Pitavastatin

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# Overview
Pitavastatin is a HMG-CoA reductase inhibitor that is FDA approved for the treatment of primary hyperlipidemia and mixed dyslipidemia.   Common adverse reactions include rhabdomyolysis with myoglobinuria, acute renal failure, myopathy (including myositis) and liver enzyme abnormalities.

# Adult Indications and Dosage

## FDA-Labeled Indications and Dosage (Adult)

### Primary Hyperlipidemia and Mixed Dyslipidemia
Indications
- Drug therapy should be one component of multiple-risk-factor intervention in individuals who require modifications of their lipid profile. Lipid-altering agents should be used in addition to a diet restricted in saturated fat and cholesterol only when the response to diet and other nonpharmacological measures has been inadequate.
- Pitavastatin is indicated as an adjunctive therapy to diet to reduce elevated total cholesterol (TC), low-density lipoprotein cholesterol (LDL-C), apolipoprotein B (Apo B), triglycerides (TG), and to increase HDL-C in adult patients with primary hyperlipidemia or mixed dyslipidemia.
General Dosing Information
- Dose range: 1 to 4 mg PO qd at any time of the day with or without food.
- The recommended starting dose:  2 mg and
- Maximum dosage: 4 mg
- . The starting dose and maintenance doses of Pitavastatin should be individualized according to patient characteristics, such as goal of therapy and response.
- After initiation or upon titration of Pitavastatin, lipid levels should be analyzed after 4 weeks and the dosage adjusted accordingly.
Dosage in Patients with Renal Impairment
- Patients with moderate and severe renal impairment (glomerular filtration rate 30  59 mL/min/1.73 m2 and 15  29 mL/min/1.73 m2 not receiving hemodialysis, respectively) as well as end-stage renal disease receiving hemodialysis should receive
- Starting dose : 1 mg once daily
- Maximum dosage:  2 mg once daily
Use with Erythromycin
- In patients taking erythromycin, a dose of Pitavastatin 1 mg PO qd should not be exceeded
Use with Rifampin
- In patients taking rifampin, a dose of Pitavastatin 2 mg PO qd should not be exceeded

## Off-Label Use and Dosage (Adult)

### Guideline-Supported Use
There is limited information regarding Off-Label Guideline-Supported Use of Pitavastatin in adult patients.

### NonGuideline-Supported Use
There is limited information regarding Off-Label non-Guideline-Supported Use of Pitavastatin in adult patients.

# Pediatric Indications and Dosage

## FDA-Labeled Indications and Dosage (Pediatric)
- Safety and effectiveness have not been established

## Off-Label Use and Dosage (Pediatric)

### Guideline-Supported Use
- There is limited information regarding Off-Label Guideline-Supported Use of Pitavastatin in pediatric patients.

### NonGuideline-Supported Use
- There is limited information regarding Off-Label NonGuideline-Supported Use of Pitavastatin in pediatric patients.

# Contraindications
- The use of Pitavastatin is contraindicated in the following conditions:
- Patients with a known hypersensitivity to any component of this product. Hypersensitivity reactions including rash, pruritus, and urticaria have been reported with Pitavastatin.
- Patients with active liver disease which may include unexplained persistent elevations of hepatic transaminase levels.
- Women who are pregnant or may become pregnant. Because HMG-CoA reductase inhibitors decrease cholesterol synthesis and possibly the synthesis of other biologically active substances derived from cholesterol, Pitavastatin may cause fetal harm when administered to pregnant women. Additionally, there is no apparent benefit to therapy during pregnancy, and safety in pregnant women has not been established. If the patient becomes pregnant while taking this drug, the patient should be apprised of the potential hazard to the fetus and the lack of known clinical benefit with continued use during pregnancy.
- Nursing mothers. Animal studies have shown that Pitavastatin passes into breast milk. Since HMG-CoA reductase inhibitors have the potential to cause serious adverse reactions in nursing infants, Pitavastatin, like other HMG-CoA reductase inhibitors, is contraindicated in pregnant or nursing mothers.
- Co-administration with cyclosporine

