ADVERSE REACTIONS SECTION.


6 ADVERSE REACTIONS. The following serious adverse reactions are discussed in greater detail in other sections of the label: Myopathy and Rhabdomyolysis [see Warnings and Precautions (5.1)] Liver Enzyme Abnormalities [see Warnings and Precautions (5.3) . Most common adverse reactions (incidence >= 2%) in patients treated with atorvastatin calcium tablets in placebo-controlled trials regardless of causality were: nasopharyngitis, arthralgia, diarrhea, pain in extremity, and urinary tract infection (6.1). To report SUSPECTED ADVERSE REACTIONS, contact Mylan at 1-877-446-3679 (1-877-4-INFO-RX) or FDA at 1-800-FDA-1088 or www.fda.gov/medwatch.. 6.1 Clinical Trials Experience. Because clinical trials are conducted under widely varying conditions, the adverse reaction rates observed in the clinical trials of drug cannot be directly compared to rates in the clinical trials of another drug and may not reflect the rates observed in practice. In the atorvastatin calcium tablets placebo-controlled clinical trial database of 16,066 patients (8,755 atorvastatin calcium tablets vs. 7,311 placebo; age range 10-93 years, 39% women, 91% Caucasians, 3% Blacks, 2% Asians, 4% other) with median treatment duration of 53 weeks, 9.7% of patients on atorvastatin calcium tablets and 9.5% of the patients on placebo discontinued due to adverse reactions regardless of causality. The five most common adverse reactions in patients treated with atorvastatin calcium tablets that led to treatment discontinuation and occurred at rate greater than placebo were: myalgia (0.7%), diarrhea (0.5%), nausea (0.4%), alanine aminotransferase increase (0.4%), and hepatic enzyme increase (0.4%). The most commonly reported adverse reactions (incidence >= 2% and greater than placebo) regardless of causality, in patients treated with atorvastatin calcium tablets in placebo-controlled trials (n 8,755) were: nasopharyngitis (8.3%), arthralgia (6.9%), diarrhea (6.8%), pain in extremity (6.0%), and urinary tract infection (5.7%). Table summarizes the frequency of clinical adverse reactions, regardless of causality, reported in >= 2% and at rate greater than placebo in patients treated with atorvastatin calcium tablets (n 8,755), from seventeen placebo-controlled trials.Table 2: Clinical Adverse Reactions Occurring in >= 2% in Patients Treated with Any Dose of Atorvastatin Calcium Tablets and at an Incidence Greater Than Placebo Regardless of Causality (% of Patients).Adverse ReactionAdverse Reaction >= 2% in any dose greater than placeboAny DoseN 8,75510 mgN 3,90820 mgN 18840 mgN 60480 mgN 4,055PlaceboN 7,311Nasopharyngitis8.312.95.37.04.28.2Arthralgia6.98.911.710.64.36.5Diarrhea6.87.36.414.15.26.3Pain in extremity6.08.53.79.33.15.9Urinary tract infection5.76.96.48.04.15.6Dyspepsia4.75.93.26.03.34.3Nausea4.03.73.77.13.83.5Musculoskeletal pain3.85.23.25.12.33.6Muscle spasms3.64.64.85.12.43.0Myalgia3.53.65.98.42.73.1Insomnia3.02.81.15.32.82.9Pharyngolaryngeal pain 2.33.91.62.80.72.1Other adverse reactions reported in placebo-controlled studies include: Body as Whole: malaise, pyrexia; Digestive System: abdominal discomfort, eructation, flatulence, hepatitis, cholestasis;Musculoskeletal System: musculoskeletal pain, muscle fatigue, neck pain, joint swelling;Metabolic and Nutritional System: transaminases increase, liver function test abnormal, blood alkaline phosphatase increase, creatine phosphokinase increase, hyperglycemia; Nervous System: nightmare; Respiratory System: epistaxis; Skin and Appendages: urticaria; Special Senses: vision blurred, tinnitus; Urogenital System: white blood cells urine positive. Anglo-Scandinavian Cardiac Outcomes Trial (ASCOT). In ASCOT [see Clinical Studies (14.1)] involving 10,305 participants (age range 40-80 years, 19% women; 94.6% Caucasians, 2.6% Africans, 1.5% South Asians, 1.3% mixed/other) treated with atorvastatin calcium tablets 10 mg daily (n 5,168) or placebo (n 5,137), the safety and tolerability profile of the group treated with atorvastatin calcium tablets was comparable to that of the group treated with placebo during median of 3.3 years of follow-up. Collaborative Atorvastatin Diabetes Study (CARDS). In CARDS [see Clinical Studies (14.1)] involving 2,838 subjects (age range 39-77 years, 32% women; 94.3% Caucasians, 2.4% South Asians, 2.3% Afro-Caribbean, 1.0% other) with type diabetes treated with atorvastatin calcium tablets 10 mg daily (n 1,428) or placebo (n 1,410), there was no difference in the overall frequency of adverse reactions or serious adverse reactions between the treatment groups during median follow-up of 3.9 years. No cases of rhabdomyolysis were reported. Treating to New Targets Study (TNT). In TNT [see Clinical Studies (14.1)] involving 10,001 subjects (age range 29-78 years, 19% women; 94.1% Caucasians, 2.9% Blacks, 1.0% Asians, 2.0% other) with clinically evident CHD treated with atorvastatin calcium tablets 10 mg daily (n 5,006) or atorvastatin calcium tablets 80 mg daily (n 4,995), there were more serious adverse reactions and discontinuations due to adverse reactions in the high-dose atorvastatin group (92, 1.8%; 497, 9.9%, respectively) as compared to the low-dose group (69, 1.4%; 404, 8.1%, respectively) during median follow-up of 4.9 years. Persistent transaminase elevations (>= x ULN twice within 4-10 days) occurred in 62 (1.3%) individuals with atorvastatin 80 mg and in nine (0.2%) individuals with atorvastatin 10 mg. Elevations of CK (>= 10 ULN) were low overall, but were higher in the high-dose atorvastatin treatment group (13, 0.3%) compared to the low-dose atorvastatin group (6, 0.1%). Incremental Decrease in Endpoints through Aggressive Lipid Lowering Study (IDEAL). In IDEAL [see Clinical Studies (14.1)] involving 8,888 subjects (age range 26-80 years, 19% women; 99.3% Caucasians, 0.4% Asians, 0.3% Blacks, 0.04% other) treated with atorvastatin calcium tablets 80 mg/day (n 4,439) or simvastatin 20-40 mg daily (n 4,449), there was no difference in the overall frequency of adverse reactions or serious adverse reactions between the treatment groups during median follow-up of 4.8 years. Stroke Prevention by Aggressive Reduction in Cholesterol Levels (SPARCL). In SPARCL involving 4,731 subjects (age range 21-92 years, 40% women; 93.3% Caucasians, 3.0% Blacks, 0.6% Asians, 3.1% other) without clinically evident CHD but with stroke or transient ischemic attack (TIA) within the previous months treated with atorvastatin calcium tablets 80 mg (n 2,365) or placebo (n 2,366) for median follow-up of 4.9 years, there was higher incidence of persistent hepatic transaminase elevations (>= x ULN twice within 4-10 days) in the atorvastatin group (0.9%) compared to placebo (0.1%). Elevations of CK (> 10 ULN) were rare, but were higher in the atorvastatin group (0.1%) compared to placebo (0.0%). Diabetes was reported as an adverse reaction in 144 subjects (6.1%) in the atorvastatin group and 89 subjects (3.8%) in the placebo group [see Warnings and Precautions (5.6) ]. In post-hoc analysis, atorvastatin calcium tablets 80 mg reduced the incidence of ischemic stroke (218/2,365, 9.2% vs. 274/2,366, 11.6%) and increased the incidence of hemorrhagic stroke (55/2,365, 2.3% vs. 33/2,366, 1.4%) compared to placebo. The incidence of fatal hemorrhagic stroke was similar between groups (17 atorvastatin calcium tablets vs. 18 placebo). The incidence of non-fatal hemorrhagic strokes was significantly greater in the atorvastatin group (38 non-fatal hemorrhagic strokes) as compared to the placebo group (16 non-fatal hemorrhagic strokes). Subjects who entered the study with hemorrhagic stroke appeared to be at increased risk for hemorrhagic stroke [7 (16%) atorvastatin calcium tablets vs. (4%) placebo]. There were no significant differences between the treatment groups for all-cause mortality: 216 (9.1%) in the atorvastatin calcium tablets 80 mg/day group vs. 211 (8.9%) in the placebo group. The proportions of subjects who experienced cardiovascular death were numerically smaller in the atorvastatin calcium tablets 80 mg group (3.3%) than in the placebo group (4.1%). The proportions of subjects who experienced non-cardiovascular death were numerically larger in the atorvastatin calcium tablets 80 mg group (5.0%) than in the placebo group (4.0%). Adverse Reactions from Clinical Studies of Atorvastatin Calcium Tablets in Pediatric Patients. In 26-week controlled study in boys and postmenarchal girls with HeFH (ages 10 years to 17 years) (n 140, 31% female; 92% Caucasians, 1.6% Blacks, 1.6% Asians, 4.8% other), the safety and tolerability profile of atorvastatin calcium tablets 10 to 20 mg daily, as an adjunct to diet to reduce total cholesterol, LDL-C, and apo levels, was generally similar to that of placebo [see Use in Specific Populations (8.4) and Clinical Studies (14.6)].. 6.2 Postmarketing Experience. The following adverse reactions have been identified during post-approval use of atorvastatin calcium tablets. Because these reactions are reported voluntarily from population of uncertain size, it is not always possible to reliably estimate their frequency or establish causal relationship to drug exposure. Adverse reactions associated with atorvastatin calcium tablet therapy reported since market introduction, that are not listed above, regardless of causality assessment, include the following: anaphylaxis, angioneurotic edema, bullous rashes (including erythema multiforme, Stevens-Johnson syndrome, and toxic epidermal necrolysis), rhabdomyolysis, myositis, fatigue, tendon rupture, fatal and non-fatal hepatic failure, dizziness, depression, peripheral neuropathy, pancreatitis and interstitial lung disease. There have been rare reports of immune-mediated necrotizing myopathy associated with statin use [see Warnings and Precautions (5.2) ].There have been rare postmarketing reports of cognitive impairment (e.g., memory loss, forgetfulness, amnesia, memory impairment, confusion) associated with statin use. These cognitive issues have been reported for all statins. The reports are generally nonserious, and reversible upon statin discontinuation, with variable times to symptom onset (1 day to years) and symptom resolution (median of weeks).

CARCINOGENESIS & MUTAGENESIS & IMPAIRMENT OF FERTILITY SECTION.


13.1 Carcinogenesis, Mutagenesis, Impairment of Fertility. In 2-year carcinogenicity study in rats at dose levels of 10, 30, and 100 mg/kg/day, rare tumors were found in muscle in high-dose females: in one, there was rhabdomyosarcoma and, in another, there was fibrosarcoma. This dose represents plasma AUC (0-24) value of approximately 16 times the mean human plasma drug exposure after an 80 mg oral dose. 2-year carcinogenicity study in mice given 100, 200, or 400 mg/kg/day resulted in significant increase in liver adenomas in high-dose males and liver carcinomas in high-dose females. These findings occurred at plasma AUC (0-24) values of approximately times the mean human plasma drug exposure after an 80 mg oral dose. In vitro, atorvastatin was not mutagenic or clastogenic in the following tests with and without metabolic activation: the Ames test with Salmonella typhimurium and Escherichia coli, the HGPRT forward mutation assay in Chinese hamster lung cells, and the chromosomal aberration assay in Chinese hamster lung cells. Atorvastatin was negative in the in vivo mouse micronucleus test. In female rats, atorvastatin at doses up to 225 mg/kg (56 times the human exposure) did not cause adverse effects on fertility. Studies in male rats performed at doses up to 175 mg/kg (15 times the human exposure) produced no changes in fertility. There was aplasia and aspermia in the epididymis of of 10 rats treated with 100 mg/kg/day of atorvastatin for months (16 times the human AUC at the 80 mg dose); testis weights were significantly lower at 30 and 100 mg/kg and epididymal weight was lower at 100 mg/kg. Male rats given 100 mg/kg/day for 11 weeks prior to mating had decreased sperm motility, spermatid head concentration, and increased abnormal sperm. Atorvastatin caused no adverse effects on semen parameters, or reproductive organ histopathology in dogs given doses of 10, 40, or 120 mg/kg for years.

CLINICAL PHARMACOLOGY SECTION.


