. However, the percentage of patients showing a ≥ 50% rise in plasma testosterone after human chorionic gonadotropin stimulation did not change significantly after therapy in these patients. The effects of HMG-CoA reductase inhibitors on spermatogenesis and fertility have not been studied in adequate numbers of patients. The effects, if any, of pravastatin on the pituitary gonadal axis in premenopausal females are unknown. Patients treated with pravastatin who display clinical evidence of endocrine dysfunction should be evaluated appropriately. Caution should also be exercised if an HMG-CoA reductase inhibitor or other agent used to lower cholesterol levels is administered to patients also receiving other drugs (e.g. ketoconazole, spironolactone, cimetidine) that may diminish the levels of activity of steroid hormones.
In a placebo controlled study of 214 paediatric patients with HeFH, of which 106 were treated with pravastatin (20 mg in the children aged 8-13 years and 40 mg in the adolescents aged 14-18 years) for two years, there were no detectable differences seen in any of the endocrine parameters [ACTH, cortisol, DHEAS, FSH, LH, TSH, estradiol (girls) or testosterone (boys)] relative to placebo. There were no detectable differences seen in height and weight changes, testicular volume changes, or Tanner scores relative to placebo.

CNS toxicity.

CNS vascular lesions, characterized by perivascular haemorrhage and edema and mononuclear cell infiltration of perivascular spaces, were seen in dogs treated with pravastatin at a dose of 25 mg/kg/day a dose that produced a plasma drug level about 50 times higher than the mean drug level in humans taking 40 mg/day. Similar CNS vascular lesions have been observed with several other drugs in this class.
A chemically similar drug in this class produced optic nerve degeneration (Wallerian degeneration of retinogeniculate fibres) in clinically normal dogs in a dose dependent fashion starting at 60 mg/kg/day, a dose that produced mean plasma drug levels about 30 times higher than the mean drug level in humans taking the highest recommended dose (as measured by total enzyme inhibitory activity). This same drug also produced vestibulocochlear Wallerian like degeneration and retinal ganglion cell chromatolysis in dogs treated for 14 weeks at 180 mg/kg/day, a dose which resulted in a mean plasma drug level similar to that seen with the 60 mg/kg dose.

Hypersensitivity.

With lovastatin an apparent hypersensitivity syndrome has been reported rarely which has included one or more of the following features: anaphylaxis, angioedema, lupus-like syndrome, polymyalgia rheumatica, thrombocytopenia, leukopenia, haemolytic anaemia, positive antinuclear antibody (ANA), erythrocytes sedimentation rate (ESR) increase, arthritis, arthralgia, urticaria, asthenia, photosensitivity, fever and malaise. Although to date hypersensitivity syndrome has not been described as such, in few instances eosinophilia and skin eruptions appear to be associated with pravastatin treatment. If hypersensitivity is suspected pravastatin should be discontinued. Patients should be advised to report promptly any signs of hypersensitivity such as angiodema, urticaria, photosensitivity, polyarthralgia, fever, malaise.

Carcinogenesis, mutagenesis, impairment of fertility.

In a 2 year oral study of rats, a statistically significant increase in the incidence of hepatocellular carcinomas was observed in male rats given 100 mg/kg daily of pravastatin. This change was not seen in male rats given 40 mg/kg or less, or in female rats at doses up to 100 mg/kg daily. Increased incidences of hepatocellular carcinomas were also observed in male and female mice dosed with pravastatin at 250 and 500 mg/kg daily, but not at 100 mg/kg/day or less. An increased incidence of pulmonary adenomas was seen in female mice dosed at 250 mg/kg/day. The AUC value for the serum concentration of pravastatin at the no effect dose level of 100 mg/kg/day in mice was 2 times higher than that in humans receiving 80 mg pravastatin per day.
The hepatocarcinogenic effect of pravastatin in rats is associated with proliferation of hepatic peroxisomes. Other HMG-CoA reductase inhibitors (simvastatin and lovastatin) also induce hepatic peroxisome proliferation and hepatocellular carcinomas in rats and mice. The clinical significance of these findings is unclear.
In six genetic toxicology studies performed with pravastatin, there was no evidence of mutagenic potential at the chromosomal or gene level.
In a study in rats, with a daily dose up to 500 mg/kg pravastatin did not produce any adverse effects on fertility or general reproductive performance.
The clinical significance of these findings is not clear.

Use in pregnancy.