# Warnings
- Cases of myopathy and rhabdomyolysis with acute renal failure secondary to myoglobinuria have been reported with HMG-CoA reductase inhibitors, including Pitavastatin. These risks can occur at any dose level, but increase in a dose-dependent manner.
- Pitavastatin should be prescribed with caution in patients with predisposing factors for myopathy. These factors include advanced age (65 years), renal impairment, and inadequately treated hypothyroidism. The risk of myopathy may also be increased with concurrent administration of fibrates or lipid-modifying doses of niacin. Pitavastatin should be administered with caution in patients with impaired renal function, in elderly patients, or when used concomitantly with fibrates or lipid-modifying doses of niacin.
- Cases of myopathy, including rhabdomyolysis, have been reported with HMG-CoA reductase inhibitors coadministered with colchicine, and caution should be exercised when prescribing Pitavastatin with colchicine.
- 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; muscle biopsy showing necrotizing myopathy without significant inflammation; improvement with immunosuppressive agents.
- Pitavastatin therapy should be discontinued if markedly elevated creatine kinase (CK) levels occur or myopathy is diagnosed or suspected. Pitavastatin therapy should also be temporarily withheld in any patient with an acute, serious condition suggestive of myopathy or predisposing to the development of renal failure secondary to rhabdomyolysis (e.g., sepsis, hypotension, dehydration, major surgery, trauma, severe metabolic, endocrine, and electrolyte disorders, or uncontrolled seizures). All patients should be advised to promptly report unexplained muscle pain, tenderness, or weakness, particularly if accompanied by malaise or fever or if muscle signs and symptoms persist after discontinuing Pitavastatin.
- Increases in serum transaminases (aspartate aminotransferase /serum glutamic-oxaloacetic transaminase, or alanine aminotransferase /serum glutamic-pyruvic transaminase) have been reported with HMG-CoA reductase inhibitors, including Pitavastatin. In most cases, the elevations were transient and resolved or improved on continued therapy or after a brief interruption in therapy.
- In placebo-controlled Phase 2 studies, ALT >3 times the upper limit of normal was not observed in the placebo, Pitavastatin 1 mg, or Pitavastatin 2 mg groups. One out of 202 patients (0.5%) administered Pitavastatin 4 mg had ALT >3 times the upper limit of normal.
- It is recommended that liver enzyme tests be performed before the initiation of Pitavastatin and if signs or symptoms of liver injury occur.
- There have been rare postmarketing reports of fatal and non-fatal hepatic failure in patients taking statins, including pitavastatin. If serious liver injury with clinical symptoms and/or hyperbilirubinemia or jaundice occurs during treatment with Pitavastatin, promptly interrupt therapy. If an alternate etiology is not found do not restart Pitavastatin.
- As with other HMG-CoA reductase inhibitors, Pitavastatin should be used with caution in patients who consume substantial quantities of alcohol. Active liver disease, which may include unexplained persistent transaminase elevations, is a contraindication to the use of Pitavastatin.
- Increases in HbA1c and fasting serum glucose levels have been reported with HMG-CoA reductase inhibitors, including Pitavastatin.

# Adverse Reactions

## Clinical Trials Experience
- Because clinical studies on Pitavastatin are conducted in varying study populations and study designs, the frequency of adverse reactions observed in the clinical studies of Pitavastatin cannot be directly compared with that in the clinical studies of other HMG-CoA reductase inhibitors and may not reflect the frequency of adverse reactions observed in clinical practice.
- Adverse reactions reported in  2% of patients in controlled clinical studies and at a rate greater than or equal to placebo are shown in Table 1. These studies had treatment duration of up to 12 weeks.
- Other adverse reactions reported from clinical studies were arthralgia, headache, influenza, and nasopharyngitis.
- The following laboratory abnormalities have also been reported: elevated creatine phosphokinase, transaminases, alkaline phosphatase, bilirubin, and glucose.
- In controlled clinical studies and their open-label extensions, 3.9% (1 mg), 3.3% (2 mg), and 3.7% (4 mg) of pitavastatin-treated patients were discontinued due to adverse reactions. The most common adverse reactions that led to treatment discontinuation were: elevated creatine phosphokinase (0.6% on 4 mg) and myalgia (0.5% on 4 mg).
- Hypersensitivity reactions including rash, pruritus, and urticaria have been reported with Pitavastatin.