12 CLINICAL PHARMACOLOGY. 12.1 Mechanism of Action. Atorvastatin is selective, competitive inhibitor of HMG-CoA reductase, the rate-limiting enzyme that converts 3-hydroxy-3-methylglutaryl-coenzyme to mevalonate, precursor of sterols, including cholesterol. In animal models, atorvastatin lowers plasma cholesterol and lipoprotein levels by inhibiting HMG-CoA reductase and cholesterol synthesis in the liver and by increasing the number of hepatic LDL receptors on the cell surface to enhance uptake and catabolism of LDL; atorvastatin also reduces LDL production and the number of LDL particles. 12.2 Pharmacodynamics. Atorvastatin, as well as some of its metabolites, are pharmacologically active in humans. The liver is the primary site of action and the principal site of cholesterol synthesis and LDL clearance. Drug dosage, rather than systemic drug concentration, correlates better with LDL-C reduction. Individualization of drug dosage should be based on therapeutic response [see Dosage and Administration (2)]. 12.3 Pharmacokinetics. Absorption. Atorvastatin calcium tablets are rapidly absorbed after oral administration; maximum plasma concentrations occur within to hours. Extent of absorption increases in proportion to atorvastatin calcium tablet dose. The absolute bioavailability of atorvastatin (parent drug) is approximately 14% and the systemic availability of HMG-CoA reductase inhibitory activity is approximately 30%. The low systemic availability is attributed to presystemic clearance in gastrointestinal mucosa and/or hepatic first-pass metabolism. Although food decreases the rate and extent of drug absorption by approximately 25% and 9%, respectively, as assessed by Cmax and AUC, LDL-C reduction is similar whether atorvastatin calcium tablets are given with or without food. Plasma atorvastatin concentrations are lower (approximately 30% for Cmax and AUC) following evening drug administration compared with morning. However, LDL-C reduction is the same regardless of the time of day of drug administration [see Dosage and Administration (2)]. Distribution. Mean volume of distribution of atorvastatin is approximately 381 liters. Atorvastatin is >= 98% bound to plasma proteins. blood/plasma ratio of approximately 0.25 indicates poor drug penetration into red blood cells. Based on observations in rats, atorvastatin is likely to be secreted in human milk [see Contraindications (4) and Use in Specific Populations (8.2)]. Metabolism. Atorvastatin is extensively metabolized to ortho- and parahydroxylated derivatives and various beta-oxidation products. In vitro inhibition of HMG-CoA reductase by ortho- and parahydroxylated metabolites is equivalent to that of atorvastatin. Approximately 70% of circulating inhibitory activity for HMG-CoA reductase is attributed to active metabolites. In vitro studies suggest the importance of atorvastatin metabolism by cytochrome P450 3A4, consistent with increased plasma concentrations of atorvastatin in humans following co-administration with erythromycin, known inhibitor of this isozyme [see Drug Interactions (7.1)]. In animals, the ortho-hydroxy metabolite undergoes further glucuronidation. Excretion. Atorvastatin and its metabolites are eliminated primarily in bile following hepatic and/or extra-hepatic metabolism; however, the drug does not appear to undergo enterohepatic recirculation. Mean plasma elimination half-life of atorvastatin in humans is approximately 14 hours, but the half-life of inhibitory activity for HMG-CoA reductase is 20 to 30 hours due to the contribution of active metabolites. Less than 2% of dose of atorvastatin is recovered in urine following oral administration. Specific Populations. Geriatric. Plasma concentrations of atorvastatin are higher (approximately 40% for Cmax and 30% for AUC) in healthy elderly subjects (age >= 65 years) than in young adults. Clinical data suggest greater degree of LDL-lowering at any dose of drug in the elderly patient population compared to younger adults [see Use in Specific Populations (8.5)]. Pediatric. Apparent oral clearance of atorvastatin in pediatric subjects appeared similar to that of adults when scaled allometrically by body weight as the body weight was the only significant covariate in atorvastatin population PK model with data including pediatric HeFH patients (ages 10 years to 17 years of age, = 29) in an open-label, 8-week study. Gender. Plasma concentrations of atorvastatin in women differ from those in men (approximately 20% higher for Cmax and 10% lower for AUC); however, there is no clinically significant difference in LDL-C reduction with atorvastatin calcium tablets between men and women. Renal Impairment. Renal disease has no influence on the plasma concentrations or LDL-C reduction of atorvastatin; thus, dose adjustment in patients with renal dysfunction is not necessary [see Dosage and Administration (2.5) and Warnings and Precautions (5.1)]. Hemodialysis. While studies have not been conducted in patients with end-stage renal disease, hemodialysis is not expected to significantly enhance clearance of atorvastatin since the drug is extensively bound to plasma proteins. Hepatic Impairment. In patients with chronic alcoholic liver disease, plasma concentrations of atorvastatin are markedly increased. Cmax and AUC are each 4-fold greater in patients with Childs-Pugh disease. Cmax and AUC are approximately 16-fold and 11-fold increased, respectively, in patients with Childs-Pugh disease [see Contraindications (4)].. Drug Interaction Studies. Atorvastatin is substrate of the hepatic transporters, OATP1B1 and OATP1B3 transporter. Metabolites of atorvastatin are substrates of OATP1B1. Atorvastatin is also identified as substrate of the efflux transporter BCRP, which may limit the intestinal absorption and biliary clearance of atorvastatin.Table 6: Effect of Co-administered Drugs on the Pharmacokinetics of AtorvastatinCo-administered Drug and Dosing RegimenAtorvastatinDose (mg)Ratio of AUCRepresents ratio of treatments (co-administered drug plus atorvastatin vs. atorvastatin alone).Ratio of Cmax See Sections 5.1 and for clinical significance.Cyclosporine 5.2 mg/kg/day, stable dose10 mg QDOnce daily for 28 days8.6910.66Tipranavir 500 mg BIDTwice daily/ritonavir 200 mg BID, days10 mg SDSingle dose 9.368.58Glecaprevir 400 mg QD/pibrentasvir 120 mg QD, days10 mg QD for days8.2822.00Telaprevir 750 mg q8hEvery hours, 10 days20 mg SD 7.8810.60The dose of saquinavir plus ritonavir in this study is not the clinically used dose. The increase in atorvastatin exposure when used clinically is likely to be higher than what was observed in this study. Therefore, caution should be applied and the lowest dose necessary should be used.Saquinavir 400 mg BID/ritonavir 400 mg BID, 15 days40 mg QD for days3.934.31Elbasvir 50 mg QD/grazoprevir 200 mg QD, 13 days10 mg SD 1.944.34Simeprevir 150 mg QD, 10 days40 mg SD 2.121.70Clarithromycin 500 mg BID, days80 mg QD for days4.545.38Darunavir 300 mg BID/ritonavir 100 mg BID, days10 mg QD for days3.452.25Itraconazole 200 mg QD, days40 mg SD 3.321.20Letermovir 480 mg QD, 10 days20 mg SD 3.292.17Fosamprenavir 700 mg BID/ritonavir 100 mg BID, 14 days10 mg QD for days2.532.84Fosamprenavir 1400 mg BID, 14 days10 mg QD for days2.304.04Nelfinavir 1250 mg BID, 14 days10 mg QD for 28 days1.742.22Grapefruit Juice, 240 mL QDGreater increases in AUC (ratio of AUC up to 2.5) and/or Cmax (ratio of Cmax up to 1.71) have been reported with excessive grapefruit consumption (>= 750 mL-1.2 liters per day).40 mg SD 1.371.16Diltiazem 240 mg QD, 28 days40 mg SD 1.511.00Erythromycin 500 mg QIDFour times daily, days10 mg SD 1.331.38Amlodipine 10 mg, single dose80 mg SD 1.180.91Cimetidine 300 mg QID, weeks10 mg QD for weeks1.000.89Colestipol 10 BID, 24 weeks40 mg QD for weeksNULL0.74Ratio based on single sample taken 8-16 post dose. Maalox TC(R) 30 mL QID, 17 days10 mg QD for 15 days0.660.67Efavirenz 600 mg QD, 14 days10 mg for days0.591.01Rifampin 600 mg QD, days (co-administered)Due to the dual interaction mechanism of rifampin, simultaneous co-administration of atorvastatin with rifampin is recommended, as delayed administration of atorvastatin after administration of rifampin has been associated with significant reduction in atorvastatin plasma concentrations.40 mg SD 1.122.90Rifampin 600 mg QD, days (doses separated)40 mg SD 0.200.60Gemfibrozil 600 mg BID, days40 mg SD 1.351.00Fenofibrate 160 mg QD, days40 mg SD 1.031.02Boceprevir 800 mg TIDThree times daily, days40 mg SD 2.322.66 Table 7: Effect of Atorvastatin on the Pharmacokinetics of Co-administered DrugsAtorvastatinCo-administered Drug and Dosing RegimenDrug/Dose (mg)Ratio of AUCRatio of Cmax 80 mg QDOnce daily for 15 daysAntipyrine, 600 mg SDSingle dose 1.030.8980 mg QD for 10 daysSee Section for clinical significance.Digoxin 0.25 mg QD, 20 days1.151.2040 mg QD for 22 daysOral contraceptive QD, months- norethindrone mg- ethinyl estradiol 35 ug1.281.191.231.3010 mg SD Tipranavir 500 mg BIDTwice daily/ritonavir 200 mg BID, days1.080.9610 mg QD for daysFosamprenavir 1400 mg BID, 14 days0.730.8210 mg QD for daysFosamprenavir 700 mg BID/ritonavir 100 mg BID, 14 days0.990.94Atorvastatin calcium tablets had no clinically significant effect on prothrombin time when administered to patients receiving chronic warfarin treatment.

CLINICAL STUDIES SECTION.