(Category D)
Category D (see Contraindications).
HMG-CoA reductase inhibitors are contraindicated in pregnancy. The risk of foetal injury outweighs the benefits of HMG-CoA reductase inhibitor therapy during pregnancy.
In two series of 178 and 143 cases where pregnant women took a HMG-CoA reductase inhibitor (statin) during the first trimester of pregnancy, serious foetal abnormalities occurred in several cases. These included limb and neurological defects, spontaneous abortions and foetal deaths. The exact risk of injury to the foetus occurring after a pregnant woman is exposed to a HMG-CoA reductase inhibitor has not been determined. The current data do not indicate that the risk of foetal injury in women exposed to HMG-CoA reductase inhibitor is high. If a pregnant woman is exposed to a HMG-CoA reductase inhibitor she should be informed of the possibility of foetal injury and discuss the implications with her pregnancy specialist.
See Contraindications.

Use in lactation.

A negligible amount of pravastatin is excreted in human breast milk. Because of the potential for adverse reactions in nursing infants, if the mother is being treated with pravastatin, nursing should be discontinued.

Paediatric use.

Safety and effectiveness of pravastatin in children and adolescents with heterozygous familial hypercholesterolemia from 8-18 years of age have been evaluated in a placebo controlled study of 2 years duration. Patients treated with pravastatin had an adverse experience profile generally similar to that observed in adults with influenza and headache commonly reported in both treatment groups. (See Adverse Effects, Paediatric use.) Doses greater than 40 mg have not been studied in this population. For dosing information see Dosage and Administration, Adult patients and Paediatric patients.
Double blind, placebo controlled pravastatin studies in children less than 8 years of age have not been conducted.

Use in the elderly.

Pharmacokinetic evaluation of pravastatin in patients over the age of 65 years indicates an increased AUC. There were no reported increases in the incidence of adverse effects in these or other studies involving patients in that age group. As a precautionary measure, the lowest dose should be administered initially.

Interstitial lung disease.

Exceptional cases of interstitial lung disease have been reported with some statins, especially with long-term therapy. Presenting features can include dyspnoea, nonproductive cough and deterioration in general health (fatigue, weight loss and fever). If it is suspected a patient has developed interstitial lung disease, statin therapy should be discontinued.

Effect on laboratory tests.

Increases in serum transaminase (ALT, AST) values and CPK have been observed. Transient, asymptomatic eosinophilia has been reported. Eosinophil counts usually returned to normal despite continued therapy. Anaemia, thrombocytopenia, and leukopenia have been reported with HMG-CoA reductase inhibitors.

Interactions

Gemfibrozil.

In a crossover study in 20 healthy male volunteers given concomitant single doses of pravastatin and gemfibrozil, there was a significant decrease in urinary excretion and protein binding of pravastatin. In addition, there was a significant increase in AUC, Cmax, and Tmax for the pravastatin metabolite SQ 31,906. Combination therapy with pravastatin and gemfibrozil is generally not recommended.

Cholestyramine/ colestipol.

When pravastatin was administered one hour before or four hours after cholestyramine or one hour before colestipol and a standard meal, there was no clinically significant decrease in bioavailability or therapeutic effect. Concomitant administration resulted in an approximately 40-50% decrease in the mean AUC of pravastatin (see Dosage and Administration).

Cyclosporin.

In a single dose study, pravastatin levels were found to be increased in cardiac patients receiving cyclosporin. In a second multidose study, in renal transplant patents receiving cyclosporin, pravastatin levels were higher than those seen in healthy volunteer studies. This does not appear to be a metabolic interaction involving P450 3A4.

Warfarin.

With concomitant administration, pravastatin did not alter the plasma protein binding of warfarin. Chronic dosing of the two drugs did not produce any changes in the anticoagulant status.

Antipyrine.

Clearance by the cytochrome P450 system was unaltered by concomitant administration of pravastatin. Since pravastatin does not appear to induce hepatic drug metabolizing enzymes, it is not expected that any significant interaction of pravastatin with other drugs (e.g. phenytoin, quinidine) metabolized by the cytochrome P450 system will occur.

Fusidic acid.

The risk of myopathy including rhabdomyolysis may be increased by the concomitant administration of systemic fusidic acid with statins. Coadministration of this combination may cause increased plasma concentrations of both agents. The mechanism of this interaction (whether it is pharmacodynamics or pharmacokinetic, or both) is yet unknown.
Although interaction studies with statins and fusidic acid have not been conducted, there have been reports of rhabdomyolysis (including some fatalities) in patients receiving this combination. If treatment with fusidic acid is necessary, statin treatment should be discontinued throughout the duration of the fusidic acid treatment (see Contraindications).

Other drugs.