## Postmarketing Experience
- The following adverse reactions have been identified during postapproval use of Pitavastatin. 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 Pitavastatin therapy reported since market introduction, regardless of causality assessment, include the following: abdominal discomfort, abdominal pain, dyspepsia, nausea, asthenia, fatigue, malaise, hepatitis, jaundice, fatal and non-fatal hepatic failure, dizziness, hypoesthesia, insomnia, depression, interstitial lung disease, erectile dysfunction and muscle spasms.
- 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 3 weeks).
- There have been rare reports of immune-mediated necrotizing myopathy associated with statin use.

# Drug Interactions
- Cyclosporine significantly increased pitavastatin exposure. Co-administration of cyclosporine with Pitavastatin is contraindicated.
- Erythromycin significantly increased pitavastatin exposure. In patients taking erythromycin, a dose of Pitavastatin 1 mg once daily should not be exceeded.
- Rifampin significantly increased pitavastatin exposure. In patients taking rifampin, a dose of Pitavastatin 2 mg once daily should not be exceeded.
- Due to an increased risk of myopathy/rhabdomyolysis when HMG-CoA reductase inhibitors are coadministered with gemfibrozil, concomitant administration of Pitavastatin with gemfibrozil should be avoided.
- Because it is known that the risk of myopathy during treatment with HMG-CoA reductase inhibitors is increased with concurrent administration of other fibrates, Pitavastatin should be administered with caution when used concomitantly with other fibrates.
- The risk of skeletal muscle effects may be enhanced when Pitavastatin is used in combination with niacin; a reduction in Pitavastatin dosage should be considered in this setting.
- Cases of myopathy, including rhabdomyolysis, have been reported with HMG-CoA reductase inhibitors coadministered with colchicine, and caution should be exercised when prescribing Pitavastatin with colchicine.
- Pitavastatin had no significant pharmacokinetic interaction with R- and S- warfarin. Pitavastatin had no significant effect on prothrombin time (PT) and international normalized ratio (INR) when administered to patients receiving chronic warfarin treatment. However, patients receiving warfarin should have their PT and INR monitored when pitavastatin is added to their therapy.

# Use in Specific Populations

### Pregnancy
Pregnancy Category (FDA): X
- Pitavastatin is contraindicated in women who are or may become pregnant. Serum cholesteroland TG increase during normal pregnancy, and cholesterolproducts are essential for fetal development. Atherosclerosis is a chronic process and discontinuation of lipid-lowering drugs during pregnancy should have little impact on long-term outcomes of primary hyperlipidemia therapy.
- There are no adequate and well-controlled studies of Pitavastatin in pregnant women, although, there have been rare reports of congenital anomalies following intrauterine exposure to HMG-CoA reductase inhibitors. In a review of about 100 prospectively followed pregnancies in women exposed to other HMG-CoA reductase inhibitors, the incidences of congenital anomalies, spontaneous abortions, and fetal deaths/stillbirths did not exceed the rate expected in the general population. However, this study was only able to exclude a three-to-four-fold increased risk of congenital anomalies over background incidence. In 89% of these cases, drug treatment started before pregnancy and stopped during the first trimester when pregnancy was identified.
- Reproductive toxicity studies have shown that pitavastatin crosses the placenta in rats and is found in fetal tissues at 36% of maternal plasma concentrations following a single dose of 1 mg/kg/day during gestation.
- Embryo-fetal developmental studies were conducted in pregnant rats treated with 3, 10, 30 mg/kg/day pitavastatin by oral gavage during organogenesis. No adverse effects were observed at 3 mg/kg/day, systemic exposures 22 times human systemic exposure at 4 mg/day based on AUC.
- Embryo-fetal developmental studies were conducted in pregnant rabbits treated with 0.1, 0.3, 1 mg/kg/day pitavastatin by oral gavage during the period of fetal organogenesis. Maternal toxicity consisting of reduced body weight and abortion was observed at all doses tested (4 times human systemic exposure at 4 mg/day based on AUC).
- In perinatal/postnatal studies in pregnant rats given oral gavage doses of pitavastatin at 0.1, 0.3, 1, 3, 10, 30 mg/kg/day from organogenesis through weaning, maternal toxicity consisting of mortality at 0.3 mg/kg/day and impaired lactation at all doses contributed to the decreased survival of neonates in all dose groups (0.1 mg/kg/day represents approximately 1 time human systemic exposure at 4 mg/day dose based on AUC).
- Pitavastatin may cause fetal harm when administered to a pregnant woman. If the patient becomes pregnant while taking Pitavastatin, the patient should be apprised of the potential risks to the fetus and the lack of known clinical benefit with continued use during pregnancy.
Pregnancy Category (AUS): 
There is no Australian Drug Evaluation Committee (ADEC) guidance on usage of Pitavastatin in women who are pregnant.

