Prescription Drugs

CLINICAL PHARMACOLOGY Mechanism Of Action LIPITOR is a selective, competitive inhibitor of HMG-CoA reductase, the rate-limiting enzyme that converts 3-hydroxy-3methylglutaryl-coenzyme A to mevalonate, a precursor of sterols, including cholesterol. In animal models, LIPITOR 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; LIPITOR also reduces LDL production and the number of LDL particles. Pharmacodynamics LIPITOR, 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]. Pharmacokinetics Absorption LIPITOR is rapidly absorbed after oral administration; maximum plasma concentrations occur within 1 to 2hours. Extent of absorption increases in proportion to LIPITOR 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 LIPITOR is given with or without food. Plasma LIPITOR 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]. Distribution Mean volume of distribution of LIPITOR is approximately 381 liters. LIPITOR is ≥ 98% bound to plasma proteins. A blood/plasma ratio of approximately 0.25 indicates poor drug penetration into red blood cells. Based on observations in rats, LIPITOR is likely to be secreted in human milk [see CONTRAINDICATIONS and Use in Specific Populations]. Metabolism LIPITOR 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 LIPITOR. Approximately 70% of circulating inhibitory activity for HMG-CoA reductase is attributed to active metabolites. In vitro studies suggest the importance of LIPITOR metabolism by cytochrome P450 3A4, consistent with increased plasma concentrations of LIPITOR in humans following co-administration with erythromycin, a known inhibitor of this isozyme [see DRUG INTERACTIONS]. In animals, the ortho-hydroxy metabolite undergoes further glucuronidation. Excretion LIPITOR 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 LIPITOR in humans is approximately 14hours, but the half-life of inhibitory activity for HMG-CoA reductase is 20 to 30hours due to the contribution of active metabolites. Less than2% of a dose of LIPITOR is recovered in urine following oral administration. Specific Populations Geriatric: Plasma concentrations of LIPITOR are higher (approximately 40% for Cmax and 30% for AUC)in healthy elderly subjects(age ≥ 65years)than in young adults. Clinical data suggest a greater degree of LDL-lowering at any dose of drug in the elderly patient population compared to younger adults [see Use in Specific Populations]. 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 10years to 17years of age, n=29) in an open-label, 8-week study. Gender: Plasma concentrations of LIPITOR 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 LIPITOR between men and women. Renal Impairment: Renal disease has no influence on the plasma concentrations or LDL-C reduction of LIPITOR; thus, dose adjustment in patients with renal dysfunction is not necessary [see DOSAGE AND ADMINISTRATION and WARNINGS AND PRECAUTIONS]. Hemodialysis: While studies have not been conducted in patients with end-stage renal disease, hemodialysis is not expected to significantly enhance clearance of LIPITOR since the drug is extensively bound to plasma proteins. Hepatic Impairment: In patients with chronic alcoholic liver disease, plasma concentrations of LIPITOR are markedly increased. Cmax and AUC are each 4-fold greater in patients with Childs-Pugh A disease. Cmax and AUC are approximately 16-fold and 11-fold increased, respectively, in patients with Childs-Pugh B disease [see CONTRAINDICATIONS]. TABLE 4: Effect of Co-administered Drugs on the Pharmacokinetics of Atorvastatin Co-administered drug and dosing regimen Atorvastatin Dose (mg) Change in AUC& Change in Cmax& #Cyclosporine 5.2 mg/kg/day, stable dose 10 mg QD for 28 days ↑ 8.7 fold ↑10.7 fold #Tipranavir 500 mg BID/ritonavir 200 mg BID, 7 days 10 mg, SD ↑ 9.4 fold ↑8.6 fold #Telaprevir 750 mg q8h, 10 days 20 mg, SD ↑ 7.88 fold ↑10.6 fold #‡Saquinavir 400 mg BID/ ritonavir 400mg BID, 15 days 40 mg QD for 4 days ↑3.9 fold ↑4.3 fold Clarithromycin 500 mg BID, 9 days 80 mg QD for 8 days ↑4.4 fold ↑ 5.4 fold #Darunavir 300 mg BID/ritonavir 100 mg BID, 9 days 10 mg QD for 4 days ↑3.4 fold ↑2.25 fold #Itraconazole 200 mg QD, 4 days 40 mg SD ↑ 3.3 fold ↑20% #Fosamprenavir 700 mg BID/ritonavir 100 mg BID, 14 days 10 mg QD for 4 days ↑2.53 fold ↑2.84 fold #Fosamprenavir 1400 mg BID, 14 days 10 mg QD for 4 days ↑2.3 fold ↑4.04 fold #Nelfinavir 1250 mg BID, 14 days 10 mg QD for 28 days ↑74% ↑2.2 fold #Grapefruit Juice, 240 mL QD * 40 mg, SD ↑ 37% ↑16% Diltiazem 240 mg QD, 28 days 40 mg, SD ↑ 51% No change Erythromycin 500 mg QID, 7 days 10 mg, SD ↑ 33% ↑ 38% Amlodipine 10 mg, single dose 80 mg, SD ↑15% ↓ 12 % Cimetidine 300 mg QID, 2 weeks 10 mg QD for 2 weeks ↓ Less than 1% ↓ 11% Colestipol 10 mg BID, 28 weeks 40 mg QD for 28 weeks Not determined ↓26%** MaaloxTC® 30 mL QD, 17 days 10 mg QD for 15 days ↓33% ↓ 34% Efavirenz 600 mg QD, 14 days 10 mg for 3 days ↓ 41% ↓1% #Rifampin 600 mg QD, 7 days (coadministered) † 40 mg SD ↑ 30% ↑2.7 fold #Rifampin 600 mg QD, 5 days (doses separated)† 40 mg SD ↓ 80% ↓ 40% #Gemfibrozil 600mg BID, 7 days 40mg SD ↑ 35% ↓ Less than 1% #Fenofibrate 160mg QD, 7 days 40mg SD ↑ 3% ↑ 2% Boceprevir 800 mg TID, 7 days 40 mg SD ↑2.30 fold ↑2.66 fold & Data given as x-fold change represent a simple ratio between co-administration and atorvastatin alone (i.e., 1-fold = no change).Data given as% change represent% difference relative to atorvastatin alone (i.e., 0% = no change). # See Sections WARNINGS AND PRECAUTIONS and DOSAGE AND ADMINISTRATION for clinical significance. * Greater increases in AUC (up to2.5fold)and/or Cmax(up to 71%)have been reported with excessive grapefruit consumption ( ≥ 750 mL -1.2 liters per day). ** Single sample taken 8-16h post dose. † 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 a significant reduction in atorvastatin plasma concentrations. ‡ The dose of saquinavir plus ritonavir in this study is not the clinically used dose. The increase in atorvastatin exposure when used clinicallyis likely to be higher than what was observed in this study. Therefore, caution should be applied and the lowest dose necessary should be used. TABLE 5: Effect of Atorvastatin on the Pharmacokinetics of Co-administered Drugs Atorvastatin Co-administered drug and dosing regimen Drug/Dose (mg) Change in AUC Change in Cmax 80 mg QD for 15 days Antipyrine, 600 mg SD ↑3% ↓ 11% 80 mg QD for 14 days # Digoxin 0.25 mg QD, 20 days ↑ 15% ↑ 20 % 40 mg QD for 22 days Oral contraceptive QD, 2 months norethindrone 1mg ↑ 28% ↑ 23% ethinyl estradiol 35μg ↑ 19% ↑ 30% 10 mg, SD Tipranavir 500 mg BID/ritonavir 200 mg BID, 7 days No change No change 10 mg QD for 4 days Fosamprenavir 1400 mg BID, 14 days ↓ 27% ↓ 18% 10 mg QD for 4 days Fosamprenavir 700 mg BID/ritonavir 100 mg BID, 14 days No change No change # See DOSAGE AND ADMINISTRATION for clinical significance. Clinical Studies Prevention Of Cardiovascular Disease In the Anglo-Scandinavian Cardiac Outcomes Trial (ASCOT), the effect of LIPITOR on fatal and non-fatal coronary heart disease was assessed in 10,305 hypertensive patients 40-80 years of age (mean of 63years), without a previous myocardial infarction and with TC levels ≤ 251mg/dL (6.5mmol/L). Additionally, all patients had at least 3 of the following cardiovascular risk factors: male gender (81.1%), age > 55years (84.5%),smoking (33.2%),diabetes (24.3%), history of CHD in a 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 mmHg for non-diabetic patients; < 130/80 mmHg for diabetic patients) and allocated to either LIPITOR10mg daily (n=5168) or placebo (n=5137), using a 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 a median duration of 3.3 years. The effect of 10mg/day of LIPITOR on lipid levels was similar to that seen in previous clinical trials. LIPITOR significantly reduced the rate of coronary events [either fatal coronary heart disease (46 events in the placebo group vs. 40 events in the LIPITOR group) or non-fatal MI (108 events in the placebo group vs. 60 events in the LIPITOR group)] with a relative risk reduction of 36% [(based on incidences of 1.9% for LIPITOR vs. 3.0% for placebo), p=0.0005 (see Figure 1)].The risk reduction was consistent regardless of age, smoking status, obesity, or presence of renal dysfunction. The effect of LIPITOR was seen regardless of baseline LDL levels. Due to the small number of events, results for women were inconclusive. Figure 1: Effect of LIPITOR 10 mg/day on Cumulative Incidence of Non-Fatal Myocardial Infarction or Coronary Heart Disease Death (in ASCOT-LLA) LIPITOR also significantly decreased the relative risk for revascularization procedures by 42%(incidences of 1.4% for LIPITOR and 2.5% for placebo). Although the reduction of fatal and non-fatal strokes did not reach a pre-defined significance level (p=0.01), a favorable trend was observed with a 26% relative risk reduction (incidences of 1.7% for LIPITOR and 2.3% for placebo). There was no significant difference between the treatment groups for death due to cardiovascular causes (p=0.51) or non-cardiovascular causes (p=0.17). In the Collaborative Atorvastatin Diabetes Study (CARDS), the effect of LIPITOR on cardiovascular disease (CVD)endpoints was assessed in 2838subjects (94%white, 68% male), ages 40-75with type 2 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 1 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 clinicaltrial, subjects were randomly allocated to either LIPITOR 10mg daily (1429) or placebo (1411) ina1:1ratio and were followed for a median duration of 3.9 years. The primary endpoint was the occurrence of any of the major cardiovascular events: myocardial infarction, acute CHD death, unstableangina, 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 HbA1c7.7%; 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 LIPITOR 10mg/day on lipid levels was similar to that seen in previous clinical trials. LIPITOR significantly reduced the rate of major cardiovascular events (primary endpoint events) (83 events in the LIPITOR group vs. 127events in the placebo group) with a relative risk reduction of 37%, HR0.63,95%CI(0.48, 0.83)(p=0.001)(see Figure 2). An effect of LIPITOR was seen regardless of age, sex, or baseline lipid levels. LIPITOR significantly reduced the risk of stroke by 48% (21events in the LIPITOR 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 LIPITOR 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 61deaths in the LIPITOR group vs. 82 deaths in the placebo group (HR 0.73, p=0.059). Figure 2: Effect of LIPITOR 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 LIPITOR80 mg/day vs. LIPITOR10 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 a target LDL-C level < 130 mg/dL after completing an 8-week, open-label, run-in period with LIPITOR 10 mg/day. Subjects were randomly assigned to either 10 mg/day or 80 mg/day of LIPITOR and followed for a 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 cardiacarrest, 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 47mg/dL during treatment with 80 mg of LIPITOR and 99, 177, 152, 129, and 48mg/dL during treatment with 10mg of LIPITOR. Treatment with LIPITOR80mg/day significantly reduced the rate of MCVE(434 events in the 80 mg/day group vs. 548eventsin the 10 mg/day group) with a relative risk reduction of 22%, HR0.78,95%CI(0.69, 0.89),p=0.0002(see Figure 3 and Table6). The overallrisk reduction was consistent regardless of age( < 65, ≥ 65) or gender. Figure 3:Effect of LIPITOR 80mg/day vs.10 mg/day on Time to Occurrence of Major Cardiovascular Events (TNT) TABLE 6: Overview of Efficacy Results in TNT Endpoint Atorvastatin 10 mg (N=5006) Atorvastatin 80 mg (N=4995) HRa (95% CI) PRIMARY ENDPOINT n (%) n (%) First major cardiovascular endpoint 548 (10.9) 434 (8.7) 0.78 (0.69, 0.89) Components of the Primary Endpoint CHD death 127 (2.5) 101 (2.0) 0.80 (0.61, 1.03) Non-fatal, non-procedure related MI 308 (6.2) 243 (4.9) 0.78 (0.66, 0.93) Resuscitated cardiac arrest 26 (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 ENDPOINTS * First CHF with hospitalization 164 (3.3) 122 (2.4) 0.74 (0.59, 0.94) First PVD endpoint 282 (5.6) 275 (5.5) 0.97 (0.83, 1.15) First CABG or other coronary revascularization procedureb 904 (18.1) 667 (13.4) 0.72 (0.65, 0.80) First documented angina endpointb 615 (12.3) 545 (10.9) 0.88 (0.79, 0.99) All-cause mortality 282 (5.6) 284 (5.7) 1.01 (0.85, 1.19) Components of All-Cause Mortality Cardiovascular death 155 (3.1) 126 (2.5) 0.81 (0.64, 1.03) Noncardiovascular death 127 (2.5) 158 (3.2) 1.25 (0.99, 1.57) Cancer death 75 (1.5) 85 (1.7) 1.13 (0.83, 1.55) Other non-CVdeath 43 (0.9) 58 (1.2) 1.35 (0.91, 2.00) Suicide, homicide, and other traumatic non-CVdeath 9 (0.2) 15 (0.3) 1.67 (0.73, 3.82) a Atorvastatin 80 mg:atorvastatin 10 mg b Component of other secondary endpoints * Secondary endpoints not included in primary endpoint HR=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 graft Confidence intervals for the Secondary Endpoints were not adjusted for multiple comparisons Of the events that comprised the primary efficacy endpoint, treatment with LIPITOR 80 mg/day significantly reduced the rate of nonfatal, non-procedure related MI and fatal and non-fatal stroke, but not CHD death or resuscitated cardiac arrest (Table6). Of the predefined secondary endpoints, treatment with LIPITOR 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 a prior history of CHF. There was no significant difference between the treatment groups for all-cause mortality (Table6). The proportions of subjects who experienced cardiovascular death, including the components of CHD death and fatal stroke, were numerically smaller in the LIPITOR 80 mg group than in the LIPITOR 10 mg treatment group. The proportions of subjects who experienced non-cardiovascular death were numerically larger in the LIPITOR80 mg group than in the LIPITOR 10 mg treatment group. In the Incremental Decrease in Endpoints Through Aggressive Lipid Lowering Study (IDEAL), treatment with LIPITOR80mg/day was compared to treatment with simvastatin 20-40 mg/day in 8,888 subjects up to80 years of age with a 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 61.7years, and an average LDL-Cof121.5 mg/dL at randomization; 76% were on stat in therapy. In this prospective, randomized, open-label, blinded endpoint (PROBE)trial with no run-in period, subjects were followed for a 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 100mg/dL during treatment with 80 mg of LIPITOR and105,179, 142, 47, and 132mg/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 LIPITOR80 mg/day group vs. 463 (10.4%) in the simvastatin 20-40 mg/day group, HR 0.89, 95% CI ( 0.78, 1.01), p=0.07. There were no significant differences between the treatment groups for all-cause mortality: 366 (8.2%) in the LIPITOR 80mg/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 LIPITOR 80 mg group and the simvastatin 20-40 mg group. Hyperlipidemia And Mixed Dyslipidemia LIPITOR reduces total-C, LDL-C, VLDL-C, apo B, and TG, and increases HDL-C in patients with hyperlipidemia (heterozygous familial and non familial)and mixed dyslipidemia(Fredrickson Types IIa and IIb). Therapeutic response is seen within 2 weeks, and maximum response is usually achieved within 4 weeks and maintained during chronic therapy. LIPITOR is effective in a 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, LIPITOR given as a single doseover 6weeks,significantly reduced total-C, LDL-C, apo B, and TG.