14 CLINICAL STUDIES. 14.1 Prevention of Cardiovascular Disease. In the Anglo-Scandinavian Cardiac Outcomes Trial (ASCOT), the effect of atorvastatin calcium tablets on fatal and non-fatal coronary heart disease was assessed in 10,305 hypertensive patients 40-80 years of age (mean of 63 years), without previous myocardial infarction and with TC levels <= 251 mg/dL (6.5 mmol/L). Additionally, all patients had at least of the following cardiovascular risk factors: male gender (81.1%), age 55 years (84.5%), smoking (33.2%), diabetes (24.3%), history of CHD in first-degree relative (26%), TC:HDL 6 (14.3%), peripheral vascular disease (5.1%), left ventricular hypertrophy (14.4%), prior cerebrovascular event (9.8%), specific ECG abnormality (14.3%), proteinuria/albuminuria (62.4%). In this double-blind, placebo-controlled study, patients were treated with anti-hypertensive therapy (Goal BP 140/90 mm Hg for non-diabetic patients; 130/80 mm Hg for diabetic patients) and allocated to either atorvastatin calcium tablets 10 mg daily (n 5,168) or placebo (n 5,137), using covariate adaptive method which took into account the distribution of nine baseline characteristics of patients already enrolled and minimized the imbalance of those characteristics across the groups. Patients were followed for median duration of 3.3 years. The effect of 10 mg/day of atorvastatin calcium tablets on lipid levels was similar to that seen in previous clinical trials. Atorvastatin calcium tablets significantly reduced the rate of coronary events [either fatal coronary heart disease (46 events in the placebo group vs. 40 events in the atorvastatin calcium tablets group) or non-fatal MI (108 events in the placebo group vs. 60 events in the atorvastatin calcium tablets group)] with relative risk reduction of 36% [(based on incidences of 1.9% for atorvastatin calcium tablets vs. 3.0% for placebo), = 0.0005 (see Figure 1)]. The risk reduction was consistent regardless of age, smoking status, obesity, or presence of renal dysfunction. The effect of atorvastatin calcium tablets was seen regardless of baseline LDL levels. Due to the small number of events, results for women were inconclusive.Figure 1: Effect of Atorvastatin Calcium Tablets 10 mg/day on Cumulative Incidence of Non-Fatal Myocardial Infarction or Coronary Heart Disease Death (in ASCOT-LLA) Atorvastatin calcium tablets also significantly decreased the relative risk for revascularization procedures by 42% (incidences of 1.4% for atorvastatin calcium tablets and 2.5% for placebo). Although the reduction of fatal and non-fatal strokes did not reach pre-defined significance level (p 0.01), favorable trend was observed with 26% relative risk reduction (incidences of 1.7% for atorvastatin calcium tablets and 2.3% for placebo). There was no significant difference between the treatment groups for death due to cardiovascular causes (p 0.51) or noncardiovascular causes (p 0.17). In the Collaborative Atorvastatin Diabetes Study (CARDS), the effect of atorvastatin calcium tablets on cardiovascular disease (CVD) endpoints was assessed in 2,838 subjects (94% white, 68% male), ages 40-75 with type diabetes based on WHO criteria, without prior history of cardiovascular disease and with LDL <= 160 mg/dL and TG <= 600 mg/dL. In addition to diabetes, subjects had or more of the following risk factors: current smoking (23%), hypertension (80%), retinopathy (30%), or microalbuminuria (9%) or macroalbuminuria (3%). No subjects on hemodialysis were enrolled in the study. In this multicenter, placebo-controlled, double-blind clinical trial, subjects were randomly allocated to either atorvastatin calcium tablets 10 mg daily (1,429) or placebo (1,411) in 1:1 ratio and were followed for median duration of 3.9 years. The primary endpoint was the occurrence of any of the major cardiovascular events: myocardial infarction, acute CHD death, unstable angina, coronary revascularization, or stroke. The primary analysis was the time to first occurrence of the primary endpoint. Baseline characteristics of subjects were: mean age of 62 years, mean HbA1c 7.7%; median LDL-C 120 mg/dL; median TC 207 mg/dL; median TG 151 mg/dL; median HDL-C 52 mg/dL. The effect of atorvastatin calcium tablets 10 mg/day on lipid levels was similar to that seen in previous clinical trials. Atorvastatin calcium tablets significantly reduced the rate of major cardiovascular events (primary endpoint events) (83 events in the atorvastatin calcium tablets group vs. 127 events in the placebo group) with relative risk reduction of 37%, HR 0.63, 95% CI (0.48, 0.83) (p 0.001) (see Figure 2). An effect of atorvastatin calcium tablets was seen regardless of age, sex, or baseline lipid levels. Atorvastatin calcium tablets significantly reduced the risk of stroke by 48% (21 events in the atorvastatin calcium tablets group vs. 39 events in the placebo group), HR 0.52, 95% CI (0.31, 0.89) (p 0.016) and reduced the risk of MI by 42% (38 events in the atorvastatin calcium tablets group vs. 64 events in the placebo group), HR 0.58, 95.1% CI (0.39, 0.86) (p 0.007). There was no significant difference between the treatment groups for angina, revascularization procedures, and acute CHD death. There were 61 deaths in the atorvastatin calcium tablets group vs. 82 deaths in the placebo group (HR 0.73, = 0.059).Figure 2: Effect of Atorvastatin Calcium Tablets 10 mg/day on Time to Occurrence of Major Cardiovascular Event (Myocardial Infarction, Acute CHD Death, Unstable Angina, Coronary Revascularization, or Stroke) in CARDS In the Treating to New Targets Study (TNT), the effect of atorvastatin calcium tablets 80 mg/day vs. atorvastatin calcium tablets 10 mg/day on the reduction in cardiovascular events was assessed in 10,001 subjects (94% white, 81% male, 38% >= 65 years) with clinically evident coronary heart disease who had achieved target LDL-C level 130 mg/dL after completing an 8-week, open-label, run-in period with atorvastatin calcium tablets 10 mg/day. Subjects were randomly assigned to either 10 mg/day or 80 mg/day of atorvastatin calcium tablets and followed for median duration of 4.9 years. The primary endpoint was the time-to-first occurrence of any of the following major cardiovascular events (MCVE): death due to CHD, non-fatal myocardial infarction, resuscitated cardiac arrest, and fatal and non-fatal stroke. The mean LDL-C, TC, TG, non-HDL, and HDL cholesterol levels at 12 weeks were 73, 145, 128, 98, and 47 mg/dL during treatment with 80 mg of atorvastatin calcium tablets and 99, 177, 152, 129, and 48 mg/dL during treatment with 10 mg of atorvastatin calcium tablets. Treatment with atorvastatin calcium tablets 80 mg/day significantly reduced the rate of MCVE (434 events in the 80 mg/day group vs. 548 events in the 10 mg/day group) with relative risk reduction of 22%, HR 0.78, 95% CI (0.69, 0.89), = 0.0002 (see Figure and Table 8). The overall risk reduction was consistent regardless of age (< 65, >= 65) or gender. Figure 3: Effect of Atorvastatin Calcium Tablets 80 mg/day vs. 10 mg/day on Time to Occurrence of Major Cardiovascular Events (TNT) Table 8: Overview of Efficacy Results in TNTHR hazard ratio; CHD coronary heart disease; CI confidence interval; MI myocardial infarction; CHF congestive heart failure; CV cardiovascular; PVD peripheral vascular disease; CABG coronary artery bypass graftConfidence intervals for the Secondary Endpoints were not adjusted for multiple comparisonsEndpointAtorvastatin 10 mg (N 5,006)Atorvastatin 80 mg (N 4,995)HRAtorvastatin 80 mg:atorvastatin 10 mg (95% CI)PRIMARY ENDPOINTn (%) n(%)First major cardiovascular endpoint548(10.9)434(8.7)0.78 (0.69, 0.89)Components of the Primary EndpointCHD death127(2.5)101(2.0)0.80 (0.61, 1.03)Non-fatal, non-procedure related MI308(6.2)243(4.9)0.78 (0.66, 0.93)Resuscitated cardiac arrest26(0.5)25(0.5)0.96 (0.56, 1.67)Stroke (fatal and non-fatal)155(3.1)117(2.3)0.75 (0.59, 0.96)SECONDARY ENDPOINTSSecondary endpoints not included in primary endpointFirst CHF with hospitalization164(3.3)122(2.4)0.74 (0.59, 0.94)First PVD endpoint282(5.6)275(5.5)0.97 (0.83, 1.15)First CABG or other coronary revascularization procedureComponent of other secondary endpoints 904(18.1)667(13.4)0.72 (0.65, 0.80)First documented angina endpoint 615(12.3)545(10.9)0.88 (0.79, 0.99)All-cause mortality282(5.6)284(5.7)1.01 (0.85, 1.19)Components of All-Cause MortalityCardiovascular death155(3.1)126(2.5)0.81 (0.64, 1.03)Noncardiovascular death127(2.5)158(3.2)1.25 (0.99, 1.57)Cancer death75(1.5)85(1.7)1.13 (0.83, 1.55)Other non-CV death43(0.9)58(1.2)1.35 (0.91, 2.00)Suicide, homicide, and other traumatic non-CV death9(0.2)15(0.3)1.67 (0.73, 3.82)Of the events that comprised the primary efficacy endpoint, treatment with atorvastatin calcium tablets 80 mg/day significantly reduced the rate of non-fatal, non-procedure related MI and fatal and non-fatal stroke, but not CHD death or resuscitated cardiac arrest (Table 8). Of the predefined secondary endpoints, treatment with atorvastatin calcium tablets 80 mg/day significantly reduced the rate of coronary revascularization, angina, and hospitalization for heart failure, but not peripheral vascular disease. The reduction in the rate of CHF with hospitalization was only observed in the 8% of patients with prior history of CHF. There was no significant difference between the treatment groups for all-cause mortality (Table 8). The proportions of subjects who experienced cardiovascular death, including the components of CHD death and fatal stroke, were numerically smaller in the atorvastatin calcium tablets 80 mg group than in the atorvastatin calcium tablets 10 mg treatment group. The proportions of subjects who experienced noncardiovascular death were numerically larger in the atorvastatin calcium tablets 80 mg group than in the atorvastatin calcium tablets 10 mg treatment group. In the Incremental Decrease in Endpoints Through Aggressive Lipid Lowering Study (IDEAL), treatment with atorvastatin calcium tablets 80 mg/day was compared to treatment with simvastatin 20-40 mg/day in 8,888 subjects up to 80 years of age with history of CHD to assess whether reduction in CV risk could be achieved. Patients were mainly male (81%), white (99%) with an average age of 61.7 years, and an average LDL-C of 121.5 mg/dL at randomization; 76% were on statin therapy. In this prospective, randomized, open-label, blinded endpoint (PROBE) trial with no run-in period, subjects were followed for median duration of 4.8 years. The mean LDL-C, TC, TG, HDL, and non-HDL cholesterol levels at Week 12 were 78, 145, 115, 45, and 100 mg/dL during treatment with 80 mg of atorvastatin calcium tablets and 105, 179, 142, 47, and 132 mg/dL during treatment with 20-40 mg of simvastatin. There was no significant difference between the treatment groups for the primary endpoint, the rate of first major coronary event (fatal CHD, non-fatal MI, and resuscitated cardiac arrest): 411 (9.3%) in the atorvastatin calcium tablets 80 mg/day group vs. 463 (10.4%) in the simvastatin 20-40 mg/day group, HR 0.89, 95% CI (0.78, 1.01), = 0.07. There were no significant differences between the treatment groups for all-cause mortality: 366 (8.2%) in the atorvastatin calcium tablets 80 mg/day group vs. 374 (8.4%) in the simvastatin 20-40 mg/day group. The proportions of subjects who experienced CV or non-CV death were similar for the atorvastatin calcium tablets 80 mg group and the simvastatin 20-40 mg group. Figure 1. Effect of Atorvastatin Calcium 10 mg/day on Cumulative Incidence of Nonfatal Myocardial Infarction or Coronary Heart Disease Death (in ASCOT-LLA). Figure 2. Effect of Atorvastatin Calcium 10 mg/day on Time to Occurrence of Major Cardiovascular Event (Myocardial Infarction, Acute CHD Death, Unstable Angina, Coronary Revascularization or Stroke) in CARDS. Figure 3. Effect of Atorvastatin Calcium 80 mg/day vs. 10 mg/day on Time to Occurrence of Major Cardiovascular Events (TNT). 14.2 Hyperlipidemia and Mixed Dyslipidemia Atorvastatin calcium tablets reduce total-C, LDL-C, VLDL-C, apo B, and TG, and increase HDL-C in patients with hyperlipidemia (heterozygous familial and nonfamilial) and mixed dyslipidemia (Fredrickson Types IIa and IIb). Therapeutic response is seen within weeks, and maximum response is usually achieved within weeks and maintained during chronic therapy. Atorvastatin calcium tablets are effective in wide variety of patient populations with hyperlipidemia, with and without hypertriglyceridemia, in men and women, and in the elderly. In two multicenter, placebo-controlled, dose-response studies in patients with hyperlipidemia, atorvastatin calcium tablets given as single dose over weeks, significantly reduced total-C, LDL-C, apo B, and TG. (Pooled results are provided in Table 9.)Table 9: Dose Response in Patients with Primary Hyperlipidemia (Adjusted Mean Change From Baseline)Results are pooled from dose-response studies. DoseNTCLDL-CApo BTGHDL-CNon-HDL-C/HDL-CPlacebo2144310-371022-29-39-32-196-342020-33-43-35-269-414021-37-50-42-296-458023-45-60-50-375-53In patients with Fredrickson Types IIa and IIb hyperlipoproteinemia pooled from 24 controlled trials, the median (25th and 75th percentile) percent changes from baseline in HDL-C for atorvastatin calcium tablets 10, 20, 40, and 80 mg were 6.4 (-1.4, 14), 8.7 (0, 17), 7.8 (0, 16), and 5.1 (-2.7, 15), respectively. Additionally, analysis of the pooled data demonstrated consistent and significant decreases in total-C, LDL-C, TG, total-C/HDL-C, and LDL-C/HDL-C. In three multicenter, double-blind studies in patients with hyperlipidemia, atorvastatin calcium tablets were compared to other statins. After randomization, patients were treated for 16 weeks with either atorvastatin calcium tablets 10 mg per day or fixed dose of the comparative agent (Table 10).Table 10: Mean Percentage Change From Baseline at Endpoint (Double-Blind, Randomized, Active-Controlled Trials)Treatment(Daily Dose)NTotal-CLDL-CApo BTGHDL-CNon-HDL-C/ HDL-CStudy 1Atorvastatin calcium tablets 10 mg707-27Significantly different from lovastatin, ANCOVA, <= 0.05 -36 -28 -17 +7-37 Lovastatin 20 mg191-19-27-20-6+7-2895% CI for DiffA negative value for the 95% CI for the difference between treatments favors atorvastatin calcium tablets for all except HDL-C, for which positive value favors atorvastatin calcium tablets. If the range does not include 0, this indicates statistically significant difference. -9.2, -6.5-10.7, -7.1-10.0, -6.5-15.2, -7.1-1.7, 2.0-11.1, -7.1Study 2Atorvastatin calcium tablets 10 mg222-25Significantly different from pravastatin, ANCOVA, <= 0.05 -35 -27 -17 +6-36 Pravastatin 20 mg77-17-23-17-9+8-2895% CI for Diff+ -10.8, -6.1-14.5, -8.2-13.4, -7.4-14.1, -0.7-4.9, 1.6-11.5, -4.1Study 3Atorvastatin calcium tablets 10 mg132-29Significantly different from simvastatin, ANCOVA, <= 0.05 -37 -34 -23 +7-39 Simvastatin 10 mg45-24-30-30-15+7-3395% CI for Diff -8.7, -2.7-10.1, -2.6-8.0, -1.1-15.1, -0.7-4.3, 3.9-9.6, -1.9The impact on clinical outcomes of the differences in lipid-altering effects between treatments shown in Table 10 is not known. Table 10 does not contain data comparing the effects of atorvastatin calcium tablets 10 mg and higher doses of lovastatin, pravastatin, and simvastatin. The drugs compared in the studies summarized in the table are not necessarily interchangeable. 14.3 Hypertriglyceridemia The response to atorvastatin calcium tablets in 64 patients with isolated hypertriglyceridemia (Fredrickson Type IV) treated across several clinical trials is shown in the table below (Table 11). For the atorvastatin calcium tablet-treated patients, median (min, max) baseline TG level was 565 (267-1502).Table 11: Combined Patients with Isolated Elevated TG: Median (min, max) Percentage Change From BaselinePlacebo(N 12)Atorvastatin Calcium Tablets 10 mg(N 37)Atorvastatin Calcium Tablets 20 mg(N 13)Atorvastatin Calcium Tablets 80 mg(N 14)Triglycerides-12.4 (-36.6, 82.7)-41.0 (-76.2, 49.4)-38.7 (-62.7, 29.5)-51.8 (-82.8, 41.3)Total-C-2.3 (-15.5, 24.4)-28.2 (-44.9, -6.8)-34.9 (-49.6, -15.2)-44.4 (-63.5, -3.8)LDL-C3.6 (-31.3, 31.6)-26.5 (-57.7, 9.8)-30.4 (-53.9, 0.3)-40.5 (-60.6, -13.8)HDL-C3.8 (-18.6, 13.4)13.8 (-9.7, 61.5)11.0 (-3.2, 25.2)7.5 (-10.8, 37.2)VLDL-C-1.0 (-31.9, 53.2)-48.8 (-85.8, 57.3)-44.6 (-62.2, -10.8)-62.0 (-88.2, 37.6)non-HDL-C-2.8 (-17.6, 30.0)-33.0 (-52.1, -13.3)-42.7 (-53.7, -17.4)-51.5 (-72.9, -4.3). 14.4 Dysbetalipoproteinemia. The results of an open-label crossover study of 16 patients (genotypes: 14 apo E2/E2 and apo E3/E2) with dysbetalipoproteinemia (Fredrickson Type III) are shown in the table below (Table 12).Table 12: Open-Label Crossover Study of 16 Patients with Dysbetalipoproteinemia (Fredrickson Type III)Median Change (min, max)Median (min, max) at Baseline (mg/dL)Atorvastatin Calcium Tablets10 mgAtorvastatin Calcium Tablets80 mgTotal-C442 (225, 1320)-37 (-85, 17)-58 (-90, -31)Triglycerides678 (273, 5990)-39 (-92, -8)-53 (-95, -30)IDL-C VLDL-C215 (111, 613)-32 (-76, 9)-63 (-90, -8)non-HDL-C411 (218, 1272)-43 (-87, -19)-64 (-92, -36). 14.5 Homozygous Familial Hypercholesterolemia. In study without concurrent control group, 29 patients ages years to 37 years with HoFH received maximum daily doses of 20 to 80 mg of atorvastatin calcium tablets. The mean LDL-C reduction in this study was 18%. Twenty-five patients with reduction in LDL-C had mean response of 20% (range of 7% to 53%, median of 24%); the remaining patients had 7% to 24% increases in LDL-C. Five of the 29 patients had absent LDL-receptor function. Of these, patients also had portacaval shunt and had no significant reduction in LDL-C. The remaining receptor-negative patients had mean LDL-C reduction of 22%. 14.6 Heterozygous Familial Hypercholesterolemia in Pediatric Patients. In double-blind, placebo-controlled study followed by an open-label phase, 187 boys and postmenarchal girls 10 years to 17 years of age (mean age 14.1 years) with heterozygous familial hypercholesterolemia (HeFH) or severe hypercholesterolemia, were randomized to atorvastatin calcium tablets (n 140) or placebo (n 47) for 26 weeks and then all received atorvastatin calcium tablets for 26 weeks. Inclusion in the study required 1) baseline LDL-C level >= 190 mg/dL or 2) baseline LDL-C level >= 160 mg/dL and positive family history of FH or documented premature cardiovascular disease in first or second-degree relative. The mean baseline LDL-C value was 218.6 mg/dL (range: 138.5-385.0 mg/dL) in the atorvastatin calcium tablets group compared to 230.0 mg/dL (range: 160.0-324.5 mg/dL) in the placebo group. The dosage of atorvastatin calcium tablets (once daily) was 10 mg for the first weeks and uptitrated to 20 mg if the LDL-C level was 130 mg/dL. The number of atorvastatin calcium tablet-treated patients who required uptitration to 20 mg after Week during the double-blind phase was 78 (55.7%). Atorvastatin calcium tablets significantly decreased plasma levels of total-C, LDL-C, triglycerides, and apolipoprotein during the 26-week double-blind phase (see Table 13).Table 13: Lipid-altering Effects of Atorvastatin Calcium Tablets in Adolescent Boys and Girls with Heterozygous Familial Hypercholesterolemia or Severe Hypercholesterolemia (Mean Percentage Change From Baseline at Endpoint in Intention-to-Treat Population)DOSAGENTotal-CLDL-CHDL-CTGApolipoprotein BPlacebo47-1.5-0.4-1.91.00.7Atorvastatin calcium tablets 140-31.4-39.62.8-12.0-34.0The mean achieved LDL-C value was 130.7 mg/dL (range: 70.0-242.0 mg/dL) in the atorvastatin calcium tablets group compared to 228.5 mg/dL (range: 152.0-385.0 mg/dL) in the placebo group during the 26-week double-blind phase. Atorvastatin was also studied in 3-year open-label, uncontrolled trial that included 163 patients with HeFH who were 10 years to 15 years old (82 boys and 81 girls). All patients had clinical diagnosis of HeFH confirmed by genetic analysis (if not already confirmed by family history). Approximately 98% were Caucasian, and less than 1% were Black or Asian. Mean LDL-C at baseline was 232 mg/dL. The starting atorvastatin dosage was 10 mg once daily and doses were adjusted to achieve target of 130 mg/dL LDL-C. The reductions in LDL-C from baseline were generally consistent across age groups within the trial as well as with previous clinical studies in both adult and pediatric placebo-controlled trials.The long-term efficacy of atorvastatin calcium tablet therapy in childhood to reduce morbidity and mortality in adulthood has not been established.

CONTRAINDICATIONS SECTION.


4 CONTRAINDICATIONS. oActive Liver Disease, Which May Include Unexplained Persistent Elevations in Hepatic Transaminase LevelsoHypersensitivity to Any Component of This MedicationoPregnancy [see Use in Specific Populations (8.1 8.3)].oLactation [see Use in Specific Populations (8.2)].. oActive Liver Disease, Which May Include Unexplained Persistent Elevations in Hepatic Transaminase Levels. oHypersensitivity to Any Component of This Medication. oPregnancy [see Use in Specific Populations (8.1 8.3)].. oLactation [see Use in Specific Populations (8.2)].. oActive liver disease, which may include unexplained persistent elevations in hepatic transaminase levels (4). oHypersensitivity to any component of this medication (4).oPregnancy (4, 8.1, 8.3).oLactation (4, 8.2).. oActive liver disease, which may include unexplained persistent elevations in hepatic transaminase levels (4). oHypersensitivity to any component of this medication (4).. oPregnancy (4, 8.1, 8.3).. oLactation (4, 8.2).

DESCRIPTION SECTION.


11 DESCRIPTION. Atorvastatin calcium tablets, USP are synthetic lipid-lowering agent. Atorvastatin is an inhibitor of 3-hydroxy-3-methylglutaryl-coenzyme (HMG-CoA) reductase. This enzyme catalyzes the conversion of HMG-CoA to mevalonate, an early and rate-limiting step in cholesterol biosynthesis. Atorvastatin calcium is Calcium (R,R)-2-(p-fluorophenyl)-,-dihydroxy-5-isopropyl-3-phenyl-4-(phenylcarbamoyl) pyrrole-1-heptanoate (1:2), trihydrate. The molecular formula of atorvastatin calcium is C66H68CaF2N4O10o3H2O and its molecular weight is 1209. Its structural formula is:Atorvastatin calcium, USP is white to off-white crystalline powder that is insoluble in aqueous solutions of pH and below. Atorvastatin calcium is very slightly soluble in distilled water, pH 7.4 phosphate buffer, and acetonitrile; slightly soluble in ethanol; and freely soluble in methanol. Atorvastatin calcium tablets for oral administration contain 10, 20, 40, or 80 mg of atorvastatin and the following inactive ingredients: anhydrous lactose, anhydrous sodium carbonate, colloidal silicon dioxide, croscarmellose sodium, hydroxypropyl cellulose, L-Arginine, magnesium stearate and microcrystalline cellulose. The film coating of the tablets contains polyvinyl alcohol, talc and titanium dioxide, and may contain polyethylene glycol or lecithin and xanthan gum. Meets USP Dissolution Test 4.. Atorvastatin Calcium Structural Formula.

DOSAGE & ADMINISTRATION SECTION.