### Labor and Delivery
There is no FDA guidance on use of Pitavastatin during labor and delivery.

### Nursing Mothers
- It is not known whether pitavastatin is excreted in human milk, however, it has been shown that a small amount of another drug in this class passes into human milk. Rat studies have shown that pitavastatin is excreted into breast milk. Because another drug in this class passes into human milk and HMG-CoA reductase inhibitors have a potential to cause serious adverse reactions in nursing infants, women who require Pitavastatin treatment should be advised not to nurse their infants or to discontinue Pitavastatin.

### Pediatric Use
- Safety and effectiveness of Pitavastatin in pediatric patients have not been established.

### Geriatic Use
- Of the 2,800 patients randomized to Pitavastatin 1 mg to 4 mg in controlled clinical studies, 1,209 (43%) were 65 years and older. No significant differences in efficacy or safety were observed between elderly patients and younger patients. However, greater sensitivity of some older individuals cannot be ruled out.

### Gender
There is no FDA guidance on the use of Pitavastatin with respect to specific gender populations.

### Race
There is no FDA guidance on the use of Pitavastatin with respect to specific racial populations.

### Renal Impairment
- Patients with moderate and severe renal impairment (glomerular filtration rate 30  59 mL/min/1.73 m2 and 15  29 mL/min/1.73 m2 not receiving hemodialysis, respectively) as well as end-stage renal disease receiving hemodialysis should receive a starting dose of Pitavastatin 1 mg once daily and a maximum dose of Pitavastatin 2 mg once daily.

### Hepatic Impairment
- Pitavastatin is contraindicated in patients with active liver disease which may include unexplained persistent elevations of hepatic transaminase levels.

### Females of Reproductive Potential and Males
There is no FDA guidance on the use of Pitavastatin in women of reproductive potentials and males.

### Immunocompromised Patients
There is no FDA guidance one the use of Pitavastatin in patients who are immunocompromised.

# Administration and Monitoring

### Administration
- Oral

### Monitoring
- FDA Package Insert for Pitavastatin contains no information regarding drug monitoring.

# IV Compatibility
- There is limited information about the IV compatibility.

# Overdosage
- There is no known specific treatment in the event of overdose of pitavastatin. In the event of overdose, the patient should be treated symptomatically and supportive measures instituted as required. Hemodialysis is unlikely to be of benefit due to high protein binding ratio of pitavastatin.

# Pharmacology

## Mechanism of Action
- Pitavastatin competitively inhibits HMG-CoA reductase, which is a rate-determining enzyme involved with biosynthesis of cholesterol, in a manner of competition with the substrate so that it inhibits cholesterol synthesis in the liver. As a result, the expression of LDL-receptors followed by the uptake of LDL from blood to liver is accelerated and then the plasma TC decreases. Further, the sustained inhibition of cholesterol synthesis in the liver decreases levels of very low density lipoproteins.

## Structure
- Pitavastatin (pitavastatin) is an inhibitor of HMG-CoA reductase. It is a synthetic lipid-lowering agent for oral administration.
- The chemical name for pitavastatin is (+)monocalcium bis{(3R, 5S, 6E)-7--3,5-dihydroxy-6-heptenoate}. The structural formula is:
- The empirical formula for pitavastatin is C50H46CaF2N2O8 and the molecular weight is 880.98. Pitavastatin is odorless and occurs as white to pale-yellow powder. It is freely soluble in pyridine, chloroform, dilute hydrochloric acid, and tetrahydrofuran, soluble in ethylene glycol, sparingly soluble in octanol, slightly soluble in methanol, very slightly soluble in water or ethanol, and practically insoluble in acetonitrile or diethyl ether. Pitavastatin is hygroscopic and slightly unstable in light.
- Each film-coated tablet of Pitavastatin contains 1.045 mg, 2.09 mg, or 4.18 mg of pitavastatin calcium, which is equivalent to 1 mg, 2 mg, or 4 mg, respectively of free base and the following inactive ingredients: lactose monohydrate, low substituted hydroxypropylcellulose, hypromellose, magnesium aluminometasilicate, magnesium stearate, and film coating containing the following inactive ingredients: hypromellose, titanium dioxide, triethyl citrate, and colloidal anhydrous silica.