(Pooled results are provided in Table7.) TABLE 7: Dose Response in Patients With Primary Hyperlipidemia (Adjusted Mean % Change From Baseline)a Dose N TC LDL-C Apo B TG HDL-C Non-HDL-C/ HDL-C Placebo 21 4 4 3 10 -3 7 10 22 -29 -39 -32 -19 6 -34 20 20 -33 -43 -35 -26 9 -41 40 21 -37 -50 -42 -29 6 -45 80 23 -45 -60 -50 -37 5 -53 a Results are pooled from 2dose-response studies. In patients with Fredrickson Types IIa and IIb hyperlipoproteinemia pooled from 24controlled trials, the median (25th and 75th percentile) percent changes from baseline in HDL-C for LIPITOR 10, 20, 40, and80mg 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, LIPITOR was compared to other statins. After randomization, patients were treated for 16 weeks with either LIPITOR10mgper day or afixed dose of the comparative agent (Table 8). TABLE 8: Mean Percentage Change From Baseline at Endpoint (Double-Blind, Randomized, Active-Controlled Trials) Treatment (Daily Dose) N Total-C LDL-C Apo B TG HDL-C Non-HDL-C/ HDL-C Study 1 LIPITOR 10 mg 707 -27a -36a -28a -17a +7 -37a Lovastatin 20 mg 191 -19 -27 -20 -6 +7 -28 95% CI for Diff1 -9.2, -6.5 -10.7, -7.1 -10.0, -6.5 -15.2, -7.1 -1.7, 2.0 -11.1, -7.1 Study 2 LIPITOR 10 mg 222 -25b -35b -27b -17b +6 -36b Pravastatin 20 mg 77 -17 -23 -17 -9 +8 -28 95% CI for Diff1 -10.8, -6.1 -14.5, -8.2 -13.4, -7.4 -14.1, -0.7 -4.9, 1.6 -11.5, -4.1 Study 3 LIPITOR 10 mg 132 -29c -37c -34c -23c +7 -39c Simvastatin 10 mg 45 -24 -30 -30 -15 +7 -33 95% CI for Diff1 -8.7, -2.7 -10.1, -2.6 -8.0, -1.1 -15.1, -0.7 -4.3, 3.9 -9.6, -1.9 1A negative value for the 95% CI for the difference between treatments favors LIPITOR for all except HDL-C, for which a positive value favors LIPITOR. If the range does not include 0, this indicates a statistically significant difference. a Significantly different from lovastatin, ANCOVA, p ≤ 0.05 b Significantly different from pravastatin, ANCOVA, p ≤ 0.05 c Significantly different from simvastatin, ANCOVA, p ≤ 0.05 The impact on clinical outcomes of the differences in lipid-altering effects between treatments shown in Table8is not known. Table8 does not contain data comparing the effects of LIPITOR10 mg and higher doses of lovastatin, pravastatin, and simvastatin. The drugs compared in the studies summarized in the table are not necessarily interchangeable. Hypertriglyceridemia The response to LIPITOR in 64 patients with isolated hypertriglyceridemia(Fredrickson Type IV) treated across several clinical trials is shown in the table below(Table 9). For the LIPITOR-treated patients, median (min, max) baseline TG level was 565(267-1502). TABLE 9: Combined Patients With Isolated Elevated TG: Median(min, max)Percentage Change From Baseline Placebo (N=12) LIPITOR 10 mg (N=37) LIPITOR 20 mg (N=13) LIPITOR 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-C 3.6 (-31.3, 31.6) -26.5 (-57.7, 9.8) -30.4 (-53.9, 0.3) -40.5 (-60.6, -13.8) HDL-C 3.8 (-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) Dysbetalipoproteinemia The results of an open-label crossover study of 16 patients (genotypes: 14 apo E2/E2 and 2 apo E3/E2) with dysbetalipoproteinemia (Fredrickson Type III) are shown in the table below (Table 10). TABLE 10: Open-Label Crossover Study of 16 Patients With Dysbetalipoproteinemia (Fredrickson Type III) Median (min, max) at Baseline (mg/dL) Median % Change (min, max) LIPITOR 10 mg LIPITOR 80 mg Total-C 442 (225, 1320) -37 (-85, 17) -58 (-90, -31) Triglycerides 678 (273, 5990) -39 (-92, -8) -53 (-95, -30) IDL-C + VLDL-C 215 (111, 613) -32 (-76, 9) -63 (-90, -8) non-HDL-C 411 (218, 1272) -43 (-87, -19) -64 (-92, -36) Homozygous Familial Hypercholesterolemia In a study without a concurrent control group, 29 patients ages 6yearsto37 years with HoFH received maximum daily doses of 20 to 80mgof LIPITOR. The mean LDL-C reduction in this study was 18%. Twenty-five patients with a reduction in LDL-Chad a mean response of 20% (range of 7% to 53%,median of 24%); the remaining 4patientshad 7% to 24% increases in LDL-C. Five of the 29 patients had absent LDL-receptor function. Of these, 2 patients also had a portacaval shunt and had no significant reduction in LDL-C. The remaining 3receptor-negative patients had a mean LDL-C reduction of 22%. Heterozygous Familial Hypercholesterolemia In Pediatric Patients In a double-blind, placebo-controlled study followed by an open-label phase, 187boys and post-menarchal girls 10years to17 years of age (mean age 14.1 years) with heterozygous familial hypercholesterolemia (HeFH)or severe hypercholesterolemia, were randomized to LIPITOR(n=140) or placebo (n=47) for 26 weeks and then all received LIPITOR for26weeks. Inclusion in the study required 1) a baseline LDL-C level ≥ 190 mg/dL or 2) a baseline LDL-C level ≥ 160 mg/dL and positive family history of FH or documented premature cardiovascular disease in a 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 LIPITOR group compared to230.0 mg/dL (range: 160.0-324.5 mg/dL)in the placebo group. The dosage of LIPITOR (once daily) was 10mgforthe first 4weeks and uptitrated to 20 mgifthe LDL-C level was > 130mg/dL. The number of LIPITOR-treated patients who required uptitration to20 mg after Week 4during the double-blind phase was78(55.7%). LIPITOR significantly decreased plasma levels of total-C, LDL-C, triglycerides, and apolipoprotein B during the 26-week double-blind phase (see Table 11). TABLE 11: Lipid-altering Effects of LIPITOR in Adolescent Boys and Girls with Heterozygous Familial Hypercholesterolemia or Severe Hypercholesterolemia(Mean Percentage Change From Baseline at Endpoint in Intention-to-Treat Population) DOSAGE N Total-C LDL-C HDL-C TG Apolipoprotein B Placebo 47 -1.5 -0.4 -1.9 1.0 0.7 LIPITOR 140 -31.4 -39.6 2.8 -12.0 -34.0 The mean achieved LDL-C value was 130.7mg/dL(range: 70.0-242.0 mg/dL) in the LIPITOR 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 a three year open-label, uncontrolled trial that included 163patientswith HeFH who were 10years to 15 years old (82boys and81girls). Allpatients had a clinical diagnosis of HeFH confirmed by genetic analysis (if not already confirmed by family history). Approximately 98% were Caucasian, andlessthan1% were Black or Asian. Mean LDL-Cat baseline was 232mg/dL. The starting atorvastatin dosage was 10 mg once daily and doses were adjusted to achieve a 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 LIPITOR therapy in childhood to reduce morbidity and mortality in adulthood has not been established.