2 DOSAGE AND ADMINISTRATION. oDose range: 10 to 80 mg once daily (2.1). oRecommended start dose: 10 or 20 mg once daily (2.1). oPatients requiring large LDL-C reduction (> 45%) may start at 40 mg once daily (2.1). oPediatric patients with HeFH: starting dose: 10 mg once daily; dose range: 10 to 20 mg/day for patients 10 years to 17 years of age (2.2).. oDose range: 10 to 80 mg once daily (2.1). oRecommended start dose: 10 or 20 mg once daily (2.1). oPatients requiring large LDL-C reduction (> 45%) may start at 40 mg once daily (2.1). oPediatric patients with HeFH: starting dose: 10 mg once daily; dose range: 10 to 20 mg/day for patients 10 years to 17 years of age (2.2).. 2.1 Hyperlipidemia and Mixed Dyslipidemia. The recommended starting dose of atorvastatin calcium tablets is 10 or 20 mg once daily. Patients who require large reduction in LDL-C (more than 45%) may be started at 40 mg once daily. The dosage range of atorvastatin calcium tablets is 10 to 80 mg once daily. Atorvastatin calcium tablets can be administered as single dose at any time of the day, with or without food. The starting dose and maintenance doses of atorvastatin calcium tablets should be individualized according to patient characteristics such as goal of therapy and response. After initiation and/or upon titration of atorvastatin calcium tablets, lipid levels should be analyzed within to weeks and dosage adjusted accordingly. 2.2 Heterozygous Familial Hypercholesterolemia in Pediatric Patients (10 Years to 17 Years of Age). The recommended starting dose of atorvastatin calcium tablets is 10 mg/day; the usual dose range is 10 to 20 mg orally once daily [see Clinical Studies (14.6)]. Doses should be individualized according to the recommended goal of therapy [see Indications and Usage (1.2) and Clinical Pharmacology (12)]. Adjustments should be made at intervals of weeks or more. 2.3 Homozygous Familial Hypercholesterolemia. The dosage of atorvastatin calcium tablets in patients with HoFH is 10 to 80 mg daily. Atorvastatin calcium tablets should be used as an adjunct to other lipid-lowering treatments (e.g., LDL apheresis) in these patients or if such treatments are unavailable. 2.4 Concomitant Lipid-Lowering Therapy. Atorvastatin calcium tablets may be used with bile acid resins. The combination of HMG-CoA reductase inhibitors (statins) and fibrates should generally be used with caution [see Warnings and Precautions (5.1) and Drug Interactions (7) ]. 2.5 Dosage in Patients with Renal Impairment. Renal disease does not affect the plasma concentrations nor LDL-C reduction of atorvastatin calcium tablets; thus, dosage adjustment in patients with renal dysfunction is not necessary [see Warnings and Precautions (5.1) and Clinical Pharmacology (12.3)]. 2.6 Dosage in Patients Taking Cyclosporine, Clarithromycin, Itraconazole, Letermovir, or Certain Protease Inhibitors. In patients taking cyclosporine or the HIV protease inhibitor tipranavir plus ritonavir or the hepatitis virus (HCV) protease inhibitor glecaprevir plus pibrentasvir or letermovir when co-administered with cyclosporine, therapy with atorvastatin calcium tablets should be avoided. In patients with HIV taking lopinavir plus ritonavir, use the lowest dose necessary of atorvastatin calcium tablets. In patients taking clarithromycin, itraconazole, elbasvir plus grazoprevir, or in patients with HIV taking combination of saquinavir plus ritonavir, darunavir plus ritonavir, fosamprenavir, fosamprenavir plus ritonavir or letermovir, therapy with atorvastatin calcium tablets should be limited to 20 mg, and appropriate clinical assessment is recommended to ensure that the lowest dose necessary of atorvastatin calcium tablets is used. In patients taking the HIV protease inhibitor nelfinavir, therapy with atorvastatin calcium tablets should be limited to 40 mg [see Warnings and Precautions (5.1) and Drug Interactions (7.1) ].

DOSAGE FORMS & STRENGTHS SECTION.


3 DOSAGE FORMS AND STRENGTHS. Atorvastatin Calcium Tablets, USP are available containing atorvastatin calcium, USP equivalent to 10 mg, 20 mg, 40 mg or 80 mg of atorvastatin.oThe 10 mg tablets are white to off-white, film-coated, oval, unscored tablets debossed with 10 on one side of the tablet and blank on the other side.oThe 20 mg tablets are white to off-white, film-coated, oval, unscored tablets debossed with 20 on one side of the tablet and blank on the other side.oThe 40 mg tablets are white to off-white, film-coated, oval, unscored tablets debossed with 40 on one side of the tablet and blank on the other side.oThe 80 mg tablets are white to off-white, film-coated, oval, unscored tablets debossed with 80 on one side of the tablet and blank on the other side. Table 1: Atorvastatin Calcium Tablet Strengths and Identifying FeaturesTablet StrengthIdentifying Features10 mg of atorvastatin10 on one side and blank on the other20 mg of atorvastatin20 on one side and blank on the other40 mg of atorvastatin40 on one side and blank on the other80 mg of atorvastatin80 on one side and blank on the other. oThe 10 mg tablets are white to off-white, film-coated, oval, unscored tablets debossed with 10 on one side of the tablet and blank on the other side.. oThe 20 mg tablets are white to off-white, film-coated, oval, unscored tablets debossed with 20 on one side of the tablet and blank on the other side.. oThe 40 mg tablets are white to off-white, film-coated, oval, unscored tablets debossed with 40 on one side of the tablet and blank on the other side.. oThe 80 mg tablets are white to off-white, film-coated, oval, unscored tablets debossed with 80 on one side of the tablet and blank on the other side. Tablets: 10, 20, 40, and 80 mg of atorvastatin (3).

DRUG INTERACTIONS SECTION.


7 DRUG INTERACTIONS. Drug Interactions That May Increase the Risk of Myopathy and Rhabdomyolysis with Atorvastatin Calcium Tablets (2.6, 5.1, 7.1, 12.3)Interacting AgentsPrescribing RecommendationsCyclosporine, tipranavir plus ritonavir, glecaprevir plus pibrentasvirAvoid atorvastatinClarithromycin, itraconazole, saquinavir plus ritonavir, darunavir plus ritonavir, fosamprenavir, fosamprenavir plus ritonavir, elbasvir plus grazoprevir, letermovirDo not exceed 20 mg atorvastatin dailyNelfinavirDo not exceed 40 mg atorvastatin dailyLopinavir plus ritonavir, simeprevir, fibric acid derivatives, erythromycin, azole antifungals, lipid-modifying doses of niacin, colchicineConsider the risk/benefit of concomitant use with atorvastatinoOther Lipid-Lowering Medications: Use with fibrate products or lipid-modifying doses (>= g/day) of niacin increases the risk of adverse skeletal muscle effects. Caution should be used when prescribing with atorvastatin calcium tablets (7). oRifampin should be simultaneously co-administered with atorvastatin calcium tablets (7.2). oOral Contraceptives: Values for norethindrone and ethinyl estradiol may be increased (7.3). oDigoxin: Patients should be monitored appropriately (7.3). oOther Lipid-Lowering Medications: Use with fibrate products or lipid-modifying doses (>= g/day) of niacin increases the risk of adverse skeletal muscle effects. Caution should be used when prescribing with atorvastatin calcium tablets (7). oRifampin should be simultaneously co-administered with atorvastatin calcium tablets (7.2). oOral Contraceptives: Values for norethindrone and ethinyl estradiol may be increased (7.3). oDigoxin: Patients should be monitored appropriately (7.3). 7.1 Drug Interactions That May Increase the Risk of Myopathy and Rhabdomyolysis with Atorvastatin Calcium Tablets Atorvastatin is substrate of CYP3A4 and transporters (e.g., OATP1B1/1B3, P-gp, or BCRP). Atorvastatin plasma levels can be significantly increased with concomitant administration of inhibitors of CYP3A4 and transporters. Table includes list of drugs that may increase exposure to atorvastatin and may increase the risk of myopathy and rhabdomyolysis when used concomitantly and instructions for preventing or managing them [see Warnings and Precautions (5.1) and Clinical Pharmacology (12.3)].Table 3: Drug Interactions That May Increase the Risk of Myopathy and Rhabdomyolysis with Atorvastatin Calcium TabletsCyclosporine or GemfibrozilClinical Impact:Atorvastatin plasma levels were significantly increased with concomitant administration of atorvastatin calcium tablets and cyclosporine, an inhibitor of CYP3A4 and OATP1B1 [see Clinical Pharmacology (12.3)]. Gemfibrozil may cause myopathy when given alone. The risk of myopathy and rhabdomyolysis is increased with concomitant use of cyclosporine or gemfibrozil with atorvastatin calcium tablets.Intervention:Concomitant use of cyclosporine or gemfibrozil with atorvastatin calcium tablets is not recommended.Anti-Viral MedicationsClinical Impact:Atorvastatin plasma levels were significantly increased with concomitant administration of atorvastatin calcium tablets with many anti-viral medications, which are inhibitors of CYP3A4 and/or transporters (e.g., BCRP, OATP1B1/1B3, P-gp, MRP2, and/or OAT2) [see Clinical Pharmacology (12.3)]. Cases of myopathy and rhabdomyolysis have been reported with concomitant use of ledipasvir plus sofosbuvir with atorvastatin calcium tablets.Intervention:oConcomitant use of tipranavir plus ritonavir or glecaprevir plus pibrentasvir with atorvastatin calcium tablets is not recommended.oIn patients taking lopinavir plus ritonavir, or simeprevir, consider the risk/benefit of concomitant use with atorvastatin.oIn patients taking saquinavir plus ritonavir, darunavir plus ritonavir, fosamprenavir, fosamprenavir plus ritonavir, elbasvir plus grazoprevir or letermovir, do not exceed atorvastatin calcium tablets 20 mg.oIn patients taking nelfinavir, do not exceed atorvastatin calcium tablets 40 mg [see Dosage and Administration (2.6)].oConsider the risk/benefit of concomitant use of ledipasvir plus sofosbuvir with atorvastatin calcium tablets.oMonitor all patients for signs and symptoms of myopathy particularly during initiation of therapy and during upward dose titration of either drug.Examples:Tipranavir plus ritonavir, glecaprevir plus pibrentasvir, lopinavir plus ritonavir, simeprevir, saquinavir plus ritonavir, darunavir plus ritonavir, fosamprenavir, fosamprenavir plus ritonavir, elbasvir plus grazoprevir, letermovir, nelfinavir, and ledipasvir plus sofosbuvir.Select Azole Antifungals or Macrolide AntibioticsClinical Impact:Atorvastatin plasma levels were significantly increased with concomitant administration of atorvastatin calcium tablets with select azole antifungals or macrolide antibiotics, due to inhibition of CYP3A4 and/or transporters [see Clinical Pharmacology (12.3)].Intervention:In patients taking clarithromycin or itraconazole, do not exceed atorvastatin calcium tablets 20 mg [see Dosage and Administration (2.6)]. Consider the risk/benefit of concomitant use of other azole antifungals or macrolide antibiotics with atorvastatin calcium tablets. Monitor all patients for signs and symptoms of myopathy particularly during initiation of therapy and during upward dose titration of either drug. Examples:Erythromycin, clarithromycin, itraconazole, ketoconazole, posaconazole, and voriconazole.NiacinClinical Impact:Cases of myopathy and rhabdomyolysis have been observed with concomitant use of lipid modifying dosages of niacin (>= gram/day niacin) with atorvastatin calcium tablets.Intervention:Consider if the benefit of using lipid modifying dosages of niacin concomitantly with atorvastatin calcium tablets outweighs the increased risk of myopathy and rhabdomyolysis. If concomitant use is decided, monitor patients for signs and symptoms of myopathy particularly during initiation of therapy and during upward dose titration of either drug.Fibrates (other than Gemfibrozil)Clinical Impact:Fibrates may cause myopathy when given alone. The risk of myopathy and rhabdomyolysis is increased with concomitant use of fibrates with atorvastatin calcium tablets.Intervention:Consider if the benefit of using fibrates concomitantly with atorvastatin calcium tablets outweighs the increased risk of myopathy and rhabdomyolysis. If concomitant use is decided, monitor patients for signs and symptoms of myopathy particularly during initiation of therapy and during upward dose titration of either drug.ColchicineClinical Impact:Cases of myopathy and rhabdomyolysis have been reported with concomitant use of colchicine with atorvastatin calcium tablets.Intervention:Consider the risk/benefit of concomitant use of colchicine with atorvastatin calcium tablets. If concomitant use is decided, monitor patients for signs and symptoms of myopathy particularly during initiation of therapy and during upward dose titration of either drug.Grapefruit JuiceClinical Impact:Grapefruit juice consumption, especially excessive consumption, more than 1.2 liters/daily, can raise the plasma levels of atorvastatin and may increase the risk of myopathy and rhabdomyolysis.Intervention:Avoid intake of large quantities of grapefruit juice, more than 1.2 liters daily, when taking atorvastatin calcium tablets.. oConcomitant use of tipranavir plus ritonavir or glecaprevir plus pibrentasvir with atorvastatin calcium tablets is not recommended.. oIn patients taking lopinavir plus ritonavir, or simeprevir, consider the risk/benefit of concomitant use with atorvastatin.. oIn patients taking saquinavir plus ritonavir, darunavir plus ritonavir, fosamprenavir, fosamprenavir plus ritonavir, elbasvir plus grazoprevir or letermovir, do not exceed atorvastatin calcium tablets 20 mg.. oIn patients taking nelfinavir, do not exceed atorvastatin calcium tablets 40 mg [see Dosage and Administration (2.6)].. oConsider the risk/benefit of concomitant use of ledipasvir plus sofosbuvir with atorvastatin calcium tablets.. oMonitor all patients for signs and symptoms of myopathy particularly during initiation of therapy and during upward dose titration of either drug.. 7.2 Drug Interactions That May Decrease Exposure to Atorvastatin Table presents drug interactions that may decrease exposure to atorvastatin and instructions for preventing or managing them.Table 4: Drug Interactions That May Decrease Exposure to AtorvastatinRifampinClinical Impact:Concomitant administration of atorvastatin calcium tablets with rifampin, an inducer of cytochrome P450 3A4 and inhibitor of OATP1B1, can lead to variable reductions in plasma concentrations of atorvastatin. Due to the dual interaction mechanism of rifampin, delayed administration of atorvastatin calcium tablets after administration of rifampin has been associated with significant reduction in atorvastatin plasma concentrations.Intervention:Administer atorvastatin calcium tablets and rifampin simultaneously.. 7.3 Atorvastatin Effects on Other Drugs Table presents atorvastatins effect on other drugs and instructions for preventing or managing them.Table 5: Atorvastatin Effects on Other DrugsOral ContraceptivesClinical Impact:Co-administration of atorvastatin calcium tablets and an oral contraceptive increased plasma concentrations of norethindrone and ethinyl estradiol [see Clinical Pharmacology (12.3)].Intervention:Consider this when selecting an oral contraceptive for patients taking atorvastatin calcium tablets.DigoxinClinical Impact:When multiple doses of atorvastatin calcium tablets and digoxin were co-administered, steady state plasma digoxin concentrations increased [see Clinical Pharmacology (12.3)].Intervention:Monitor patients taking digoxin appropriately.

FEMALES & MALES OF REPRODUCTIVE POTENTIAL SECTION.


8.3 Females and Males of Reproductive Potential Contraception. Atorvastatin calcium tablets may cause fetal harm when administered to pregnant woman. Advise females of reproductive potential to use effective contraception during treatment with atorvastatin calcium tablets [see Use in Specific Populations (8.1)].

GERIATRIC USE SECTION.


8.5 Geriatric Use. Of the 39,828 patients who received atorvastatin calcium tablets in clinical studies, 15,813 (40%) were >= 65 years old and 2,800 (7%) were >= 75 years old. No overall differences in safety or effectiveness were observed between these subjects and younger subjects, and other reported clinical experience has not identified differences in responses between the elderly and younger patients, but greater sensitivity of some older adults cannot be ruled out. Since advanced age (>= 65 years) is predisposing factor for myopathy, atorvastatin calcium tablets should be prescribed with caution in the elderly.

HOW SUPPLIED SECTION.