## Pharmacodynamics
- In a randomized, double-blind, placebo-controlled, 4-way parallel, active-comparator study with moxifloxacin in 174 healthy participants, Pitavastatin was not associated with clinically meaningful prolongation of the QTc interval or heart rate at daily doses up to 16 mg (4 times the recommended maximum daily dose).

## Pharmacokinetics
Absorption
- Pitavastatin peak plasma concentrations are achieved about 1 hour after oral administration. Both Cmax and AUC0-inf increased in an approximately dose-proportional manner for single Pitavastatin doses from 1 to 24 mg once daily. The absolute bioavailability of pitavastatin oral solution is 51%. Administration of Pitavastatin with a high fat meal (50% fat content) decreases pitavastatin Cmax by 43% but does not significantly reduce pitavastatin AUC. The Cmax and AUC of pitavastatin did not differ following evening or morning drug administration. In healthy volunteers receiving 4 mg pitavastatin, the percent change from baseline for LDL-C following evening dosing was slightly greater than that following morning dosing. Pitavastatin was absorbed in the small intestine but very little in the colon.
Distribution
- Pitavastatin is more than 99% protein bound in human plasma, mainly to albumin and alpha 1-acid glycoprotein, and the mean volume of distribution is approximately 148 L. Association of pitavastatin and/or its metabolites with the blood cells is minimal.
Metabolism
- Pitavastatin is marginally metabolized by CYP2C9 and to a lesser extent by CYP2C8. The major metabolite in human plasma is the lactone which is formed via an ester-type pitavastatin glucuronide conjugate by uridine 5'-diphosphate (UDP) glucuronosyltransferase (UGT1A3 and UGT2B7).
Excretion
- A mean of 15% of radioactivity of orally administered, single 32 mg 14C-labeled pitavastatin dose was excreted in urine, whereas a mean of 79% of the dose was excreted in feces within 7 days. The mean plasma elimination half-life is approximately 12 hours.
Race
- In pharmacokinetic studies pitavastatin Cmax and AUC were 21 and 5% lower, respectively in Black or African American healthy volunteers compared with those of Caucasian healthy volunteers. In pharmacokinetic comparison between Caucasian volunteers and Japanese volunteers, there were no significant differences in Cmax and AUC.
Gender
- In a pharmacokinetic study which compared healthy male and female volunteers, pitavastatin Cmax and AUC were 60 and 54% higher, respectively in females. This had no effect on the efficacy or safety of Pitavastatin in women in clinical studies.
Geriatric
- In a pharmacokinetic study which compared healthy young and elderly (65 years) volunteers, pitavastatin Cmax and AUC were 10 and 30% higher, respectively, in the elderly. This had no effect on the efficacy or safety of Pitavastatin in elderly subjects in clinical studies.
Renal Impairment
- In patients with moderate renal impairment (glomerular filtration rate of 30  59 mL/min/1.73 m2) and end stage renal disease receiving hemodialysis, pitavastatin AUC0-inf is 102 and 86% higher than those of healthy volunteers, respectively, while pitavastatin Cmax is 60 and 40% higher than those of healthy volunteers, respectively. Patients received hemodialysis immediately before pitavastatin dosing and did not undergo hemodialysis during the pharmacokinetic study. Hemodialysis patients have 33 and 36% increases in the mean unbound fraction of pitavastatin as compared to healthy volunteers and patients with moderate renal impairment, respectively.
- In another pharmacokinetic study, patients with severe renal impairment (glomerular filtration rate 15  29 mL/min/1.73 m2) not receiving hemodialysis were administered a single dose of Pitavastatin 4 mg. The AUC0-inf and the Cmax were 36 and 18% higher, respectively, compared with those of healthy volunteers. For both patients with severe renal impairment and healthy volunteers, the mean percentage of protein-unbound pitavastatin was approximately 0.6%.
- The effect of mild renal impairment on pitavastatin exposure has not been studied.
Hepatic Impairment
- The disposition of pitavastatin was compared in healthy volunteers and patients with various degrees of hepatic impairment. The ratio of pitavastatin Cmax between patients with moderate hepatic impairment (Child-Pugh B disease) and healthy volunteers was 2.7. The ratio of pitavastatin AUCinf between patients with moderate hepatic impairment and healthy volunteers was 3.8. The ratio of pitavastatin Cmax between patients with mild hepatic impairment (Child-Pugh A disease) and healthy volunteers was 1.3. The ratio of pitavastatin AUCinf between patients with mild hepatic impairment and healthy volunteers was 1.6. Mean pitavastatin t12 for moderate hepatic impairment, mild hepatic impairment, and healthy were 15, 10, and 8 hours, respectively.
Drug-Drug Interactions
- The principal route of pitavastatin metabolism is glucuronidation via liver UGTs with subsequent formation of pitavastatin lactone. There is only minimal metabolism by the cytochrome P450 system.
Warfarin
- The steady-state pharmacodynamics (international normalized ratio  and prothrombin time ) and pharmacokinetics of warfarin in healthy volunteers were unaffected by the co-administration of Pitavastatin 4 mg daily. However, patients receiving warfarin should have their PT time or INR monitored when pitavastatin is added to their therapy.