Find Lowest Prices on LIPITOR® (atorvastatin calcium) Tablets DESCRIPTION LIPITOR is a synthetic lipid-lowering agent. Atorvastatin is an inhibitor of 3-hydroxy-3-methylglutaryl-coenzyme A (HMG-CoA) reductase. This enzyme catalyzes the conversion of HMG-CoA to mevalonate, an early andrate-limiting step in cholesterol biosynthesis. Atorvastatin calcium is [R-(R*, R*)]-2-(4-fluorophenyl)-β, δ-dihydroxy-5-(1-methylethyl)-3-phenyl-4-[(phenylamino)carbonyl]-1Hpyrrole-1-heptanoic acid, calcium salt (2:1)trihydrate. The empirical formula of atorvastatin calcium is(C33H34FN2O5)2Ca•3H2O and its molecular weight is 1209.42. Its structural formula is: Atorvastatin calcium is a white to off-white crystalline powder that is insoluble in aqueous solutions of pH 4and 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. LIPITOR Tablets for oral administration contain 10, 20, 40, or 80 mg of atorvastatin and the following inactive ingredients: calcium carbonate, USP; candelilla wax,FCC; croscarmellose sodium, NF; hydroxypropyl cellulose, NF; lactose monohydrate, NF; magnesium stearate, NF; microcrystalline cellulose, NF; Opadry White YS-1-7040(hypromellose, polyethylene glycol, talc, titanium dioxide); polysorbate 80, NF; simethicone emulsion.

INDICATIONS Therapy with lipid-alteringagents should be only one component of multiple risk factor intervention in individuals at significantly increased risk for atherosclerotic vascular diseasedue to hypercholesterolemia. Drug therapy is recommended as an adjunct to diet when the response to a diet restricted in saturated fat and cholesterol and other non-pharmacologic measures alone has been inadequate. In patients with CHD or multiple risk factors for CHD, LIPITOR can be started simultaneously with diet. 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 a family history of early coronary heart disease, LIPITOR is indicated to: Reduce the risk of myocardial infarction Reduce the risk of stroke Reduce the risk for revascularization procedures and angina In adult patients with type 2 diabetes, and without clinically evident coronary heart disease, but with multiple risk factors for coronary heart disease such as retinopathy, albuminuria, smoking, or hypertension, LIPITOR is indicated to: Reduce the risk of myocardial infarction Reduce the risk of stroke In adult patients with clinically evident coronary heart disease, LIPITOR is indicated to: Reduce the risk of non-fatalmyocardial infarction Reduce the risk of fatal and non-fatal stroke Reduce the risk for revascularization procedures Reduce the risk of hospitalization for CHF Reduce the risk of angina Hyperlipidemia LIPITOR is indicated: As an adjunct to diet to reduce elevated total-C, LDL-C, apo B, and TGlevels and to increase HDL-C in adult patients with primary hypercholesterolemia (heterozygous familial and non familial) and mixed dyslipidemia(Fredrickson Types IIa and IIb); As an adjunct to diet for the treatment of adult patients with elevated serum TG levels (Fredrickson Type IV); For the treatment of adult patients with primary dysbetalipoproteinemia (Fredrickson Type III) who do not respond adequately to diet; To reduce total-C and LDL-Cin patients with homozygous familial hypercholesterolemia(HoFH)as an adjunct to other lipid-lowering treatments (e.g., LDL apheresis) or if such treatments are unavailable; As an adjunct to diet to reduce total-C, LDL-C, and apo B 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: LDL-C remains ≥ 190 mg/dL or LDL-C remains ≥ 160 mg/dL and: there is a positive family history of premature cardiovascular disease or two or more other CVD risk factors are present in the pediatric patient Limitations Of Use LIPITOR has not been studied in conditions where the major lipoprotein abnormality is elevation of chylomicrons(Fredrickson Types I and V). DOSAGE AND ADMINISTRATION Hyperlipidemia And Mixed Dyslipidemia The recommended starting dose of LIPITOR is 10 or 20 mg once daily. Patients who require a large reduction in LDL-C (more than 45%) may be started at 40 mg once daily. The dosage range of LIPITOR is 10to 80mg once daily. LIPITOR can be administered as a single dose at any time of the day, with or without food. The starting dose and maintenance doses of LIPITOR should be individualized according to patient characteristics such as goal of therapy and response. After initiation and/or upon titration of LIPITOR, lipid levels should be analyzed within 2 to 4weeks and dosage adjusted accordingly. Heterozygous Familial Hypercholesterolemia In Pediatric Patients (10Years to17Years of Age) The recommended starting dose of LIPITOR is 10 mg/day; the usual dose range is 10 to 20mg orally once daily [see Clinical Studies]. Doses should be individualized according to the recommended goal of therapy [see INDICATIONS AND USAGE and CLINICAL PHARMACOLOGY]. Adjustments should be made at intervals of 4 weeks or more. Homozygous Familial Hypercholesterolemia The dosage of LIPITOR in patients with HoFH is 10to 80mg daily. LIPITOR should be used as an adjunct to other lipid-lowering treatments (e.g., LDL apheresis) in these patients or if such treatments are unavailable. Concomitant Lipid-Lowering Therapy LIPITOR 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 and DRUG INTERACTIONS]. Dosage In Patients With Renal Impairment Renal disease does not affect the plasma concentrations nor LDL-Creduction of LIPITOR; thus, dosage adjustment in patients with renal dysfunction is not necessary [see WARNINGS AND PRECAUTIONS and CLINICAL PHARMACOLOGY]. Dosage In Patients Taking Cyclosporine, Clarithromycin, Itraconazole, Or Certain Protease Inhibitors In patients taking cyclosporine or the HIV protease inhibitors (tipranavir plus ritonavir) or the hepatitis C protease inhibitor (telaprevir), therapy with LIPITOR should be avoided. In patients with HIV taking lopinavir plus ritonavir, caution should be used when prescribing LIPITOR and the lowest dose necessary employed. In patients taking clarithromycin, itraconazole, or in patients with HIV taking a combination of saquinavir plus ritonavir, darunavir plus ritonavir, fosamprenavir, or fosamprenavir plus ritonavir, therapy with LIPITOR should be limited to20 mg, and appropriate clinical assessment is recommended to ensure that the lowest dose necessary of LIPITOR is employed. In patients taking the HIV protease inhibitornelfinaviror the hepatitis C protease inhibitor boceprevir, therapy with LIPITOR should be limited to 40 mg, and appropriate clinical assessment is recommended to ensure that the lowest dose necessary of LIPITOR is employed [see WARNINGS AND PRECAUTIONS and DRUG INTERACTIONS]. HOW SUPPLIED Dosage Forms And Strengths LIPITOR tablets are white elliptical, film-coated, and are available in four strengths (see Table 1). Table 1: LIPITOR Tablet Strengths and Identifying Features Tablet Strength Identifying Features 10 mg of atorvastatin “PD 155” on one side and “10” on the other 20 mg of atorvastatin “PD 156” on one side and “20” on the other. 40 mg of atorvastatin “PD 157’ on one side and “40” on the other 80 mg of atorvastatin “PD 158” on one side and “80” on the other Storage And Handling 10 mg tablets (10 mg of atorvastatin):coded “PD 155” on one side and “10” on the other. NDC 0071-0155-23 bottles of 90 NDC 0071-0155-34 bottles of 5000 NDC 0071-0155-40 10 x 10 unit dose blisters NDC 0071-0155-10 bottles of 1000 20 mg tablets (20 mg of atorvastatin): coded “PD 156” on one side and “20” on the other. NDC 0071-0156-23 bottles of 90 NDC 0071-0156-40 10 x 10 unit dose blisters NDC 0071-0156-94 bottles of 5000 NDC 0071-0156-10 bottles of 1000 40 mg tablets (40 mg of atorvastatin): coded “PD 157” on oneside and “40” on the other. NDC 0071-0157-23 bottles of 90 NDC 0071-0157-73 bottles of 500 NDC 0071-0157-88 bottles of 2500 NDC 0071-0157-40 10 x 10 unit dose blisters 80 mg tablets (80 mg of atorvastatin): coded “PD 158” on one side and “80” on the other. NDC 0071-0158-23 bottles of 90 NDC 0071-0158-73 bottles of 500 NDC 0071-0158-88 bottles of 2500 NDC 0071-0158-92 8 x 8 unit dose blisters Storage Store at controlled room temperature 20 -25°C (68-77°F) [see USP]. Distributed by: Parke-Davis, Division of Pfizer Inc., NY, NY 10017. Revised: May 2017