16 HOW SUPPLIED/STORAGE AND HANDLING. Atorvastatin Calcium Tablets, USP are available containing atorvastatin calcium, USP equivalent to 10 mg, 20 mg, 40 mg or 80 mg of atorvastatin.The 10 mg tablets are white to off-white, film-coated, oval, unscored tablets debossed with 10 on one side of the tablet and blank on the other side. They are available as follows:NDC 0378-3950-77bottles of 90 tabletsNDC 0378-3950-05bottles of 500 tabletsThe 20 mg tablets are white to off-white, film-coated, oval, unscored tablets debossed with 20 on one side of the tablet and blank on the other side. They are available as follows:NDC 0378-3951-77bottles of 90 tabletsNDC 0378-3951-05bottles of 500 tabletsThe 40 mg tablets are white to off-white, film-coated, oval, unscored tablets debossed with 40 on one side of the tablet and blank on the other side. They are available as follows:NDC 0378-3952-77bottles of 90 tabletsNDC 0378-3952-05bottles of 500 tabletsThe 80 mg tablets are white to off-white, film-coated, oval, unscored tablets debossed with 80 on one side of the tablet and blank on the other side. They are available as follows:NDC 0378-3953-77bottles of 90 tabletsNDC 0378-3953-05bottles of 500 tabletsStorage: Store at 20 to 25C (68 to 77F). [See USP Controlled Room Temperature.] Dispense in tight, light-resistant container as defined in the USP using child-resistant closure.

INDICATIONS & USAGE SECTION.


1 INDICATIONS AND USAGE. Therapy with lipid-altering agents should be only one component of multiple risk factor intervention in individuals at significantly increased risk for atherosclerotic vascular disease due to hypercholesterolemia. Drug therapy is recommended as an adjunct to diet when the response to diet restricted in saturated fat and cholesterol and other nonpharmacologic measures alone has been inadequate. In patients with CHD or multiple risk factors for CHD, atorvastatin calcium tablets can be started simultaneously with diet. Atorvastatin calcium tablets are an HMG-CoA reductase inhibitor indicated as an adjunct therapy to diet to: oReduce the risk of MI, stroke, revascularization procedures, and angina in adult patients without CHD, but with multiple risk factors (1.1). oReduce the risk of MI and stroke in adult patients with type diabetes without CHD, but with multiple risk factors (1.1). oReduce the risk of non-fatal MI, fatal and non-fatal stroke, revascularization procedures, hospitalization for CHF, and angina in adult patients with CHD (1.1). oReduce elevated total-C, LDL-C, apo B, and TG levels and increase HDL-C in adult patients with primary hyperlipidemia (heterozygous familial and nonfamilial) and mixed dyslipidemia (1.2). oReduce elevated TG in adult patients with hypertriglyceridemia and primary dysbetalipoproteinemia (1.2). oReduce total-C and LDL-C in patients with homozygous familial hypercholesterolemia (HoFH) (1.2). oReduce elevated total-C, LDL-C, and apo levels in pediatric patients, 10 years to 17 years of age, with heterozygous familial hypercholesterolemia (HeFH) after failing an adequate trial of diet therapy (1.2). Limitations of Use: Atorvastatin calcium tablets have not been studied in Fredrickson Types and dyslipidemias (1.3). oReduce the risk of MI, stroke, revascularization procedures, and angina in adult patients without CHD, but with multiple risk factors (1.1). oReduce the risk of MI and stroke in adult patients with type diabetes without CHD, but with multiple risk factors (1.1). oReduce the risk of non-fatal MI, fatal and non-fatal stroke, revascularization procedures, hospitalization for CHF, and angina in adult patients with CHD (1.1). oReduce elevated total-C, LDL-C, apo B, and TG levels and increase HDL-C in adult patients with primary hyperlipidemia (heterozygous familial and nonfamilial) and mixed dyslipidemia (1.2). oReduce elevated TG in adult patients with hypertriglyceridemia and primary dysbetalipoproteinemia (1.2). oReduce total-C and LDL-C in patients with homozygous familial hypercholesterolemia (HoFH) (1.2). oReduce elevated total-C, LDL-C, and apo levels in pediatric patients, 10 years to 17 years of age, with heterozygous familial hypercholesterolemia (HeFH) after failing an adequate trial of diet therapy (1.2). 1.1 Prevention of Cardiovascular Disease in Adults. In adult patients without clinically evident coronary heart disease, but with multiple risk factors for coronary heart disease such as age, smoking, hypertension, low HDL-C, or family history of early coronary heart disease, atorvastatin calcium tablets are indicated to: oReduce the risk of myocardial infarction oReduce the risk of stroke oReduce the risk for revascularization procedures and angina In adult patients with type diabetes, and without clinically evident coronary heart disease, but with multiple risk factors for coronary heart disease such as retinopathy, albuminuria, smoking, or hypertension, atorvastatin calcium tablets are indicated to: oReduce the risk of myocardial infarction oReduce the risk of strokeIn adult patients with clinically evident coronary heart disease, atorvastatin calcium tablets are indicated to: oReduce the risk of non-fatal myocardial infarction oReduce the risk of fatal and non-fatal stroke oReduce the risk for revascularization procedures oReduce the risk of hospitalization for CHF oReduce the risk of angina oReduce the risk of myocardial infarction oReduce the risk of stroke oReduce the risk for revascularization procedures and angina oReduce the risk of myocardial infarction oReduce the risk of stroke. oReduce the risk of non-fatal myocardial infarction oReduce the risk of fatal and non-fatal stroke oReduce the risk for revascularization procedures oReduce the risk of hospitalization for CHF oReduce the risk of angina 1.2 Hyperlipidemia. Atorvastatin calcium tablets are indicated: oAs an adjunct to diet to reduce elevated total-C, LDL-C, apo B, and TG levels and to increase HDL-C in adult patients with primary hypercholesterolemia (heterozygous familial and nonfamilial) and mixed dyslipidemia (Fredrickson Types IIa and IIb); oAs an adjunct to diet for the treatment of adult patients with elevated serum TG levels (Fredrickson Type IV); oFor the treatment of adult patients with primary dysbetalipoproteinemia (Fredrickson Type III) who do not respond adequately to diet; oTo reduce total-C and LDL-C in patients with homozygous familial hypercholesterolemia (HoFH) as an adjunct to other lipid-lowering treatments (e.g., LDL apheresis) or if such treatments are unavailable; oAs an adjunct to diet to reduce total-C, LDL-C, and apo levels in pediatric patients, 10 years to 17 years of age, with heterozygous familial hypercholesterolemia (HeFH) if after an adequate trial of diet therapy the following findings are present: a.LDL-C remains >= 190 mg/dL or b.LDL-C remains >= 160 mg/dL and: othere is positive family history of premature cardiovascular disease or otwo or more other CVD risk factors are present in the pediatric patient oAs an adjunct to diet to reduce elevated total-C, LDL-C, apo B, and TG levels and to increase HDL-C in adult patients with primary hypercholesterolemia (heterozygous familial and nonfamilial) and mixed dyslipidemia (Fredrickson Types IIa and IIb); oAs an adjunct to diet for the treatment of adult patients with elevated serum TG levels (Fredrickson Type IV); oFor the treatment of adult patients with primary dysbetalipoproteinemia (Fredrickson Type III) who do not respond adequately to diet; oTo reduce total-C and LDL-C in patients with homozygous familial hypercholesterolemia (HoFH) as an adjunct to other lipid-lowering treatments (e.g., LDL apheresis) or if such treatments are unavailable; oAs an adjunct to diet to reduce total-C, LDL-C, and apo levels in pediatric patients, 10 years to 17 years of age, with heterozygous familial hypercholesterolemia (HeFH) if after an adequate trial of diet therapy the following findings are present: a.LDL-C remains >= 190 mg/dL or b.LDL-C remains >= 160 mg/dL and: othere is positive family history of premature cardiovascular disease or otwo or more other CVD risk factors are present in the pediatric patient a.LDL-C remains >= 190 mg/dL or b.LDL-C remains >= 160 mg/dL and: othere is positive family history of premature cardiovascular disease or otwo or more other CVD risk factors are present in the pediatric patient othere is positive family history of premature cardiovascular disease or otwo or more other CVD risk factors are present in the pediatric patient 1.3 Limitations of Use. Atorvastatin calcium tablets have not been studied in conditions where the major lipoprotein abnormality is elevation of chylomicrons (Fredrickson Types and V).

INFORMATION FOR PATIENTS SECTION.


17 PATIENT COUNSELING INFORMATION. Advise the patient to read the FDA-approved patient labeling (Patient Information).Patients taking atorvastatin calcium tablets should be advised that cholesterol is chronic condition and they should adhere to their medication along with their National Cholesterol Education Program (NCEP)-recommended diet, regular exercise program as appropriate, and periodic testing of fasting lipid panel to determine goal attainment. Patients should be advised about substances they should not take concomitantly with atorvastatin [see Warnings and Precautions (5.1)]. Patients should also be advised to inform other healthcare professionals prescribing new medication that they are taking atorvastatin calcium tablets. 17.1 Muscle Pain. All patients starting therapy with atorvastatin calcium tablets should be advised of the risk of myopathy and told to report promptly any unexplained muscle pain, tenderness, or weakness particularly if accompanied by malaise or fever or if these muscle signs or symptoms persist after discontinuing atorvastatin calcium tablets. The risk of this occurring is increased when taking certain types of medication or consuming larger quantities (> liter) of grapefruit juice. They should discuss all medication, both prescription and over the counter, with their healthcare professional. 17.2 Liver Enzymes. It is recommended that liver enzyme tests be performed before the initiation of atorvastatin calcium tablets and if signs or symptoms of liver injury occur. All patients treated with atorvastatin calcium tablets should be advised to report promptly any symptoms that may indicate liver injury, including fatigue, anorexia, right upper abdominal discomfort, dark urine, or jaundice.. 17.3 Embryofetal Toxicity. Advise females of reproductive potential of the risk to fetus, to use effective contraception during treatment and to inform their healthcare provider of known or suspected pregnancy [see Contraindications (4) and Use in Specific Populations (8.1, 8.3)]. 17.4 Lactation. Advise women not to breastfeed during treatment with atorvastatin calcium tablets [see Contraindications (4) and Use in Specific Populations (8.2)]. The brands listed are trademarks of their respective owners.

LACTATION SECTION.


8.2 Lactation Risk Summary. Atorvastatin calcium tablet use is contraindicated during breastfeeding [see Contraindications (4)]. There is no available information on the effects of the drug on the breastfed infant or the effects of the drug on milk production. It is not known whether atorvastatin is present in human milk, but it has been shown that another drug in this class passes into human milk and atorvastatin is present in rat milk. Because of the potential for serious adverse reactions in breastfed infant, advise women that breastfeeding is not recommended during treatment with atorvastatin calcium tablets.

MECHANISM OF ACTION SECTION.


12.1 Mechanism of Action. Atorvastatin is selective, competitive inhibitor of HMG-CoA reductase, the rate-limiting enzyme that converts 3-hydroxy-3-methylglutaryl-coenzyme to mevalonate, precursor of sterols, including cholesterol. In animal models, atorvastatin lowers plasma cholesterol and lipoprotein levels by inhibiting HMG-CoA reductase and cholesterol synthesis in the liver and by increasing the number of hepatic LDL receptors on the cell surface to enhance uptake and catabolism of LDL; atorvastatin also reduces LDL production and the number of LDL particles.

NONCLINICAL TOXICOLOGY SECTION.


13 NONCLINICAL TOXICOLOGY. 13.1 Carcinogenesis, Mutagenesis, Impairment of Fertility. In 2-year carcinogenicity study in rats at dose levels of 10, 30, and 100 mg/kg/day, rare tumors were found in muscle in high-dose females: in one, there was rhabdomyosarcoma and, in another, there was fibrosarcoma. This dose represents plasma AUC (0-24) value of approximately 16 times the mean human plasma drug exposure after an 80 mg oral dose. 2-year carcinogenicity study in mice given 100, 200, or 400 mg/kg/day resulted in significant increase in liver adenomas in high-dose males and liver carcinomas in high-dose females. These findings occurred at plasma AUC (0-24) values of approximately times the mean human plasma drug exposure after an 80 mg oral dose. In vitro, atorvastatin was not mutagenic or clastogenic in the following tests with and without metabolic activation: the Ames test with Salmonella typhimurium and Escherichia coli, the HGPRT forward mutation assay in Chinese hamster lung cells, and the chromosomal aberration assay in Chinese hamster lung cells. Atorvastatin was negative in the in vivo mouse micronucleus test. In female rats, atorvastatin at doses up to 225 mg/kg (56 times the human exposure) did not cause adverse effects on fertility. Studies in male rats performed at doses up to 175 mg/kg (15 times the human exposure) produced no changes in fertility. There was aplasia and aspermia in the epididymis of of 10 rats treated with 100 mg/kg/day of atorvastatin for months (16 times the human AUC at the 80 mg dose); testis weights were significantly lower at 30 and 100 mg/kg and epididymal weight was lower at 100 mg/kg. Male rats given 100 mg/kg/day for 11 weeks prior to mating had decreased sperm motility, spermatid head concentration, and increased abnormal sperm. Atorvastatin caused no adverse effects on semen parameters, or reproductive organ histopathology in dogs given doses of 10, 40, or 120 mg/kg for years.

OVERDOSAGE SECTION.


10 OVERDOSAGE. There is no specific treatment for atorvastatin calcium tablet overdosage. In the event of an overdose, the patient should be treated symptomatically, and supportive measures instituted as required. Due to extensive drug binding to plasma proteins, hemodialysis is not expected to significantly enhance atorvastatin clearance.

PACKAGE LABEL.PRINCIPAL DISPLAY PANEL.


PRINCIPAL DISPLAY PANEL 10 mgNDC 0378-3950-77Atorvastatin CalciumTablets, USP10 mgRx only 90 TabletsEach film-coated tablet containsatorvastatin calcium, USPequivalent to 10 mg of atorvastatin.Usual Dosage: See accompanyingprescribing information.Keep this and all medication out of the reach of children.Store at 20 to 25C (68 to 77F).[See USP Controlled RoomTemperature.]Manufactured for: Mylan Pharmaceuticals Inc. Morgantown, WV 26505 U.S.A.Made in IndiaMylan.comRM3950MM2Dispense in tight, light-resistantcontainer as defined in the USPusing child-resistant closure.Keep container tightly closed.Code No.: MH/DRUGS/25/NKD/89. Atorvastatin Calcium Tablets 10 mg Bottle Label.

PEDIATRIC USE SECTION.


8.4 Pediatric Use. Heterozygous Familial Hypercholesterolemia (HeFH). The safety and effectiveness of atorvastatin calcium tablets have been established in pediatric patients,10 years to 17 years of age, with HeFH as an adjunct to diet to reduce total cholesterol, LDL-C, and apo levels when, after an adequate trial of diet therapy, the following are present:oLDL-C >= 190 mg/dL, oroLDL-C >= 160 mg/dL andoa positive family history of FH, or premature CVD in first, or second-degree relative, or otwo or more other CVD risk factors are present. Use of atorvastatin calcium tablets for this indication is supported by evidence from [see Dosage and Administration (2.2), Adverse Reactions (6.1), Clinical Pharmacology (12.3), and Clinical Studies (14.6)]:oA placebo-controlled clinical trial of months duration in 187 boys and postmenarchal girls, 10 years to 17 years of age. Patients treated with 10 mg or 20 mg daily atorvastatin calcium tablets had an adverse reaction profile generally similar to that of patients treated with placebo. In this limited controlled study, there was no significant effect on growth or sexual maturation in boys or on menstrual cycle length in girls.oA 3-year open-label uncontrolled trial that included 163 pediatric patients 10 to 15 years of age with HeFH who were titrated to achieve target LDL-C 130 mg/dL. The safety and efficacy of atorvastatin calcium tablets in lowering LDL-C appeared generally consistent with that observed for adult patients, despite limitations of the uncontrolled study design.Advise postmenarchal girls of contraception recommendations, if appropriate for the patient [see Use in Specific Populations (8.1), (8.3)].The long-term efficacy of atorvastatin calcium tablet therapy initiated in childhood to reduce morbidity and mortality in adulthood has not been established.The safety and efficacy of atorvastatin calcium tablets have not been established in pediatric patients younger than 10 years of age with HeFH.. oLDL-C >= 190 mg/dL, or. oLDL-C >= 160 mg/dL andoa positive family history of FH, or premature CVD in first, or second-degree relative, or otwo or more other CVD risk factors are present. oa positive family history of FH, or premature CVD in first, or second-degree relative, or otwo or more other CVD risk factors are present.. oA placebo-controlled clinical trial of months duration in 187 boys and postmenarchal girls, 10 years to 17 years of age. Patients treated with 10 mg or 20 mg daily atorvastatin calcium tablets had an adverse reaction profile generally similar to that of patients treated with placebo. In this limited controlled study, there was no significant effect on growth or sexual maturation in boys or on menstrual cycle length in girls.. oA 3-year open-label uncontrolled trial that included 163 pediatric patients 10 to 15 years of age with HeFH who were titrated to achieve target LDL-C 130 mg/dL. The safety and efficacy of atorvastatin calcium tablets in lowering LDL-C appeared generally consistent with that observed for adult patients, despite limitations of the uncontrolled study design.. Homozygous Familial Hypercholesterolemia (HoFH). Clinical efficacy of atorvastatin calcium tablets with dosages up to 80 mg/day for year was evaluated in an uncontrolled study of patients with HoFH including pediatric patients [see Clinical Studies (14.5)].