Unlike simvastatin and atorvastatin, pravastatin is not significantly metabolised in vivo by cytochrome P450 3A4. Therefore, plasma concentrations of pravastatin are not significantly elevated when cytochrome P450 3A4 is inhibited by agents such as diltiazem and itraconazole.
In interaction studies with aspirin, gemfibrozil, nicotinic acid or probucol, no statistically significant differences in bioavailability were seen when pravastatin was administered. In other interaction studies antacids (one hour prior to pravastatin) reduce and cimetidine increase the bioavailability of pravastatin; these changes were not statistically significant.
During clinical trials, no noticeable drug interactions were reported when pravastatin was added to: diuretics, antihypertensives, digitalis, angiotensin converting enzyme inhibitors, calcium channel blocker, beta-blockers, or nitroglycerins.

Adverse Effects

Pravastatin is generally well tolerated. Adverse events, both clinical and laboratory, are usually mild and transient. In all clinical studies (controlled and uncontrolled), approximately 2% of patients were discontinued from treatment due to adverse experiences attributable to pravastatin.
The safety and tolerability of pravastatin at a dose of 80 mg in two controlled trials, with a mean exposure of 8.6 months were similar to that of pravastatin at lower doses. However, musculoskeletal adverse events, gastrointestinal adverse events and CK elevations are slightly more common with an 80 mg dose.
In seven randomized double blind placebo controlled trials involving over 21,500 patients treated with pravastatin 40 mg (N = 10,784) or placebo (N = 10,719), the safety and tolerability in the pravastatin group was comparable to that of the placebo group. Over 19,000 patients were followed for a median of 4.8-5.9 years, while the remaining patients were followed for two years or more.
Clinical adverse events probably or possibly related, or of uncertain relationship to therapy, occurring in at least 0.5% of patients treated with pravastatin or placebo in these long-term morbidity/ mortality trials are shown in Table 7.

Lens.

In 820 patients treated with pravastatin for periods up to a year or more, there was no evidence that pravastatin was associated with cataract formation. In placebo controlled studies, 294 patients (92 on placebo/ control, 202 on pravastatin) were evaluated using the Lens Opacity Classification System (a sophisticated method of lens assessment) at six months and one year following the initiation of treatment. When compared with the baseline evaluation, the final examination revealed the following. (See Table 8.)
There was no statistically significant difference in the change in lens opacity between the control and pravastatin treatment groups during this time interval.
Comparative data indicate that pravastatin is 100-fold less potent than both lovastatin and simvastatin (other HMG-CoA reductase inhibitors) in inhibiting cholesterol biosynthesis in rat lens and 40-fold less potent than lovastatin in inhibiting cholesterol biosynthesis in rabbit lens. Furthermore, unlike lovastatin and simvastatin, cataracts have not been observed in animal studies (beagle dogs) when chronic oral doses of pravastatin were administered for two years.
In three large placebo controlled trials West of Scotland Study [WOS], Cholesterol and Recurrent Events Study [CARE], Long-Term Intervention with Pravastatin in Ischaemic Disease [LIPID] (see Clinical Trials) involving a total of 19,786 patients treated with pravastatin (N = 9895) or placebo (N = 9873), the safety and tolerability profile in the pravastatin group was comparable to that of the placebo group over the median 4.8-5.9 years of follow up.
The following effects have been reported with drugs in this class; not all the effects listed below have necessarily been associated with pravastatin therapy.

Skeletal.

Myopathy, rhabdomyolysis, arthralgia.

Rhabdomyolysis.

(Examples of signs and symptoms are muscle weakness, muscle swelling, muscle pain, dark urine, myoglobinuria, elevated serum creatine kinase, acute renal failure, cardiac arrhythmia.) Rhabdomyolysis may be fatal (see Contraindications, Precautions and Interactions with Other Medicines).

Neurological.

Dysfunction of certain cranial nerves (including alteration of taste, impairment of extraocular movement, facial paresis), tremor, vertigo, memory loss, paraesthesia, peripheral neuropathy, peripheral nerve palsy, anxiety, insomnia, depression.

Hypersensitivity reactions.

An apparent hypersensitivity syndrome has been reported rarely which has included one or more of the following features: anaphylaxis, angioedema, lupus erythematous-like syndrome, polymyalgia rheumatica, dermatomyositis, vasculitis, purpura, thrombocytopenia, leukopenia, haemolytic anaemia, positive antinuclear antibody, ESR increase, eosinophilia, arthritis, arthralgia, urticaria, asthenia, photosensitivity, fever, chills, flushing, malaise, dyspnea, toxic epidermal necrolysis, erythema multiforme, including Stevens-Johnson syndrome.

Gastrointestinal.

Pancreatitis, hepatitis, including chronic active hepatitis, cholestatic jaundice, fatty change in liver, and, rarely, cirrhosis, fulminant hepatic necrosis, and hepatoma; anorexia, vomiting.

Skin.

Alopecia, pruritus. A variety of skin changes (e.g. nodules, discolouration, dryness of skin/ mucous membranes, changes to hair/ nails) have been reported.