## Nonclinical Toxicology

## Carcinogenesis, Mutagenesis, Impairment of Fertility
- In a 92-week carcinogenicity study in mice given pitavastatin, at the maximum tolerated dose of 75 mg/kg/day with systemic maximum exposures (AUC) 26 times the clinical maximum exposure at 4 mg/day, there was an absence of drug-related tumors.
- In a 92-week carcinogenicity study in rats given pitavastatin at 1, 5, 25 mg/kg/day by oral gavage there was a significant increase in the incidence of thyroid follicular cell tumors at 25 mg/kg/day, which represents 295 times human systemic exposures based on AUC at the 4 mg/day maximum human dose.
- In a 26-week transgenic mouse (Tg rasH2) carcinogenicity study where animals were given pitavastatin at 30, 75, and 150 mg/kg/day by oral gavage, no clinically significant tumors were observed.
- Pitavastatin was not mutagenic in the Ames test with Salmonella typhimurium and Escherichia coli with and without metabolic activation, the micronucleus test following a single administration in mice and multiple administrations in rats, the unscheduled DNA synthesis test in rats, and a Comet assay in mice. In the chromosomal aberration test, clastogenicity was observed at the highest doses tested which also elicited high levels of cytotoxicity.
- Pitavastatin had no adverse effects on male and female rat fertility at oral doses of 10 and 30 mg/kg/day, respectively, at systemic exposures 56- and 354-times clinical exposure at 4 mg/day based on AUC.
- Pitavastatin treatment in rabbits resulted in mortality in males and females given 1 mg/kg/day (30-times clinical systemic exposure at 4 mg/day based on AUC) and higher during a fertility study. Although the cause of death was not determined, rabbits had gross signs of renal toxicity (kidneys whitened) indicative of possible ischemia. Lower doses (15-times human systemic exposure) did not show significant toxicity in adult males and females. However, decreased implantations, increased resorptions, and decreased viability of fetuses were observed.

## Animal Toxicology and/or Pharmacology

### Central Nervous System Toxicity
- CNS vascular lesions, characterized by perivascular hemorrhages, edema, and mononuclear cell infiltration of perivascular spaces, have been observed in dogs treated with several other members of this drug class. A chemically similar drug in this class produced dose-dependent optic nerve degeneration (Wallerian degeneration of retinogeniculate fibers) in dogs, at a dose that produced plasma drug levels about 30 times higher than the mean drug level in humans taking the highest recommended dose. Wallerian degeneration has not been observed with pitavastatin. Cataracts and lens opacities were seen in dogs treated for 52 weeks at a dose level of 1 mg/kg/day (9 times clinical exposure at the maximum human dose of 4 mg/day based on AUC comparisons.