PHARMACODYNULLMICS SECTION.


12.2 Pharmacodynamics. Atorvastatin, as well as some of its metabolites, are pharmacologically active in humans. The liver is the primary site of action and the principal site of cholesterol synthesis and LDL clearance. Drug dosage, rather than systemic drug concentration, correlates better with LDL-C reduction. Individualization of drug dosage should be based on therapeutic response [see Dosage and Administration (2)].

PHARMACOKINETICS SECTION.


12.3 Pharmacokinetics. Absorption. Atorvastatin calcium tablets are rapidly absorbed after oral administration; maximum plasma concentrations occur within to hours. Extent of absorption increases in proportion to atorvastatin calcium tablet dose. The absolute bioavailability of atorvastatin (parent drug) is approximately 14% and the systemic availability of HMG-CoA reductase inhibitory activity is approximately 30%. The low systemic availability is attributed to presystemic clearance in gastrointestinal mucosa and/or hepatic first-pass metabolism. Although food decreases the rate and extent of drug absorption by approximately 25% and 9%, respectively, as assessed by Cmax and AUC, LDL-C reduction is similar whether atorvastatin calcium tablets are given with or without food. Plasma atorvastatin concentrations are lower (approximately 30% for Cmax and AUC) following evening drug administration compared with morning. However, LDL-C reduction is the same regardless of the time of day of drug administration [see Dosage and Administration (2)]. Distribution. Mean volume of distribution of atorvastatin is approximately 381 liters. Atorvastatin is >= 98% bound to plasma proteins. blood/plasma ratio of approximately 0.25 indicates poor drug penetration into red blood cells. Based on observations in rats, atorvastatin is likely to be secreted in human milk [see Contraindications (4) and Use in Specific Populations (8.2)]. Metabolism. Atorvastatin is extensively metabolized to ortho- and parahydroxylated derivatives and various beta-oxidation products. In vitro inhibition of HMG-CoA reductase by ortho- and parahydroxylated metabolites is equivalent to that of atorvastatin. Approximately 70% of circulating inhibitory activity for HMG-CoA reductase is attributed to active metabolites. In vitro studies suggest the importance of atorvastatin metabolism by cytochrome P450 3A4, consistent with increased plasma concentrations of atorvastatin in humans following co-administration with erythromycin, known inhibitor of this isozyme [see Drug Interactions (7.1)]. In animals, the ortho-hydroxy metabolite undergoes further glucuronidation. Excretion. Atorvastatin and its metabolites are eliminated primarily in bile following hepatic and/or extra-hepatic metabolism; however, the drug does not appear to undergo enterohepatic recirculation. Mean plasma elimination half-life of atorvastatin in humans is approximately 14 hours, but the half-life of inhibitory activity for HMG-CoA reductase is 20 to 30 hours due to the contribution of active metabolites. Less than 2% of dose of atorvastatin is recovered in urine following oral administration. Specific Populations. Geriatric. Plasma concentrations of atorvastatin are higher (approximately 40% for Cmax and 30% for AUC) in healthy elderly subjects (age >= 65 years) than in young adults. Clinical data suggest greater degree of LDL-lowering at any dose of drug in the elderly patient population compared to younger adults [see Use in Specific Populations (8.5)]. Pediatric. Apparent oral clearance of atorvastatin in pediatric subjects appeared similar to that of adults when scaled allometrically by body weight as the body weight was the only significant covariate in atorvastatin population PK model with data including pediatric HeFH patients (ages 10 years to 17 years of age, = 29) in an open-label, 8-week study. Gender. Plasma concentrations of atorvastatin in women differ from those in men (approximately 20% higher for Cmax and 10% lower for AUC); however, there is no clinically significant difference in LDL-C reduction with atorvastatin calcium tablets between men and women. Renal Impairment. Renal disease has no influence on the plasma concentrations or LDL-C reduction of atorvastatin; thus, dose adjustment in patients with renal dysfunction is not necessary [see Dosage and Administration (2.5) and Warnings and Precautions (5.1)]. Hemodialysis. While studies have not been conducted in patients with end-stage renal disease, hemodialysis is not expected to significantly enhance clearance of atorvastatin since the drug is extensively bound to plasma proteins. Hepatic Impairment. In patients with chronic alcoholic liver disease, plasma concentrations of atorvastatin are markedly increased. Cmax and AUC are each 4-fold greater in patients with Childs-Pugh disease. Cmax and AUC are approximately 16-fold and 11-fold increased, respectively, in patients with Childs-Pugh disease [see Contraindications (4)].. Drug Interaction Studies. Atorvastatin is substrate of the hepatic transporters, OATP1B1 and OATP1B3 transporter. Metabolites of atorvastatin are substrates of OATP1B1. Atorvastatin is also identified as substrate of the efflux transporter BCRP, which may limit the intestinal absorption and biliary clearance of atorvastatin.Table 6: Effect of Co-administered Drugs on the Pharmacokinetics of AtorvastatinCo-administered Drug and Dosing RegimenAtorvastatinDose (mg)Ratio of AUCRepresents ratio of treatments (co-administered drug plus atorvastatin vs. atorvastatin alone).Ratio of Cmax See Sections 5.1 and for clinical significance.Cyclosporine 5.2 mg/kg/day, stable dose10 mg QDOnce daily for 28 days8.6910.66Tipranavir 500 mg BIDTwice daily/ritonavir 200 mg BID, days10 mg SDSingle dose 9.368.58Glecaprevir 400 mg QD/pibrentasvir 120 mg QD, days10 mg QD for days8.2822.00Telaprevir 750 mg q8hEvery hours, 10 days20 mg SD 7.8810.60The dose of saquinavir plus ritonavir in this study is not the clinically used dose. The increase in atorvastatin exposure when used clinically is likely to be higher than what was observed in this study. Therefore, caution should be applied and the lowest dose necessary should be used.Saquinavir 400 mg BID/ritonavir 400 mg BID, 15 days40 mg QD for days3.934.31Elbasvir 50 mg QD/grazoprevir 200 mg QD, 13 days10 mg SD 1.944.34Simeprevir 150 mg QD, 10 days40 mg SD 2.121.70Clarithromycin 500 mg BID, days80 mg QD for days4.545.38Darunavir 300 mg BID/ritonavir 100 mg BID, days10 mg QD for days3.452.25Itraconazole 200 mg QD, days40 mg SD 3.321.20Letermovir 480 mg QD, 10 days20 mg SD 3.292.17Fosamprenavir 700 mg BID/ritonavir 100 mg BID, 14 days10 mg QD for days2.532.84Fosamprenavir 1400 mg BID, 14 days10 mg QD for days2.304.04Nelfinavir 1250 mg BID, 14 days10 mg QD for 28 days1.742.22Grapefruit Juice, 240 mL QDGreater increases in AUC (ratio of AUC up to 2.5) and/or Cmax (ratio of Cmax up to 1.71) have been reported with excessive grapefruit consumption (>= 750 mL-1.2 liters per day).40 mg SD 1.371.16Diltiazem 240 mg QD, 28 days40 mg SD 1.511.00Erythromycin 500 mg QIDFour times daily, days10 mg SD 1.331.38Amlodipine 10 mg, single dose80 mg SD 1.180.91Cimetidine 300 mg QID, weeks10 mg QD for weeks1.000.89Colestipol 10 BID, 24 weeks40 mg QD for weeksNULL0.74Ratio based on single sample taken 8-16 post dose. Maalox TC(R) 30 mL QID, 17 days10 mg QD for 15 days0.660.67Efavirenz 600 mg QD, 14 days10 mg for days0.591.01Rifampin 600 mg QD, days (co-administered)Due to the dual interaction mechanism of rifampin, simultaneous co-administration of atorvastatin with rifampin is recommended, as delayed administration of atorvastatin after administration of rifampin has been associated with significant reduction in atorvastatin plasma concentrations.40 mg SD 1.122.90Rifampin 600 mg QD, days (doses separated)40 mg SD 0.200.60Gemfibrozil 600 mg BID, days40 mg SD 1.351.00Fenofibrate 160 mg QD, days40 mg SD 1.031.02Boceprevir 800 mg TIDThree times daily, days40 mg SD 2.322.66 Table 7: Effect of Atorvastatin on the Pharmacokinetics of Co-administered DrugsAtorvastatinCo-administered Drug and Dosing RegimenDrug/Dose (mg)Ratio of AUCRatio of Cmax 80 mg QDOnce daily for 15 daysAntipyrine, 600 mg SDSingle dose 1.030.8980 mg QD for 10 daysSee Section for clinical significance.Digoxin 0.25 mg QD, 20 days1.151.2040 mg QD for 22 daysOral contraceptive QD, months- norethindrone mg- ethinyl estradiol 35 ug1.281.191.231.3010 mg SD Tipranavir 500 mg BIDTwice daily/ritonavir 200 mg BID, days1.080.9610 mg QD for daysFosamprenavir 1400 mg BID, 14 days0.730.8210 mg QD for daysFosamprenavir 700 mg BID/ritonavir 100 mg BID, 14 days0.990.94Atorvastatin calcium tablets had no clinically significant effect on prothrombin time when administered to patients receiving chronic warfarin treatment.

PREGNULLNCY SECTION.


8.1 Pregnancy. Risk Summary. Atorvastatin calcium tablets are contraindicated for use in pregnant women since safety in pregnant women has not been established and there is no apparent benefit of lipid lowering drugs during pregnancy. Because HMG-CoA reductase inhibitors decrease cholesterol synthesis and possibly the synthesis of other biologically active substances derived from cholesterol, atorvastatin calcium tablets may cause fetal harm when administered to pregnant woman. Atorvastatin calcium tablets should be discontinued as soon as pregnancy is recognized [see Contraindications (4)]. Limited published data on the use of atorvastatin are insufficient to determine drug-associated risk of major congenital malformations or miscarriage. In animal reproduction studies in rats and rabbits there was no evidence of embryo-fetal toxicity or congenital malformations at doses up to 30 and 20 times, respectively, the human exposure at the maximum recommended human dose (MRHD) of 80 mg, based on body surface area (mg/m2). In rats administered atorvastatin during gestation and lactation, decreased postnatal growth and development was observed at doses >= times the MRHD (see Data).The estimated background risk of major birth defects and miscarriage for the indicated population is unknown. In the U.S. general population, the estimated background risk of major birth defects and miscarriage in clinically recognized pregnancies is 2-4% and 15-20%, respectively.. Data. Human Data Limited published data on atorvastatin calcium from observational studies, meta-analyses and case reports have not shown an increased risk of major congenital malformations or miscarriage. Rare reports of congenital anomalies have been received following intrauterine exposure to other HMG-CoA reductase inhibitors. In review of approximately 100 prospectively followed pregnancies in women exposed to simvastatin or lovastatin, the incidences of congenital anomalies, spontaneous abortions, and fetal deaths/stillbirths did not exceed what would be expected in the general population. The number of cases is adequate to exclude >= to 4-fold increase in congenital anomalies over the background incidence. In 89% of the prospectively followed pregnancies, drug treatment was initiated prior to pregnancy and was discontinued at some point in the first trimester when pregnancy was identified.. Animal Data Atorvastatin crosses the rat placenta and reaches level in fetal liver equivalent to that of maternal plasma. Atorvastatin was administered to pregnant rats and rabbits during organogenesis at oral doses up to 300 mg/kg/day and 100 mg/kg/day, respectively. Atorvastatin was not teratogenic in rats at doses up to 300 mg/kg/day or in rabbits at doses up to 100 mg/kg/day. These doses resulted in multiples of about 30 times (rat) or 20 times (rabbit) the human exposure at the MRHD based on surface area (mg/m2). In rats, the maternally toxic dose of 300 mg/kg resulted in increased post-implantation loss and decreased fetal body weight. At the maternally toxic doses of 50 and 100 mg/kg/day in rabbits, there was increased post-implantation loss, and at 100 mg/kg/day fetal body weights were decreased.In study in pregnant rats administered 20, 100, or 225 mg/kg/day from gestation day through to lactation day 20 (weaning), there was decreased survival at birth, postnatal day 4, weaning, and post-weaning in pups of mothers dosed with 225 mg/kg/day, dose at which maternal toxicity was observed. Pup body weight was decreased through postnatal day 21 at 100 mg/kg/day, and through postnatal day 91 at 225 mg/kg/day. Pup development was delayed (rotarod performance at 100 mg/kg/day and acoustic startle at 225 mg/kg/day; pinnae detachment and eye-opening at 225 mg/kg/day). These doses correspond to times (100 mg/kg) and 22 times (225 mg/kg) the human exposure at the MRHD, based on AUC.

RECENT MAJOR CHANGES SECTION.


Warnings and Precautions, Myopathy and Rhabdomyolysis (5.1) 11/2020Warnings and Precautions, Immune-Mediated Necrotizing Myopathy (5.2) 9/2020.

RISKS.


Risk Summary. Atorvastatin calcium tablets are contraindicated for use in pregnant women since safety in pregnant women has not been established and there is no apparent benefit of lipid lowering drugs during pregnancy. Because HMG-CoA reductase inhibitors decrease cholesterol synthesis and possibly the synthesis of other biologically active substances derived from cholesterol, atorvastatin calcium tablets may cause fetal harm when administered to pregnant woman. Atorvastatin calcium tablets should be discontinued as soon as pregnancy is recognized [see Contraindications (4)]. Limited published data on the use of atorvastatin are insufficient to determine drug-associated risk of major congenital malformations or miscarriage. In animal reproduction studies in rats and rabbits there was no evidence of embryo-fetal toxicity or congenital malformations at doses up to 30 and 20 times, respectively, the human exposure at the maximum recommended human dose (MRHD) of 80 mg, based on body surface area (mg/m2). In rats administered atorvastatin during gestation and lactation, decreased postnatal growth and development was observed at doses >= times the MRHD (see Data).The estimated background risk of major birth defects and miscarriage for the indicated population is unknown. In the U.S. general population, the estimated background risk of major birth defects and miscarriage in clinically recognized pregnancies is 2-4% and 15-20%, respectively.

SPL PATIENT PACKAGE INSERT SECTION.