PATIENT INFORMATION LIPITOR® (atorvastatin calcium) Read the Patient Information that comes with LIPITOR before you start taking it and each time you get a 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 LIPITOR, ask your doctor or pharmacist. What is LIPITOR? LIPITOR is a prescription medicine that lowers cholesterol in your blood. It lowers the LDL-C (“bad” cholesterol) and triglycerides in your blood. It can raise your HDL-C (“good” cholesterol) as well. LIPITOR is for adults and children over 10 whose cholesterol does not come down enough with exercise and a low-fat diet alone. LIPITOR 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: age, smoking, high blood pressure, low HDL-C, heart disease in the family. LIPITOR can lower the risk for heart attack or stroke in patients with diabetes and risk factors such as: eye problems, kidney problems, smoking, or high blood pressure. LIPITOR starts to work in about 2 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 family. Who Should Not Take LIPITOR? Do not take LIPITOR if you: are pregnant or think you may be pregnant, or are planning to become pregnant. LIPITORmay harm your unborn baby. If you get pregnant, stop taking LIPITOR and call your doctor right away. are breast feeding. LIPITOR can pass into your breast milkand may harm your baby. have liver problems. are allergic to LIPITOR or any of its ingredients. The active ingredient is atorvastatin. See the end of this leaflet for a complete list of ingredients in LIPITOR. LIPITOR dosinghas not been established in children under 10 years of age. Before You Start LIPITOR Tell your doctor if you: have muscle aches or weakness drink more than 2 glasses of alcohol daily have diabetes have a thyroid problem have kidney problems Some medicines should not be taken with LIPITOR. Tell your doctor about all the medicines you take, including prescription and non-prescription medicines, vitamins, and herbal supplements. LIPITOR and certain other medicines can interact causing serious side effects. Especially tell your doctor if you take medicines for: your immune system cholesterol infections birth control heart failure HIV or AIDS Know all the medicines you take. Keep a list of them with you to show your doctor and pharmacist. How Should I Take LIPITOR? Take LIPITOR exactly as prescribed by your doctor. Do not change your dose or stop LIPITOR without talking to your doctor. Your doctor may do blood tests to check your cholesterol levels during your treatment with LIPITOR. Your dose of LIPITOR may be changed based on these blood test results. Take LIPITOR each day at any time of day at about the same time each day. LIPITOR can be taken with or without food. Don't break LIPITOR tablets before taking. Your doctor should start you on a low-fat diet before giving you LIPITOR. Stay on this low-fat diet when you take LIPITOR. If you miss a dose of LIPITOR, take it as soon as you remember. Do not take LIPITOR 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 2 doses of LIPITOR at the same time. If you take too much LIPITOR or overdose, call your doctor or Poison Control Center right away. Or go to the nearest emergency room. What Should I Avoid While Taking LIPITOR? Talk to your doctor before you start any new medicines. This includes prescription and nonprescription medicines, vitamins, and herbal supplements. LIPITOR and certain other medicines can interact causing serious side effects. Do not get pregnant. If you get pregnant, stop taking LIPITOR right away and call your doctor. What are the Possible Side Effects of LIPITOR? LIPITOR can cause serious side effects. These side effects have happened only to a small number of people. Your doctor can monitor you for them. These side effects usually go away if your dose is lowered or LIPITOR is stopped. These serious side effects include: Muscle problems. LIPITOR can cause serious muscle problems that can lead to kidney problems, including kidney failure. You have a higher chance for muscle problems if you are taking certain other medicines with LIPITOR. Liver problems. Your doctor should do blood tests to check your liver before you start taking LIPITOR and if you have symptoms of liver problems while you take LIPITOR. Call your doctor right away if you have the following symptoms of liver problems: feel tired or weak loss of appetite upper belly pain dark amber colored urine yellowing of your skin or the whites of your eyes Call your doctor right away if you have: muscle problems like weakness, tenderness, or pain that happen without a good reason, especially if you also have a fever or feel more tired than usual. This may be an early sign of a rare muscle problem. muscle problems that do not go away even after your doctor has advised you to stop taking LIPITOR. Your doctor may do further tests to diagnose the cause of your muscle problems. allergic 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. nausea and vomiting. passing brown or dark-colored urine. you feel more tired than usual your skin and whites of your eyes get yellow. stomach pain. allergic skin reactions. In clinical studies, patients reported the following common side effects while taking LIPITOR: diarrhea, upset stomach, muscle and joint pain, and alterations in some laboratory blood tests. The following additional side effects have been reported with LIPITOR: tiredness, tendon problems, memory loss, and confusion. Talk to your doctor or pharmacist if you have side effects that botheryou or that will not go away. These are not all the side effects of LIPITOR. Ask your doctor or pharmacist for a complete list. How do I store LIPITOR Store LIPITOR at room temperature, 68 to 77°F (20 to 25°C). Do not keep medicine that is out of date or that you no longer need. Keep LIPITOR 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 LIPITOR Medicines are sometimes prescribed for conditions that are not mentioned in patient information leaflets. Do not use LIPITOR for a condition for which it was not prescribed. Do not give LIPITOR to other people, even if they have the same problem you have. It may harm them. This leaflet summarizes the most important information about LIPITOR. If you would like more information, talk with your doctor. You can ask your doctor or pharmacist for information about LIPITOR that is written for health professionals. Or you can go to the LIPITOR website at www.lipitor.com. What are the Ingredients in LIPITOR? Active Ingredient: atorvastatin calcium Inactive Ingredients: calcium carbonate, USP; candelilla wax, FCC; croscarmellose sodium, NF; hydroxypropyl cellulose, NF; lactose monohydrate, NF; magnesium stearate, NF; microcrystalline cellulose, NF; Opadry White YS-1-7040 (hypromellose, polyethylene glycol, talc, titanium dioxide); polysorbate 80, NF; simethicone emulsion.