# Clinical Studies

## Primary hyperlipidemia or Mixed Dyslipidemia
Dose-ranging study
- A multicenter, randomized, double-blind, placebo-controlled, dose-ranging study was performed to evaluate the efficacy of Pitavastatin compared with placebo in 251 patients with primary hyperlipidemia(Table 4). Pitavastatin given as a single daily dose for 12 weeks significantly reduced plasma LDL-C, TC, TG, and Apo-B compared to placebo and was associated with variable increases in HDL-C across the dose range.
Active-controlled study with atorvastatin (NK-104-301)
- Pitavastatin was compared with the HMG-CoA reductase inhibitor atorvastatin in a randomized, multicenter, double-blind, double-dummy, active-controlled, non-inferiority Phase 3 study of 817 patients with primary hyperlipidemiaor mixed dyslipidemia. Patients entered a 6- to 8-week wash-out/dietary lead-in period and then were randomized to a 12-week treatment with either Pitavastatin or atorvastatin (Table 5). Non-inferiority of pitavastatin to a given dose of atorvastatin was considered to be demonstrated if the lower bound of the 95% CI for the mean treatment difference was greater than 6% for the mean percent change in LDL-C.
- Lipid results are shown in Table 5. For the percent change from baseline to endpoint in LDL-C, Pitavastatin was non-inferior to atorvastatin for the two pairwise comparisons: Pitavastatin 2 mg vs. atorvastatin 10 mg and Pitavastatin 4 mg vs. atorvastatin 20 mg. Mean treatment differences (95% CI) were 0% (-3%, 3%) and 1% (-2%, 4%), respectively.
Active-controlled study with simvastatin (NK-104-302)
- Pitavastatin was compared with the HMG-CoA reductase inhibitor simvastatin in a randomized, multicenter, double-blind, double-dummy, active-controlled, non-inferiority Phase 3 study of 843 patients with primary hyperlipidemiaor mixed dyslipidemia. Patients entered a 6- to 8-week wash-out/dietary lead-in period and then were randomized to a 12 week treatment with either Pitavastatin or simvastatin (Table 6). Non-inferiority of pitavastatin to a given dose of simvastatin was considered to be demonstrated if the lower bound of the 95% CI for the mean treatment difference was greater than 6% for the mean percent change in LDL-C.
- Lipid results are shown in Table 6. For the percent change from baseline to endpoint in LDL-C, Pitavastatin was non-inferior to simvastatin for the two pairwise comparisons: Pitavastatin 2 mg vs. simvastatin 20 mg and Pitavastatin 4 mg vs. simvastatin 40 mg. Mean treatment differences (95% CI) were 4% (1%, 7%) and 1% (-2%, 4%), respectively.
Active-controlled study with pravastatin in elderly (NK-104-306)
- Pitavastatin was compared with the HMG-CoA reductase inhibitor pravastatin in a randomized, multicenter, double-blind, double-dummy, parallel group, active-controlled non-inferiority Phase 3 study of 942 elderly patients (65 years) with primary hyperlipidemiaor mixed dyslipidemia. Patients entered a 6- to 8-week wash-out/dietary lead-in period, and then were randomized to a once daily dose of Pitavastatin or pravastatin for 12 weeks (Table 7). Non-inferiority of Pitavastatin to a given dose of pravastatin was assumed if the lower bound of the 95% CI for the treatment difference was greater than -6% for the mean percent change in LDL-C.
- Lipid results are shown in Table 7. Pitavastatin significantly reduced LDL-C compared to pravastatin as demonstrated by the following pairwise dose comparisons: Pitavastatin 1 mg vs. pravastatin 10 mg, Pitavastatin 2 mg vs. pravastatin 20 mg and Pitavastatin 4 mg vs. pravastatin 40 mg. Mean treatment differences (95% CI) were 9% (6%, 12%), 10% (7%, 13%) and 10% (7%, 13% ), respectively.
Active-controlled study with simvastatin in patients with  2 risk factors for coronary heart disease (NK-104-304)
- Pitavastatin was compared with the HMG-CoA reductase inhibitor simvastatin in a randomized, multicenter, double-blind, double-dummy, active-controlled, non-inferiority Phase 3 study of 351 patients with primary hyperlipidemiaor mixed dyslipidemia with 2 risk factors for coronary heart disease. After a 6- to 8-week wash-out/dietary lead-in period, patients were randomized to a 12-week treatment with either Pitavastatin or simvastatin (Table 8). Non-inferiority of Pitavastatin to simvastatin was considered to be demonstrated if the lower bound of the 95% CI for the mean treatment difference was greater than -6% for the mean percent change in LDL-C.
- Lipid results are shown in Table 8. Pitavastatin 4 mg was non-inferior to simvastatin 40 mg for percent change from baseline to endpoint in LDL-C. The mean treatment difference (95% CI) was 0% (-2%, 3%).
Active-controlled study with atorvastatin in patients with type II diabetes mellitus (NK-104-305)
- Pitavastatin was compared with the HMG-CoA reductase inhibitor atorvastatin in a randomized, multicenter, double-blind, double-dummy, parallel group, active-controlled, non-inferiority Phase 3 study of 410 subjects with type II diabetes mellitus and combined dyslipidemia. Patients entered a 6- to 8-week washout/dietary lead-in period and were randomized to a once daily dose of Pitavastatin or atorvastatin for 12 weeks. Non-inferiority of Pitavastatin was considered to be demonstrated if the lower bound of the 95% CI for the mean treatment difference was greater than -6% for the mean percent change in LDL-C.
- Lipid results are shown in Table 9. The treatment difference (95% CI) for LDL-C percent change from baseline was -2% (-6.2%, 1.5%). The two treatment groups were not statistically different on LDL-C. However, the lower limit of the CI was -6.2%, slightly exceeding the -6% non-inferiority limit so that the non-inferiority objective was not achieved.