Patient Information. Atorvastatin Calcium Tablets, USP(a tor va stat in kal see um)Read the Patient Information that comes with atorvastatin calcium tablets before you start taking them and each time you get refill. There may be new information. This leaflet does not take the place of talking with your doctor about your condition or treatment. If you have any questions about atorvastatin calcium tablets, ask your doctor or pharmacist. What are atorvastatin calcium tablets Atorvastatin calcium tablets are prescription medicine that lowers cholesterol in your blood. They lower the LDL-C (bad cholesterol) and triglycerides in your blood. They can raise your HDL-C (good cholesterol) as well. Atorvastatin calcium tablets are for adults and children over 10 whose cholesterol does not come down enough with exercise and low-fat diet alone. Atorvastatin calcium tablets can lower the risk for heart attack, stroke, certain types of heart surgery, and chest pain in patients who have heart disease or risk factors for heart disease such as: oage, smoking, high blood pressure, low HDL-C, heart disease in the family. Atorvastatin calcium tablets can lower the risk for heart attack or stroke in patients with diabetes and risk factors such as: oeye problems, kidney problems, smoking, or high blood pressure. Atorvastatin calcium tablets start to work in about weeks. What is cholesterol Cholesterol and triglycerides are fats that are made in your body. They are also found in foods. You need some cholesterol for good health, but too much is not good for you. Cholesterol and triglycerides can clog your blood vessels. It is especially important to lower your cholesterol if you have heart disease, smoke, have diabetes or high blood pressure, are older, or if heart disease starts early in your family. Who should not take atorvastatin calcium tablets Do not take atorvastatin calcium tablets if you: oare pregnant or think you may be pregnant, or are planning to become pregnant. Atorvastatin calcium tablets may harm your unborn baby. If you get pregnant, stop taking atorvastatin calcium tablets and call your doctor right away. oare breastfeeding. Atorvastatin can pass into your breast milk and may harm your baby. ohave liver problems. oare allergic to atorvastatin calcium tablets or any of their ingredients. The active ingredient is atorvastatin. See the end of this leaflet for complete list of ingredients in atorvastatin calcium tablets. Atorvastatin calcium tablet dosing has not been established in children under 10 years of age. Before you start atorvastatin calcium tablets:Tell your doctor if you: ohave muscle aches or weakness odrink more than glasses of alcohol daily ohave diabetes ohave thyroid problem ohave kidney problems Some medicines should not be taken with atorvastatin calcium tablets. Tell your doctor about all the medicines you take, including prescription and non-prescription medicines, vitamins, and herbal supplements. Atorvastatin calcium tablets and certain other medicines can interact causing serious side effects. Especially tell your doctor if you take medicines for: oyour immune system ocholesterol oinfections obirth control oheart failure oHIV or AIDS ohepatitis virusoanti-virals Know all the medicines you take. Keep list of them with you to show your doctor and pharmacist. How should take atorvastatin calcium tablets oTake atorvastatin calcium tablets exactly as prescribed by your doctor. Do not change your dose or stop atorvastatin calcium tablets without talking to your doctor. Your doctor may do blood tests to check your cholesterol levels during your treatment with atorvastatin calcium tablets. Your dose of atorvastatin calcium tablets may be changed based on these blood test results. oTake atorvastatin calcium tablets each day at any time of day at about the same time each day. Atorvastatin calcium tablets can be taken with or without food. Dont break atorvastatin calcium tablets before taking. oYour doctor should start you on low-fat diet before giving you atorvastatin calcium tablets. Stay on this low-fat diet when you take atorvastatin calcium tablets. oIf you miss dose of atorvastatin calcium tablets, take it as soon as you remember. Do not take atorvastatin calcium tablets if it has been more than 12 hours since you missed your last dose. Wait and take the next dose at your regular time. Do not take doses of atorvastatin calcium tablets at the same time. oIf you take too many atorvastatin calcium tablets or overdose, call your doctor or Poison Control Center right away. Or go to the nearest emergency room. What should avoid while taking atorvastatin calcium tablets oTalk to your doctor before you start any new medicines. This includes prescription and non-prescription medicines, vitamins, and herbal supplements. Atorvastatin calcium tablets and certain other medicines can interact causing serious side effects. oDo not get pregnant. If you get pregnant, stop taking atorvastatin calcium tablets right away and call your doctor. What are the possible side effects of atorvastatin calcium tablets Atorvastatin calcium tablets can cause serious side effects. These side effects have happened only to small number of people. Your doctor can monitor you for them. These side effects usually go away if your dose is lowered or atorvastatin calcium tablets are stopped. These serious side effects include: oMuscle problems. Atorvastatin calcium tablets can cause serious muscle problems that can lead to kidney problems, including kidney failure. You have higher chance for muscle problems if you are taking certain other medicines with atorvastatin calcium tablets. oLiver problems. Your doctor should do blood tests to check your liver before you start taking atorvastatin calcium tablets and if you have symptoms of liver problems while you take atorvastatin calcium tablets. Call your doctor right away if you have the following symptoms of liver problems:ofeel tired or weakoloss of appetiteoupper belly painodark amber colored urineoyellowing of your skin or the whites of your eyesCall your doctor right away if you have: omuscle problems like weakness, tenderness, or pain that happen without good reason, especially if you also have fever or feel more tired than usual. This may be an early sign of rare muscle problem.omuscle problems that do not go away even after your doctor has advised you to stop taking atorvastatin calcium tablets. Your doctor may do further tests to diagnose the cause of your muscle problems.oallergic reactions including swelling of the face, lips, tongue, and/or throat that may cause difficulty in breathing or swallowing which may require treatment right away. onausea and vomiting. opassing brown or dark-colored urine. oyou feel more tired than usual oyour skin and whites of your eyes get yellow. ostomach pain. oallergic skin reactions. In clinical studies, patients reported the following common side effects while taking atorvastatin calcium tablets: diarrhea, upset stomach, muscle and joint pain, and alterations in some laboratory blood tests. The following additional side effects have been reported with atorvastatin calcium tablets: tiredness, tendon problems, memory loss, and confusion. Talk to your doctor or pharmacist if you have side effects that bother you or that will not go away. These are not all the side effects of atorvastatin calcium tablets. Ask your doctor or pharmacist for complete list. Call your doctor for medical advice about side effects. You may report side effects to FDA at 1-800-FDA-1088.How do store atorvastatin calcium tabletsoStore atorvastatin calcium tablets at room temperature, 20 to 25C (68 to 77F). oDo not keep medicine that is out of date or that you no longer need. oKeep atorvastatin calcium tablets and all medicines out of the reach of children. Be sure that if you throw medicine away, it is out of the reach of children. General information about atorvastatin calcium tabletsMedicines are sometimes prescribed for conditions that are not mentioned in patient information leaflets. Do not use atorvastatin calcium tablets for condition for which they were not prescribed. Do not give atorvastatin calcium tablets to other people, even if they have the same problem you have. They may harm them. This leaflet summarizes the most important information about atorvastatin calcium tablets. If you would like more information, talk with your doctor. You can ask your doctor or pharmacist for information about atorvastatin calcium tablets that is written for health professionals. Or you can call Mylan at 1-877-446-3679 (1-877-4-INFO-RX). What are the ingredients in atorvastatin calcium tabletsActive Ingredient: atorvastatin calcium Inactive Ingredients: anhydrous lactose, anhydrous sodium carbonate, colloidal silicon dioxide, croscarmellose sodium, hydroxypropyl cellulose, L-Arginine, magnesium stearate and microcrystalline cellulose. The film coating of the tablets contains polyvinyl alcohol, talc and titanium dioxide, and may contain polyethylene glycol or lecithin and xanthan gum.Manufactured for: Mylan Pharmaceuticals Inc. Morgantown, WV 26505 U.S.A.Manufactured by: Mylan Laboratories Limited Hyderabad -- 500 096, India75078118Revised: 12/2020MX:ATOR:R16ppt/MX:PL:ATOR:R10p/MX:PL:ATOR:R10pt. oage, smoking, high blood pressure, low HDL-C, heart disease in the family. oeye problems, kidney problems, smoking, or high blood pressure.. oare pregnant or think you may be pregnant, or are planning to become pregnant. Atorvastatin calcium tablets may harm your unborn baby. If you get pregnant, stop taking atorvastatin calcium tablets and call your doctor right away. oare breastfeeding. Atorvastatin can pass into your breast milk and may harm your baby. ohave liver problems. oare allergic to atorvastatin calcium tablets or any of their ingredients. The active ingredient is atorvastatin. See the end of this leaflet for complete list of ingredients in atorvastatin calcium tablets. ohave muscle aches or weakness odrink more than glasses of alcohol daily ohave diabetes ohave thyroid problem ohave kidney problems oyour immune system ocholesterol oinfections obirth control oheart failure oHIV or AIDS ohepatitis virus. oanti-virals oTake atorvastatin calcium tablets exactly as prescribed by your doctor. Do not change your dose or stop atorvastatin calcium tablets without talking to your doctor. Your doctor may do blood tests to check your cholesterol levels during your treatment with atorvastatin calcium tablets. Your dose of atorvastatin calcium tablets may be changed based on these blood test results. oTake atorvastatin calcium tablets each day at any time of day at about the same time each day. Atorvastatin calcium tablets can be taken with or without food. Dont break atorvastatin calcium tablets before taking. oYour doctor should start you on low-fat diet before giving you atorvastatin calcium tablets. Stay on this low-fat diet when you take atorvastatin calcium tablets. oIf you miss dose of atorvastatin calcium tablets, take it as soon as you remember. Do not take atorvastatin calcium tablets if it has been more than 12 hours since you missed your last dose. Wait and take the next dose at your regular time. Do not take doses of atorvastatin calcium tablets at the same time. oIf you take too many atorvastatin calcium tablets or overdose, call your doctor or Poison Control Center right away. Or go to the nearest emergency room. oTalk to your doctor before you start any new medicines. This includes prescription and non-prescription medicines, vitamins, and herbal supplements. Atorvastatin calcium tablets and certain other medicines can interact causing serious side effects. oDo not get pregnant. If you get pregnant, stop taking atorvastatin calcium tablets right away and call your doctor. oMuscle problems. Atorvastatin calcium tablets can cause serious muscle problems that can lead to kidney problems, including kidney failure. You have higher chance for muscle problems if you are taking certain other medicines with atorvastatin calcium tablets. oLiver problems. Your doctor should do blood tests to check your liver before you start taking atorvastatin calcium tablets and if you have symptoms of liver problems while you take atorvastatin calcium tablets. Call your doctor right away if you have the following symptoms of liver problems:ofeel tired or weakoloss of appetiteoupper belly painodark amber colored urineoyellowing of your skin or the whites of your eyes. ofeel tired or weak. oloss of appetite. oupper belly pain. odark amber colored urine. oyellowing of your skin or the whites of your eyes. omuscle problems like weakness, tenderness, or pain that happen without good reason, especially if you also have fever or feel more tired than usual. This may be an early sign of rare muscle problem.. omuscle problems that do not go away even after your doctor has advised you to stop taking atorvastatin calcium tablets. Your doctor may do further tests to diagnose the cause of your muscle problems.. oallergic reactions including swelling of the face, lips, tongue, and/or throat that may cause difficulty in breathing or swallowing which may require treatment right away. onausea and vomiting. opassing brown or dark-colored urine. oyou feel more tired than usual oyour skin and whites of your eyes get yellow. ostomach pain. oallergic skin reactions. oStore atorvastatin calcium tablets at room temperature, 20 to 25C (68 to 77F). oDo not keep medicine that is out of date or that you no longer need. oKeep atorvastatin calcium tablets and all medicines out of the reach of children. Be sure that if you throw medicine away, it is out of the reach of children.

SPL UNCLASSIFIED SECTION.


1.1 Prevention of Cardiovascular Disease in Adults. In adult patients without clinically evident coronary heart disease, but with multiple risk factors for coronary heart disease such as age, smoking, hypertension, low HDL-C, or family history of early coronary heart disease, atorvastatin calcium tablets are indicated to: oReduce the risk of myocardial infarction oReduce the risk of stroke oReduce the risk for revascularization procedures and angina In adult patients with type diabetes, and without clinically evident coronary heart disease, but with multiple risk factors for coronary heart disease such as retinopathy, albuminuria, smoking, or hypertension, atorvastatin calcium tablets are indicated to: oReduce the risk of myocardial infarction oReduce the risk of strokeIn adult patients with clinically evident coronary heart disease, atorvastatin calcium tablets are indicated to: oReduce the risk of non-fatal myocardial infarction oReduce the risk of fatal and non-fatal stroke oReduce the risk for revascularization procedures oReduce the risk of hospitalization for CHF oReduce the risk of angina oReduce the risk of myocardial infarction oReduce the risk of stroke oReduce the risk for revascularization procedures and angina oReduce the risk of myocardial infarction oReduce the risk of stroke. oReduce the risk of non-fatal myocardial infarction oReduce the risk of fatal and non-fatal stroke oReduce the risk for revascularization procedures oReduce the risk of hospitalization for CHF oReduce the risk of angina.

USE IN SPECIFIC POPULATIONS SECTION.