SIDE EFFECTS The following serious adverse reactions are discussed in greater detail in other sections of the label: Rhabdomyolysis and myopathy [see WARNINGS AND PRECAUTIONS] Liver enzyme abnormalities [see WARNINGS AND PRECAUTIONS] Clinical Trials Experience Because clinical trials are conducted under widely varying conditions, the adverse reaction rates observed in the clinical trials of a drug cannot be directly compared to rates in the clinical trials of another drug and may not reflect the rates observed in clinical practice. In the LIPITOR placebo-controlled clinical trial database of 16,066patients (8755 LIPITOR vs. 7311 placebo; age range 10-93 years, 39% women, 91% Caucasians, 3% Blacks, 2% Asians, 4% other)with a median treatment duration of 53 weeks, 9.7% of patients on LIPITOR 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 LIPITOR that led to treatment discontinuation and occurred at a 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 patient streated with LIPITOR in placebo controlled trials (n=8755) were: nasopharyngitis (8.3%), arthralgia (6.9%), diarrhea (6.8%), pain in extremity (6.0%), and urinary tract infection (5.7%). Table 3 summarizes the frequency of clinicaladverse reactions, regardless of causality, reported in ≥ 2% and at a rate greater than placebo in patients treated with LIPITOR (n=8755), from seventeen placebo-controlled trials. Table 3: Clinical adverse reactions occurring in ≥ 2% in patients treated with any dose of LIPITOR and at an incidence greater than placebo regardless of causality (% of patients). Adverse Reaction* Any dose N=8755 10 mg N=3908 20 mg N=188 40 mg N=604 80 mg N=4055 Placebo N=7311 Nasopharyngitis 8.3 12.9 5.3 7.0 4.2 8.2 Arthralgia 6.9 8.9 11.7 10.6 4.3 6.5 Diarrhea 6.8 7.3 6.4 14.1 5.2 6.3 Pain in extremity 6.0 8.5 3.7 9.3 3.1 5.9 Urinary tract infection 5.7 6.9 6.4 8.0 4.1 5.6 Dyspepsia 4.7 5.9 3.2 6.0 3.3 4.3 Nausea 4.0 3.7 3.7 7.1 3.8 3.5 Musculoskeletal pain 3.8 5.2 3.2 5.1 2.3 3.6 Muscle Spasms 3.6 4.6 4.8 5.1 2.4 3.0 Myalgia 3.5 3.6 5.9 8.4 2.7 3.1 Insomnia 3.0 2.8 1.1 5.3 2.8 2.9 Pharyngolaryngeal pain 2.3 3.9 1.6 2.8 0.7 2.1 *Adverse Reaction ≥ 2% in any dose greater than placebo Other Adverse Reactions Reported in Placebo-controlled Studies Include: Body as a 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] 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 LIPITOR 10 mg daily (n=5,168) or placebo (n=5,137), the safety and tolerability profile of the group treated with LIPITOR was comparable to that of the group treated with placebo during a median of 3.3 years of follow-up. Collaborative Atorvastatin Diabetes Study (CARDS) In CARDS [see Clinical Studies] 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 2 diabetes treated with LIPITOR 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 a median follow-up of 3.9 years. No cases of rhabdomyolysis were reported. Treating to New Targets Study(TNT) In TNT [see Clinical Studies] 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 LIPITOR10mg daily (n=5006) orLIPITOR80 mg daily (n=4995), 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 a median follow-up of 4.9 years. Persistent transaminase elevations ( ≥ 3x ULN twice within 4-10days) occurred in 62 (1.3%) individuals with atorvastatin80mg andinnine(0.2%)individualswithatorvastatin10mg.ElevationsofCK( ≥ 10x 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] 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 LIPITOR80 mg/day (n=4439)or simvastatin 20-40 mg daily (n=4449), there was no difference in the overall frequency of adverse reactions or serious adverse reactions between the treatment groups during a median follow-up of 4.8 years. Stroke Prevention by Aggressive Reduction in Cholesterol Levels (SPARCL) In SPARCL involving 4731 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 a stroke or transient ischemic attack (TIA) within the previous 6 months treated with LIPITOR 80 mg (n=2365) or placebo (n=2366) for a median follow-up of 4.9 years, there was a higher incidence of persistent hepatic transaminase elevations ( ≥ 3xULN twice within 4-10days) in the atorvastatin group (0.9%) compared to placebo (0.1%). Elevations of CK ( > 10 x 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]. In a post-hoc analysis, LIPITOR 80 mg reduced the incidence of ischemic stroke(218/2365, 9.2% vs. 274/2366, 11.6%) and increased the incidence of hemorrhagic stroke (55/2365, 2.3% vs. 33/2366, 1.4%)compared to placebo. The incidence of fatal hemorrhagic stroke was similar between groups (17LIPITOR vs. 18placebo). 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 a hemorrhagic stroke appeared to be at increased risk for hemorrhagic stroke [7 (16%) LIPITOR vs.2 (4%) placebo]. There were no significant differences between the treatment groups for all-cause mortality: 216 (9.1%) in the LIPITOR 80mg/day group vs. 211(8.9%)in the placebo group. The proportions of subjects who experienced cardiovascular death were numerically smaller in the LIPITOR80 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 LIPITOR80 mg group (5.0%) than in the placebo group(4.0%). Adverse Reactions From Clinical Studies Of LIPITOR In Pediatric Patients In a 26-weekcontrolled study in boys and postmenarchal girls with HeFH (ages 10years to17 years)(n=140, 31% female; 92% Caucasians, 1.6% Blacks, 1.6% Asians, 4.8% other), the safety and tolerability profile of LIPITOR10 to 20mg daily, as an adjunct to diet to reduce total cholesterol, LDL-C, and apoB levels, was generally similar to that of placebo [see Use in Special Populations and Clinical Studies]. Postmarketing Experience The following adverse reactions have been identified during post-approval use of LIPITOR. Because these reactions are reported voluntarily from a population of uncertain size, it is not always possible to reliably estimate their frequency or establish a causal relationship to drug exposure. Adverse reactions associated with LIPITOR therapy reported since market introduction, that are notlisted 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 stat in use [see WARNINGS AND PRECAUTIONS]. 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 aregenerally nonserious, and reversible upon statin discontinuation, with variable times to symptom onset (1 day to years) andsymptom resolution (median of 3 weeks). DRUG INTERACTIONS The risk of myopathy during treatment with statins is increased with concurrent administration of fibric acid derivatives, lipid-modifying doses of niacin, cyclosporine, or strong CYP 3A4 inhibitors (e.g., clarithromycin, HIV protease inhibitors, and itraconazole) [see WARNINGS AND PRECAUTIONS and CLINICAL PHARMACOLOGY]. Strong Inhibitors Of CYP 3A4 LIPITOR is metabolized by cytochrome P450 3A4.Concomitant administration of LIPITOR with strong inhibitors of CYP 3A4 can lead to increases in plasma concentrations of atorvastatin. The extent of interaction and potentiation of effects depend on the variability of effect on CYP 3A4. Clarithromycin Atorvastatin AUC was significantly increased with concomitant administration of LIPITOR 80 mg with clarithromycin (500mg twice daily)compared to that of LIPITOR alone [see CLINICAL PHARMACOLOGY]. Therefore, in patients taking clarithromycin, caution should be used when the LIPITOR dose exceeds 20mg [see DOSAGE AND ADMINISTRATION and WARNINGS AND PRECAUTIONS]. Combination Of Protease Inhibitors Atorvastatin AUC was significantly increased with concomitant administration of LIPITOR with several combinations of HIV protease inhibitors, as well as with the hepatitis C protease inhibitor telaprevir, compared to that of LIPITOR alone [see CLINICAL PHARMACOLOGY]. Therefore, in patients taking the HIV protease inhibitor tipranavir plus ritonavir, or the hepatitis C protease inhibitor telaprevir, concomitant use of LIPITOR should be avoided. In patients taking the HIV protease inhibitor lopinavir plus ritonavir, caution should be used when prescribing LIPITOR and the lowest dose necessary should be used. In patients taking the HIV protease inhibitors saquinavir plus ritonavir, darunavir plus ritonavir, fosamprenavir, or fosamprenavir plus ritonavir, the dose of LIPITOR should not exceed 20 mg and should be used with caution [see DOSAGE AND ADMINISTRATION and WARNINGS AND PRECAUTIONS]. In patients taking the HIV protease inhibitor nelfinavir or the hepatitis C protease inhibitor boceprevir, the dose of LIPITOR should not exceed 40 mg and close clinical monitoring is recommended. Itraconazole Atorvastatin AUC was significantly increased with concomitant administration of LIPITOR 40 mg and itraconazole200mg [see CLINICAL PHARMACOLOGY]. Therefore, in patients taking itraconazole, caution should be used when the LIPITOR dose exceeds 20 mg [see DOSAGE AND ADMINISTRATION and WARNINGS AND PRECAUTIONS]. Grapefruit Juice Contains one or more components that inhibit CYP 3A4 and can increase plasma concentrations of atorvastatin, especially with excessive grapefruit juice consumption ( > 1.2 liters per day). Cyclosporine Atorvastatin and atorvastatin-metabolites are substrates of the OATP1B1 transporter. Inhibitors of the OATP1B1 (e.g., cyclosporine) can increase the bioavailability of atorvastatin. Atorvastatin AUC was significantly increased with concomitant administration of LIPITOR 10 mg and cyclosporine 5.2 mg/kg/day compared to that of LIPITOR alone [see CLINICAL PHARMACOLOGY]. The co-administration of LIPITOR with cyclosporine should be avoided[see WARNINGS AND PRECAUTIONS]. Gemfibrozil Due to an increased risk of myopathy/rhabdomyolysis when HMG-CoA reductase inhibitors are co-administered with gemfibrozil, concomitant administration of LIPITOR with gemfibrozil should be avoided [see WARNINGS AND PRECAUTIONS]. Other Fibrates Because it is known that the risk of myopathy during treatment with HMG-CoA reductase inhibitors is increased with concurrent administration of other fibrates, LIPITOR should be administered with caution when used concomitantly with other fibrates [see WARNINGS AND PRECAUTIONS]. Niacin The risk of skeletal muscle effects may be enhanced when LIPITOR is used in combination with niacin; a reduction in LIPITOR dosage should be considered in this setting [see WARNINGS AND PRECAUTIONS]. Rifampin Or Other Inducers Of Cytochrome P450 3A4 Concomitant administration of LIPITOR with inducers of cytochrome P450 3A4 (e.g., efavirenz, rifampin) can lead to variable reductionsin plasma concentrations of atorvastatin. Due to the dual interaction mechanism of rifampin, simultaneous co-administration of LIPITOR with rifampin is recommended, as delayed administration of LIPITOR after administration of rifampin has been associated with a significant reduction in atorvastatin plasma concentrations. Digoxin When multiple doses of LIPITOR and digoxin were co-administered, steady state plasma digoxin concentrations increased by approximately 20%. Patients takingdigoxin should be monitored appropriately. Oral Contraceptives Co-administration of LIPITOR and an oral contraceptive increased AUC values for norethindrone and ethinyl estradiol[see CLINICAL PHARMACOLOGY].These increases should be considered when selecting an oral contraceptive for a woman taking LIPITOR. Warfarin LIPITOR had no clinically significant effect onprothrombin time when administered to patients receiving chronic warfarin treatment. Colchicine Cases of myopathy, including rhabdomyolysis, have been reported withatorvastatin co-administered with colchicine, and caution should be exercised when prescribing atorvastatin with colchicine.