# How Supplied
- Pitavastatin tablets for oral administration are provided as white, film-coated tablets that contain 1 mg, 2 mg, or 4 mg of pitavastatin. Each tablet has KC debossed on one side and a code number specific to the tablet strength on the other.

## Packaging
- Pitavastatin (pitavastatin) Tablets are supplied as:
- NDC 66869-104-90 : 1 mg. Round white film-coated tablet debossed KC on one face and 1 on the reverse; HDPE bottles of 90 tablets
- NDC 66869-204-90 : 2 mg. Round white film-coated tablet debossed KC on one face and 2 on the reverse; HDPE bottles of 90 tablets
- NDC 66869-404-90 : 4 mg. Round white film-coated tablet debossed KC on one face and 4 on the reverse; HDPE bottles of 90 tablets

## Storage
- Store at room temperature between 15C and 30C (59 to 86 F). Protect from light.

# Images

## Drug Images

## Package and Label Display Panel

# Patient Counseling Information

# Patient Counseling Information
- The patient should be informed of the following:

## Dosing Time
- Pitavastatin can be taken at any time of the day with or without food.

## Muscle Pain
- Patients should be advised to promptly notify their physician of any unexplained muscle pain, tenderness, or weakness particularly if accompanied by malaise or fever, or if these muscle signs or symptoms persist after discontinuing Pitavastatin. They should discuss all medication, both prescription and over the counter, with their physician.

## Pregnancy
- Women of childbearing age should use an effective method of birth control to prevent pregnancy while using Pitavastatin. Discuss future pregnancy plans with your healthcare professional, and discuss when to stop Pitavastatin if you are trying to conceive. If you are pregnant, stop taking Pitavastatin and call your healthcare professional.

## Breastfeeding
- Women who are breastfeeding should not use Pitavastatin. If you have a lipid disorder and are breastfeeding, stop taking Pitavastatin and consult with your healthcare professional.

## Liver Enzymes
- It is recommended that liver enzyme tests be checked before the initiation of Pitavastatin and if signs or symptoms of liver injury occur. All patients treated with Pitavastatin should be advised to report promptly any symptoms that may indicate liver injury, including fatigue, anorexia, right upper abdominal discomfort, dark urine or jaundice.

# Precautions with Alcohol
- As with other HMG-CoA reductase inhibitors, Pitavastatin should be used with caution in patients who consume substantial quantities of alcohol.

# Brand Names
Livalo

# Look-Alike Drug Names
- Pitavastatin - pravastatin

# Drug Shortage Status

# Price