8 USE IN SPECIFIC POPULATIONS. oHepatic impairment: Plasma concentrations markedly increased in patients with chronic alcoholic liver disease (8.6, 12.3). oFemales of reproductive potential: Advise females of reproductive potential to use effective contraception during treatment with atorvastatin calcium tablets (8.3). oHepatic impairment: Plasma concentrations markedly increased in patients with chronic alcoholic liver disease (8.6, 12.3). oFemales of reproductive potential: Advise females of reproductive potential to use effective contraception during treatment with atorvastatin calcium tablets (8.3). 8.1 Pregnancy. Risk Summary. Atorvastatin calcium tablets are contraindicated for use in pregnant women since safety in pregnant women has not been established and there is no apparent benefit of lipid lowering drugs during pregnancy. Because HMG-CoA reductase inhibitors decrease cholesterol synthesis and possibly the synthesis of other biologically active substances derived from cholesterol, atorvastatin calcium tablets may cause fetal harm when administered to pregnant woman. Atorvastatin calcium tablets should be discontinued as soon as pregnancy is recognized [see Contraindications (4)]. Limited published data on the use of atorvastatin are insufficient to determine drug-associated risk of major congenital malformations or miscarriage. In animal reproduction studies in rats and rabbits there was no evidence of embryo-fetal toxicity or congenital malformations at doses up to 30 and 20 times, respectively, the human exposure at the maximum recommended human dose (MRHD) of 80 mg, based on body surface area (mg/m2). In rats administered atorvastatin during gestation and lactation, decreased postnatal growth and development was observed at doses >= times the MRHD (see Data).The estimated background risk of major birth defects and miscarriage for the indicated population is unknown. In the U.S. general population, the estimated background risk of major birth defects and miscarriage in clinically recognized pregnancies is 2-4% and 15-20%, respectively.. Data. Human Data Limited published data on atorvastatin calcium from observational studies, meta-analyses and case reports have not shown an increased risk of major congenital malformations or miscarriage. Rare reports of congenital anomalies have been received following intrauterine exposure to other HMG-CoA reductase inhibitors. In review of approximately 100 prospectively followed pregnancies in women exposed to simvastatin or lovastatin, the incidences of congenital anomalies, spontaneous abortions, and fetal deaths/stillbirths did not exceed what would be expected in the general population. The number of cases is adequate to exclude >= to 4-fold increase in congenital anomalies over the background incidence. In 89% of the prospectively followed pregnancies, drug treatment was initiated prior to pregnancy and was discontinued at some point in the first trimester when pregnancy was identified.. Animal Data Atorvastatin crosses the rat placenta and reaches level in fetal liver equivalent to that of maternal plasma. Atorvastatin was administered to pregnant rats and rabbits during organogenesis at oral doses up to 300 mg/kg/day and 100 mg/kg/day, respectively. Atorvastatin was not teratogenic in rats at doses up to 300 mg/kg/day or in rabbits at doses up to 100 mg/kg/day. These doses resulted in multiples of about 30 times (rat) or 20 times (rabbit) the human exposure at the MRHD based on surface area (mg/m2). In rats, the maternally toxic dose of 300 mg/kg resulted in increased post-implantation loss and decreased fetal body weight. At the maternally toxic doses of 50 and 100 mg/kg/day in rabbits, there was increased post-implantation loss, and at 100 mg/kg/day fetal body weights were decreased.In study in pregnant rats administered 20, 100, or 225 mg/kg/day from gestation day through to lactation day 20 (weaning), there was decreased survival at birth, postnatal day 4, weaning, and post-weaning in pups of mothers dosed with 225 mg/kg/day, dose at which maternal toxicity was observed. Pup body weight was decreased through postnatal day 21 at 100 mg/kg/day, and through postnatal day 91 at 225 mg/kg/day. Pup development was delayed (rotarod performance at 100 mg/kg/day and acoustic startle at 225 mg/kg/day; pinnae detachment and eye-opening at 225 mg/kg/day). These doses correspond to times (100 mg/kg) and 22 times (225 mg/kg) the human exposure at the MRHD, based on AUC. 8.2 Lactation Risk Summary. Atorvastatin calcium tablet use is contraindicated during breastfeeding [see Contraindications (4)]. There is no available information on the effects of the drug on the breastfed infant or the effects of the drug on milk production. It is not known whether atorvastatin is present in human milk, but it has been shown that another drug in this class passes into human milk and atorvastatin is present in rat milk. Because of the potential for serious adverse reactions in breastfed infant, advise women that breastfeeding is not recommended during treatment with atorvastatin calcium tablets. 8.3 Females and Males of Reproductive Potential Contraception. Atorvastatin calcium tablets may cause fetal harm when administered to pregnant woman. Advise females of reproductive potential to use effective contraception during treatment with atorvastatin calcium tablets [see Use in Specific Populations (8.1)]. 8.4 Pediatric Use. Heterozygous Familial Hypercholesterolemia (HeFH). The safety and effectiveness of atorvastatin calcium tablets have been established in pediatric patients,10 years to 17 years of age, with HeFH as an adjunct to diet to reduce total cholesterol, LDL-C, and apo levels when, after an adequate trial of diet therapy, the following are present:oLDL-C >= 190 mg/dL, oroLDL-C >= 160 mg/dL andoa positive family history of FH, or premature CVD in first, or second-degree relative, or otwo or more other CVD risk factors are present. Use of atorvastatin calcium tablets for this indication is supported by evidence from [see Dosage and Administration (2.2), Adverse Reactions (6.1), Clinical Pharmacology (12.3), and Clinical Studies (14.6)]:oA placebo-controlled clinical trial of months duration in 187 boys and postmenarchal girls, 10 years to 17 years of age. Patients treated with 10 mg or 20 mg daily atorvastatin calcium tablets had an adverse reaction profile generally similar to that of patients treated with placebo. In this limited controlled study, there was no significant effect on growth or sexual maturation in boys or on menstrual cycle length in girls.oA 3-year open-label uncontrolled trial that included 163 pediatric patients 10 to 15 years of age with HeFH who were titrated to achieve target LDL-C 130 mg/dL. The safety and efficacy of atorvastatin calcium tablets in lowering LDL-C appeared generally consistent with that observed for adult patients, despite limitations of the uncontrolled study design.Advise postmenarchal girls of contraception recommendations, if appropriate for the patient [see Use in Specific Populations (8.1), (8.3)].The long-term efficacy of atorvastatin calcium tablet therapy initiated in childhood to reduce morbidity and mortality in adulthood has not been established.The safety and efficacy of atorvastatin calcium tablets have not been established in pediatric patients younger than 10 years of age with HeFH.. oLDL-C >= 190 mg/dL, or. oLDL-C >= 160 mg/dL andoa positive family history of FH, or premature CVD in first, or second-degree relative, or otwo or more other CVD risk factors are present. oa positive family history of FH, or premature CVD in first, or second-degree relative, or otwo or more other CVD risk factors are present.. oA placebo-controlled clinical trial of months duration in 187 boys and postmenarchal girls, 10 years to 17 years of age. Patients treated with 10 mg or 20 mg daily atorvastatin calcium tablets had an adverse reaction profile generally similar to that of patients treated with placebo. In this limited controlled study, there was no significant effect on growth or sexual maturation in boys or on menstrual cycle length in girls.. oA 3-year open-label uncontrolled trial that included 163 pediatric patients 10 to 15 years of age with HeFH who were titrated to achieve target LDL-C 130 mg/dL. The safety and efficacy of atorvastatin calcium tablets in lowering LDL-C appeared generally consistent with that observed for adult patients, despite limitations of the uncontrolled study design.. Homozygous Familial Hypercholesterolemia (HoFH). Clinical efficacy of atorvastatin calcium tablets with dosages up to 80 mg/day for year was evaluated in an uncontrolled study of patients with HoFH including pediatric patients [see Clinical Studies (14.5)].. 8.5 Geriatric Use. Of the 39,828 patients who received atorvastatin calcium tablets in clinical studies, 15,813 (40%) were >= 65 years old and 2,800 (7%) were >= 75 years old. No overall differences in safety or effectiveness were observed between these subjects and younger subjects, and other reported clinical experience has not identified differences in responses between the elderly and younger patients, but greater sensitivity of some older adults cannot be ruled out. Since advanced age (>= 65 years) is predisposing factor for myopathy, atorvastatin calcium tablets should be prescribed with caution in the elderly. 8.6 Hepatic Impairment. Atorvastatin calcium tablets are contraindicated in patients with active liver disease which may include unexplained persistent elevations in hepatic transaminase levels [see Contraindications (4) and Clinical Pharmacology (12.3)].

WARNINGS AND PRECAUTIONS SECTION.


5 WARNINGS AND PRECAUTIONS. oMyopathy and Rhabdomyolysis: Risks increase when higher doses are used concomitantly with cyclosporine and strong CYP3A4 inhibitors (e.g., clarithromycin, itraconazole, human immunodeficiency virus (HIV) or hepatitis virus (HCV) protease inhibitors). Predisposing factors include advanced age (> 65), uncontrolled hypothyroidism, and renal impairment. Rare cases of rhabdomyolysis with acute renal failure secondary to myoglobinuria have been reported. Advise patients to promptly report to their physician unexplained and/or persistent muscle pain, tenderness, or weakness. Atorvastatin calcium tablet therapy should be discontinued if myopathy is diagnosed or suspected (2.6, 5.1, 8.5). oImmune-Mediated Necrotizing Myopathy (IMNM): There have been rare reports of IMNM, an autoimmune myopathy, associated with statin use. IMNM is characterized by: proximal muscle weakness and elevated serum creatine kinase, which persist despite discontinuation of statin treatment; positive anti-HMG CoA reductase antibody; muscle biopsy showing necrotizing myopathy; and improvement with immunosuppressive agents (5.2).oLiver enzyme abnormalities: Persistent elevations in hepatic transaminases can occur. Check liver enzyme tests before initiating therapy and as clinically indicated thereafter (5.3). oA higher incidence of hemorrhagic stroke was seen in patients without CHD but with stroke or TIA within the previous months in the atorvastatin calcium tablets 80 mg group vs. placebo (5.6).. oMyopathy and Rhabdomyolysis: Risks increase when higher doses are used concomitantly with cyclosporine and strong CYP3A4 inhibitors (e.g., clarithromycin, itraconazole, human immunodeficiency virus (HIV) or hepatitis virus (HCV) protease inhibitors). Predisposing factors include advanced age (> 65), uncontrolled hypothyroidism, and renal impairment. Rare cases of rhabdomyolysis with acute renal failure secondary to myoglobinuria have been reported. Advise patients to promptly report to their physician unexplained and/or persistent muscle pain, tenderness, or weakness. Atorvastatin calcium tablet therapy should be discontinued if myopathy is diagnosed or suspected (2.6, 5.1, 8.5). oImmune-Mediated Necrotizing Myopathy (IMNM): There have been rare reports of IMNM, an autoimmune myopathy, associated with statin use. IMNM is characterized by: proximal muscle weakness and elevated serum creatine kinase, which persist despite discontinuation of statin treatment; positive anti-HMG CoA reductase antibody; muscle biopsy showing necrotizing myopathy; and improvement with immunosuppressive agents (5.2).. oLiver enzyme abnormalities: Persistent elevations in hepatic transaminases can occur. Check liver enzyme tests before initiating therapy and as clinically indicated thereafter (5.3). oA higher incidence of hemorrhagic stroke was seen in patients without CHD but with stroke or TIA within the previous months in the atorvastatin calcium tablets 80 mg group vs. placebo (5.6).. 5.1 Myopathy and Rhabdomyolysis. Atorvastatin calcium tablets may cause myopathy (muscle pain, tenderness, or weakness with creatine kinase (CK) above ten times the upper limit of normal) and rhabdomyolysis (with or without acute renal failure secondary to myoglobinuria). Rare fatalities have occurred as result of rhabdomyolysis with statin use, including atorvastatin calcium tablets.. Risk Factors for Myopathy. Risk factors for myopathy include age 65 years or greater, uncontrolled hypothyroidism, renal impairment, concomitant use with certain other drugs, and higher atorvastatin calcium tablet dosage [see Drug Interactions (7.1) ].. Steps to Prevent or Reduce the Risk of Myopathy and Rhabdomyolysis. Atorvastatin exposure may be increased by drug interactions due to inhibition of cytochrome P450 enzyme 3A4 (CYP3A4) and/or transporters (e.g., breast cancer resistant protein [BCRP], organic anion-transporting polypeptide [OATP1B1/OATP1B3] and P-glycoprotein [P-gp]), resulting in an increased risk of myopathy and rhabdomyolysis. Concomitant use of cyclosporine, gemfibrozil, tipranavir plus ritonavir, or glecaprevir plus pibrentasvir with atorvastatin calcium tablets is not recommended. Atorvastatin calcium tablet dosage modifications are recommended for patients taking certain anti-viral, azole antifungals, or macrolide antibiotic medications [see Dosage and Administration (2.6)]. Cases of myopathy/rhabdomyolysis have been reported with atorvastatin co-administered with lipid modifying doses (> gram/day) of niacin, fibrates, colchicine, and ledipasvir plus sofosbuvir. Consider if the benefit of use of these products outweighs the increased risk of myopathy and rhabdomyolysis [see Drug Interactions (7.1)].Concomitant intake of large quantities, more than 1.2 liters daily, of grapefruit juice is not recommended in patients taking atorvastatin calcium tablets [see Drug Interactions (7.1)].Discontinue atorvastatin calcium tablets if markedly elevated CK levels occur or myopathy is diagnosed or suspected. Muscle symptoms and CK increases may resolve if atorvastatin calcium tablets are discontinued. Temporarily discontinue atorvastatin calcium tablets in patients experiencing an acute or serious condition at high risk of developing renal failure secondary to rhabdomyolysis (e.g., sepsis; shock; severe hypovolemia; major surgery; trauma; severe metabolic, endocrine, or electrolyte disorders; or uncontrolled epilepsy).Inform patients of the risk of myopathy and rhabdomyolysis when starting or increasing the atorvastatin calcium tablet dosage. Instruct patients to promptly report any unexplained muscle pain, tenderness or weakness, particularly if accompanied by malaise or fever.. 5.2Immune-Mediated Necrotizing Myopathy There have been rare reports of immune-mediated necrotizing myopathy (IMNM), an autoimmune myopathy, associated with statin use. IMNM is characterized by: proximal muscle weakness and elevated serum creatine kinase, which persist despite discontinuation of statin treatment; positive anti-HMG CoA reductase antibody; muscle biopsy showing necrotizing myopathy; and improvement with immunosuppressive agents. Additional neuromuscular and serologic testing may be necessary. Treatment with immunosuppressive agents may be required. Consider risk of IMNM carefully prior to initiation of different statin. If therapy is initiated with different statin, monitor for signs and symptoms of IMNM.. 5.3 Liver Dysfunction. Statins, like some other lipid-lowering therapies, have been associated with biochemical abnormalities of liver function. Persistent elevations (> times the upper limit of normal [ULN] occurring on or more occasions) in serum transaminases occurred in 0.7% of patients who received atorvastatin calcium tablets in clinical trials. The incidence of these abnormalities was 0.2%, 0.2%, 0.6%, and 2.3% for 10, 20, 40, and 80 mg, respectively. One patient in clinical trials developed jaundice. Increases in liver function tests (LFT) in other patients were not associated with jaundice or other clinical signs or symptoms. Upon dose reduction, drug interruption, or discontinuation, transaminase levels returned to or near pretreatment levels without sequelae. Eighteen of 30 patients with persistent LFT elevations continued treatment with reduced dose of atorvastatin calcium tablets. It is recommended that liver enzyme tests be obtained prior to initiating therapy with atorvastatin calcium tablets and repeated as clinically indicated. There have been rare postmarketing reports of fatal and non-fatal hepatic failure in patients taking statins, including atorvastatin. If serious liver injury with clinical symptoms and/or hyperbilirubinemia or jaundice occurs during treatment with atorvastatin calcium tablets, promptly interrupt therapy. If an alternate etiology is not found, do not restart atorvastatin calcium tablets.Atorvastatin calcium tablets should be used with caution in patients who consume substantial quantities of alcohol and/or have history of liver disease. Active liver disease or unexplained persistent transaminase elevations are contraindications to the use of atorvastatin calcium tablets [see Contraindications (4)]. 5.4 Endocrine Function. Increases in HbA1c and fasting serum glucose levels have been reported with HMG-CoA reductase inhibitors, including atorvastatin calcium tablets.Statins interfere with cholesterol synthesis and theoretically might blunt adrenal and/or gonadal steroid production. Clinical studies have shown that atorvastatin calcium tablets do not reduce basal plasma cortisol concentration or impair adrenal reserve. The effects of statins on male fertility have not been studied in adequate numbers of patients. The effects, if any, on the pituitary-gonadal axis in premenopausal women are unknown. Caution should be exercised if statin is administered concomitantly with drugs that may decrease the levels or activity of endogenous steroid hormones, such as ketoconazole, spironolactone, and cimetidine. 5.5 CNS Toxicity. Brain hemorrhage was seen in female dog treated for months at 120 mg/kg/day. Brain hemorrhage and optic nerve vacuolation were seen in another female dog that was sacrificed in moribund condition after 11 weeks of escalating doses up to 280 mg/kg/day. The 120 mg/kg dose resulted in systemic exposure approximately 16 times the human plasma area-under-the-curve (AUC, 0-24 hours) based on the maximum human dose of 80 mg/day. single tonic convulsion was seen in each of male dogs (one treated at 10 mg/kg/day and one at 120 mg/kg/day) in 2-year study. No CNS lesions have been observed in mice after chronic treatment for up to years at doses up to 400 mg/kg/day or in rats at doses up to 100 mg/kg/day. These doses were to 11 times (mouse) and to 16 times (rat) the human AUC (0-24) based on the maximum recommended human dose of 80 mg/day. CNS vascular lesions, characterized by perivascular hemorrhages, edema, and mononuclear cell infiltration of perivascular spaces, have been observed in dogs treated with other members of this class. chemically similar drug in this class produced optic nerve degeneration (Wallerian degeneration of retinogeniculate fibers) in clinically normal dogs in dose-dependent fashion at dose that produced plasma drug levels about 30 times higher than the mean drug level in humans taking the highest recommended dose. 5.6 Use in Patients with Recent Stroke or TIA. In post-hoc analysis of the Stroke Prevention by Aggressive Reduction in Cholesterol Levels (SPARCL) study where atorvastatin calcium tablets 80 mg vs. placebo was administered in 4,731 subjects without CHD who had stroke or TIA within the preceding months, higher incidence of hemorrhagic stroke was seen in the atorvastatin calcium tablets 80 mg group compared to placebo (55, 2.3% atorvastatin vs. 33, 1.4% placebo; HR: 1.68, 95% CI: 1.09, 2.59; = 0.0168). The incidence of fatal hemorrhagic stroke was similar across treatment groups (17 vs. 18 for the atorvastatin and placebo groups, respectively). The incidence of non-fatal hemorrhagic stroke was significantly higher in the atorvastatin group (38, 1.6%) as compared to the placebo group (16, 0.7%). Some baseline characteristics, including hemorrhagic and lacunar stroke on study entry, were associated with higher incidence of hemorrhagic stroke in the atorvastatin group [see Adverse Reactions (6.1)].