WARNINGS Included as part of the PRECAUTIONS section. PRECAUTIONS Skeletal Muscle Rare cases of rhabdomyolysis with acute renal failure secondary to myoglobinuria have been reported with LIPITOR and with other drugs in this class. A history of renal impairment may be a risk factor for the development of rhabdomyolysis. Such patients merit closer monitoring for skeletal muscle effects. Atorvastatin, like other statins, occasionally causes myopathy, defined as muscle aches or muscle weakness in conjunction with increases in creatine phosphokinase (CPK) values > 10 times ULN. The concomitant use of higher doses of atorvastatin with certain drugs such as cyclosporine and strong CYP3A4 inhibitors (e.g., clarithromycin, itraconazole, and HIV protease inhibitors) increases the risk of myopathy/rhabdomyolysis. There have been rare reports of immune-mediated necrotizing myopathy (IMNM), an autoimmune myopathy, associated with statin use. IMNM is characterized by: proximalmuscle weakness and elevated serum creatine kinase, which persist despite discontinuation of statin treatment; muscle biopsy showing necrotizing myopathy without significant inflammation; improvement with immunosuppressive agents. Myopathy should be considered in any patient with diffuse myalgias, muscle tenderness or weakness, and/or marked elevation of CPK. Patients should be advised to report promptly unexplained muscle pain, tenderness, or weakness, particularly if accompanied by malaise or fever or if muscle signs and symptoms persist after discontinuing LIPITOR. LIPITOR therapy should be discontinued if markedly elevated CPK levels occur or myopathy is diagnosed or suspected. The risk of myopathy during treatment with drugs in this class is increased with concurrent administration of cyclosporine, fibric acid derivatives, erythromycin, clarithromycin, the hepatitis C protease inhibitor telaprevir, combinations of HIV protease inhibitors, including saquinavir plus ritonavir, lopinavir plus ritonavir, tipranavir plus ritonavir, darunavirplus ritonavir, fosamprenavir, and fosamprenavir plus ritonavir, niacin, or azole antifungals. Physicians considering combined therapy with LIPITOR and fibric acid derivatives, erythromycin, clarithromycin, a combination ofsaquinavir plusritonavir, lopinavir plus ritonavir, darunavir plusritonavir, fosamprenavir, or fosamprenavir plus ritonavir,azole antifungals, or lipid-modifying doses of niacin should carefully weigh the potential benefits and risks and should carefully monitor patients for any signs or symptoms of muscle pain, tenderness, or weakness, particularly during the initial months of therapy and during any periods of upward dosage titration of either drug. Lower starting and maintenance doses of atorvastatin should be considered when taken concomitantly with the aforementioned drugs [see DRUG INTERACTIONS]. Periodic creatine phosphokinase(CPK) determinations may be considered in such situations, but there is no assurance that such monitoring will prevent the occurrence of severe myopathy. Prescribing recommendations for interacting agents are summarized in Table2 [see DOSAGE AND ADMINISTRATION, DRUG INTERACTIONS, and CLINICAL PHARMACOLOGY]. Table 2: Drug Interactions Associated with Increased Risk of Myopathy/Rhabdomyolysis Interacting Agents Prescribing Recommendations Cyclosporine, HIVprotease inhibitors (tipranavir plus ritonavir), hepatitis Cprotease inhibitor (telaprevir) Avoid atorvastatin HIV pro tease inhibitor (lopinavir plus ritonavir) Use with caution and lowest dose necessary Clarithromycin, itraconazole, HIV pro tease inhibitors (saquinavir plus ritonavir*, darunavir plus ritonavir, fo s amprenavir, fosamprenavir plus ritonavir) Do not exceed 20 mg atorvastatin daily HIV pro tease inhibitor (nelfinavir) Hepatitis Cprotease inhibitor (boceprevir) Do not exceed 40 mg atorvastatin daily *Use with caution and with the lowest dose necessary Cases of myopathy, including rhabdomyolysis, have been reported with atorvastatinco-administered with colchicine, and caution should be exercised when prescribing atorvastatin with colchicine [see DRUG INTERACTIONS]. LIPITOR therapy should be temporarily withheld or discontinued in any patient with anacute, serious condition suggestive of a myopathy or having a risk factor predisposing to the development of renal failure secondary to rhabdomyolysis(e.g., severe acute infection, hypotension, major surgery, trauma, severe metabolic, endocrine and electrolyte disorders, and uncontrolled seizures). Liver Dysfunction Statins, like some other lipid-lowering therapies, have been associated with biochemical abnormalities of liver function. Persistent elevations ( > 3times the upper limit of normal[ULN] occurring on 2 or more occasions) in serum transaminases occurred in 0.7% of patients who received LIPITOR in clinical trials. The incidence of these abnormalities was 0.2%, 0.2%, 0.6%, and 2.3% for 10, 20, 40, and80 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 a reduced dose of LIPITOR. It is recommended that liver enzyme tests be obtained prior to initiating therapy with LIPITOR and repeated as clinically indicated. There have been rare post marketing 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 LIPITOR, promptly interrupt therapy. If an alternate etiologyis not found, do not restart LIPITOR. LIPITOR should be used with caution in patients who consume substantial quantities of alcohol and/or have a history of liver disease. Active liver disease or unexplained persistent transaminase elevations are contraindications to the use of LIPITOR [see CONTRAINDICATIONS]. Endocrine Function Increases in HbA1c and fasting serum glucose levels have been reported with HMG-CoA reductase inhibitors, including LIPITOR. Statins interfere with cholesterol synthesis and theoretically might blunt adrenal and/or gonadal steroid production. Clinical studies have shown that LIPITOR does 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 a statin is administered concomitantly with drugs that may decrease the levels or activity of endogenous steroidhormones, such as ketoconazole, spironolactone, and cimetidine. CNS Toxicity Brain hemorrhage was seen in a female dog treated for 3 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 120mg/kg doseresulted in a systemic exposure approximately 16times the human plasma area-under-the-curve (AUC, 0-24 hours) based on the maximum human dose of 80 mg/day. A single tonic convulsion was seen in each of 2 male dogs (one treated at 10 mg/kg/day and one at 120 mg/kg/day) in a 2-year study. No CNS lesions have been observed in mice after chronic treatment for up to 2years at doses up to 400 mg/kg/day or in rats at doses upto 100 mg/kg/day. These doses were 6 to 11times (mouse) and 8 to 16 times (rat) the human AUC (0-24) based on the maximum recommended human dose of 80mg/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. A chemically similar drug in this class produced optic nerve degeneration (Wallerian degeneration of retinogeniculate fibers) in clinically normal dogs in a dose-dependent fashion at a dose that produced plasma drug levels about 30 times higher than the mean drug level in humans taking the highest recommended dose. Use In Patients With Recent Stroke Or TIA In a post-hoc analysis of the Stroke Prevention by Aggressive Reduction in Cholesterol Levels (SPARCL) study where LIPITOR 80 mg vs. placebo was administered in 4,731subjects without CHD who had a stroke or TIA within the preceding 6 months, a higher incidence of hemorrhagic stroke was seen in the LIPITOR80mg group compared to placebo (55, 2.3%atorvastatin vs. 33, 1.4% placebo; HR: 1.68, 95%CI:1.09,2.59;p=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 nonfatal 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 a higher incidence of hemorrhagic stroke in the atorvastatin group [see ADVERSE REACTIONS]. Patient Counseling Information Advise the patient to read the FDA-approved