Reproductive.

Gynecomastia, loss of libido, erectile dysfunction.

Eye.

Progression of cataracts (lens opacities), ophthalmoplegia.

Laboratory abnormalities.

Elevated transaminases, alkaline phosphatase, and bilirubin; thyroid function abnormalities (see Precautions).

Sleep disturbances including insomnia and nightmares.


Depression.


Sexual dysfunction.


Exceptional cases of interstitial lung disease, especially with long term therapy.


Paediatric use.

In a two year double blind placebo controlled study involving 100 boys and 114 girls with HeFH, there were no serious adverse events or discontinuations for adverse events attributable to pravastatin. Pravastatin was generally well tolerated in paediatric patients and the adverse reaction profile was similar to that observed in adults. The incidence of headache was 23.6% vs. 15.7%; musculoskeletal pain, 16.0% vs. 7.4%; CPK elevations greater than four times the pretreatment level 3.8% vs. 2.8%, and dizziness 5.7% vs. 0%, in pravastatin treated patients vs. placebo treated patients, respectively (see Clinical Trials, Paediatric study and Precautions, Paediatric use).

Dosage and Administration

Prior to initiating Cholvastin (pravastatin sodium), the patient should be placed on a standard cholesterol lowering diet (AHA Phase 1 or NCEP Step 1) for a maximum of 3 to 6 months, depending upon the severity of the lipid elevation. Dietary therapy should be continued during treatment.

Adult patients.

The recommended starting dose is 10 to 20 mg once daily at bedtime. In primary hypercholesterolemic patients with significant renal or hepatic dysfunction, and in the elderly, a starting dose of 10 mg daily at bedtime is recommended. For maximum effect Cholvastin should be taken at bedtime on an empty stomach.
Since the maximal effect of a given dose is seen within four weeks, periodic lipid determinations should be performed at this time and dosage adjusted according to the patient's response to therapy and established treatment guidelines. The recommended dosage range is 10 to 80 mg administered once a day at bedtime.
Cholvastin may be given in divided doses.
For the prevention of coronary heart disease in patients with hypercholesterolemia the dose is 40 mg per day as a single dose. The same dose is recommended for secondary prevention of MI in patients with average (normal) serum cholesterol.

Paediatric patients.

Children (ages 8 to 13 years, inclusive).

The recommended dose is 20 mg once daily in children 8-13 years of age. Doses greater than 20 mg have not been studied in this patient population.

Adolescents (ages 14 to 18 years).

The recommended dose is 40 mg once daily in adolescents 14 to 18 years of age. Doses greater than 40 mg have not been studied in this patient population.
Children and adolescents treated with pravastatin should be re-evaluated in adulthood and appropriate changes made to their cholesterol lowering regimen to achieve adult goals for LDL-C.

Cyclosporin.

In patients taking cyclosporin, with or without other immunosuppressive drugs, concomitantly with pravastatin, therapy should be initiated with 10 mg per day and titration to higher doses should be performed with caution.

Concomitant therapy.

Pravastatin has been administered concurrently with cholestyramine, colestipol, nicotinic acid, probucol and gemfibrozil. Preliminary data suggest that the addition of either probucol or gemfibrozil to therapy with lovastatin or pravastatin is not associated with greater reduction in LDL cholesterol than that achieved with lovastatin or pravastatin alone. No adverse reactions unique to the combination or in addition to those previously reported for each drug alone have been reported. Myopathy and rhabdomyolysis (with or without acute renal failure) have been reported when another HMG-CoA reductase inhibitor was used in combination with immunosuppressive drugs, gemfibrozil, erythromycin, or lipid lowering doses of nicotinic acid. Concomitant therapy with HMG-CoA reductase inhibitors and these agents is generally not recommended (see Precautions, Skeletal muscle and Interactions with Other Medicines).
The efficacy and safety of pravastatin 80 mg in combination with other lipid lowering agents have not been investigated.

Overdosage

There has been limited experience with overdosage of pravastatin. To date, there are two reported cases, both of which were asymptomatic and not associated with clinical laboratory test abnormalities. Of these two cases, one occurred in a clinical trial patient who ingested 3 g pravastatin; the other ingested 280 mg pravastatin, as marketed tablets. Both cases also involved overdose of concomitant medications. Should overdose occur, treat symptomatically and institute supportive measures as required.
Contact the Poisons Information Centre on 131 126 for advice on management.

Presentation

Tablets (dark yellow to yellow mottled, circular, biconvex, uncoated, scored on reverse), 20 mg (marked P2 on one side); 40 mg (marked P3 on one side): 30's (blister pack).

Storage

Store below 25°C. Protect from light and moisture.

Poison Schedule

S4.