patient labeling (PATIENT INFORMATION). Patients taking LIPITOR shouldbe advised that cholesterol is a chronic condition and they should adhere to their medication along with their National Cholesterol Education Program (NCEP)-recommended diet, a regular exercise program as appropriate, and periodic testing of a fasting lipid panel to determine goal attainment. Patients should be advised about substances they should not take concomitantly with atorvastatin [see WARNINGS AND PRECAUTIONS]. Patients should also be advised to in for mother healthcare professionals prescribing a new medication that they are taking LIPITOR. Muscle Pain All patients starting therapy with LIPITOR 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 LIPITOR. The risk of this occurring is increased when taking certain types of medication or consuming larger quantities ( > 1liter) of grapefruit juice. They should discuss all medication, both prescription and over the counter, with their healthcare professional. Liver Enzymes It is recommended that liver enzyme tests be performed before the initiation of LIPITOR and if signs or symptoms of liver injury occur. All patients treated with LIPITOR should be advised to report promptly any symptoms that may indicate liver injury, including fatigue, anorexia, right upper abdominal discomfort, dark urine, or jaundice. Embryofetal Toxicity Advise females of reproductive potential of the risk to a fetus, to use effective contraception during treatment and to inform their healthcare provider of a known or suspected pregnancy [see CONTRAINDICATIONS and Use in Specific Populations]. Lactation Advise women not to breastfeed during treatment with LIPITOR[see CONTRAINDICATIONS and Use in Specific Populations]. Nonclinical Toxicology Carcinogenesis, Mutagenesis, Impairment Of Fertility In a 2-year carcinogenicity study in rats at dose levels of 10, 30, and100mg/kg/day, 2 rare tumors were found in muscle in high-dose females: in one, there was a rhabdomyosarcoma and, in another, there was a fibrosarcoma. This dose represents a plasma AUC (0-24) value of approximately 16times the mean human plasma drug exposure after an 80 mg oraldose. A 2-year carcinogenicity studyin mice given 100,200, or 400 mg/kg/day resulted in a 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 6times 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 negativein the in vivo mouse micronucleus test. In female rats, atorvastatinat doses up to 225 mg/kg (56 times the human exposure) did not cause adverse effectson 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 2 of 10rats treated with 100 mg/kg/dayof atorvastatinfor 3 months (16 times the human AUC at the 80mg dose); testis weights were significantly lower at 30 and 100mg/kg and epididymal weight was lower at 100mg/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 two years. Use In Specific Populations Pregnancy Risk Summary LIPITOR is 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, LIPITOR may cause fetal harm when administered to a pregnant woman. LIPITOR should be discontinued as soon as pregnancy is recognized [see CONTRAINDICATIONS]. Limited published data on the use of atorvastatin are insufficient to determine a 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 malformation sat 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 ≥ 6 times the MRHD (see Data). The estimated back ground 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 1520%, respectively. Data Human Data Limited published data on atorvastatin calcium from observational studies, meta-analyses and case report shave 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 a 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 a ≥ 3to 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 a 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 300mg/kg/day and 100mg/kg/day, respectively. Atorvastatin was notteratogenic in rats at doses up to 300mg/kg/day or in rabbits at doses up to 100mg/kg/day. These doses resulted in multiples of about 30 times (rat) or20 times (rabbit) the human exposure at the MRHD based on surface area (mg/m²).In rats, the maternally toxic dose of 300mg/kg resulted in increased post-implantation loss and decreased fetal body weight. At the maternally toxic doses of 50 and 100mg/kg/day in rabbits, there was increased post-implantation loss, and at 100mg/kg/day fetal body weights were decreased. In a study inpregnantratsadministered20, 100, or 225 mg/kg/day from gestation day7 through to lactation day20(weaning), there was decreased survival at birth, postnatal day 4, weaning, and post-weaning in pups of mothers dosed with 225mg/kg/day, a dose at which maternal toxicity was observed. Pup body weight was decreased through postnatal day 21at 100 mg/kg/day, and through postnatal day91 at 225 mg/kg/day. Pup development was delayed (rotorod performance at 100mg/kg/day and acoustic startle at 225 mg/kg/day; pinnae detachment and eye-opening at 225mg/kg/day). These doses correspond to 6 times (100 mg/kg) and 22times (225 mg/kg) the human exposure at the MRHD, based on AUC. Lactation Risk Summary LIPITOR use is contraindicated during breastfeeding [see CONTRAINDICATIONS]. 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 at orvastatin is present in human milk, but it has been shown that another drug in this class passes into human milk and at orvastatin is present in rat milk. Because of the potential for serious adverse reactions in a breastfedinfant, advise women that breastfeeding is not recommended during treatment with LIPITOR. Females And Males Of Reproductive Potential Contraception LIPITOR may cause fetal harm when administered to a pregnant woman. Advise females of reproductive potential to use effective contraception during treatment with LIPITOR [see Use in Specific Populations]. Pediatric Use Heterozygous Familial Hypercholesterolemia(HeFH) The safety and effectiveness of LIPITOR have been established in pediatric patients,10years to 17 years of age, with HeFH as an adjunct to diet to reduce total cholesterol, LDL-C, and apoB levels when, after an adequate trial of diet therapy, the following are present: LDL-C ≥ 190 mg/dL, or LDL-C ≥ 160 mg/Dl and A positive family history of FH, or premature CVD in a first, or second-degree relative, or two or more other CVD risk factors are present. Use of LIPITOR for this indication is supported by evidence from[see DOSAGE AND ADMINISTRATION, ADVERSE REACTIONS, CLINICAL PHARMACOLOGY, and Clinical Studies]: A placebo-controlled clinical trial of 6 months duration in 187 boys and postmenarchal girls,10 years to 17 years of age. Patients treated with 10 mg or20 mg daily LIPITOR 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. A three year open-label uncontrolled trial that included163 pediatric patients 10 to 15years of age with HeFH who were titrated to achieve a target LDL-C < 130 mg/dL. The safety and efficacy of LIPITOR 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]. The long-term efficacy of LIPITOR therapy initiated inchild hood to reduce morbidity and mortality in adulthood has not been established. The safety and efficacy of LIPITOR have not been established in pediatric patients younger than 10 years of age with HeFH. Homozygous Familial Hypercholesterolemia (HoFH) Clinical efficacy of LIPITOR with dosages up to 80mg/day for 1 year was evaluated in an uncontrolled study of patients with HoFH including 8 pediatric patients [see Clinical Studies]. Geriatric Use Of the 39,828 patients who received LIPITOR 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 someolder adults cannot be ruled out. Since advanced age ( ≥ 65 years) is a predisposing factor for myopathy, LIPITOR should be prescribed with caution in the elderly. Hepatic Impairment Lipitor is contraindicated in patients with active liver disease which may include unexplained persistent elevations in hepatic transaminase levels [see CONTRAINDICATIONS and CLINICAL PHARMACOLOGY].