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Simvastatin: Drug information

Simvastatin: Drug information
(For additional information see "Simvastatin: Patient drug information" and see "Simvastatin: Pediatric drug information")

For abbreviations, symbols, and age group definitions used in Lexicomp (show table)
Special Alerts
Statin Pregnancy Contraindication Update July 2021

After a comprehensive review of all available data, the FDA is requesting all statin manufacturers to remove the contraindication in the prescribing information against using statins in pregnant patients. Although statin therapy should be discontinued in most pregnant patients, health care providers should consider the ongoing therapeutic needs of the individual patient, especially patients at very high risk of cardiovascular events during pregnancy, such as patients with homozygous familial hypercholesterolemia or those with established cardiovascular disease. Additionally, breastfeeding is still not recommended in patients taking a statin; health care providers should determine whether it is better to temporarily stop statin therapy while breastfeeding or to continue statin therapy and not have the patient breastfeed. If ongoing statin treatment is necessary, infant formula and other alternatives are available. The FDA expects that removing the contraindication will enable health care providers and patients to make individual decisions about benefit and risk, especially for those at very high risk of heart attack or stroke.

Further information is available at https://www.fda.gov/drugs/drug-safety-and-availability/fda-requests-removal-strongest-warning-against-using-cholesterol-lowering-statins-during-pregnancy.

Brand Names: US
  • FloLipid;
  • Zocor
Brand Names: Canada
  • AG-Simvastatin;
  • APO-Simvastatin;
  • Auro-Simvastatin;
  • BIO-Simvastatin [DSC];
  • DOM-Simvastatin [DSC];
  • JAMP-Simvastatin;
  • Mar-Simvastatin;
  • MINT-Simvastatin;
  • PHARMA-Simvastatin;
  • PMS-Simvastatin [DSC];
  • PRIVA-Simvastatin [DSC];
  • SANDOZ Simvastatin [DSC];
  • Simvastatin-10;
  • Simvastatin-20;
  • Simvastatin-40;
  • Simvastatin-80;
  • TARO-Simvastatin;
  • TEVA-Simvastatin;
  • Zocor
Pharmacologic Category
  • Antilipemic Agent, HMG-CoA Reductase Inhibitor
Dosing: Adult

Dosage guidance:

Safety: Simvastatin 80 mg/day is not recommended due to increased risk of myopathy. If patient is unable to achieve low-density lipoprotein cholesterol (LDL-C) goal with simvastatin 40 mg/day, switch to a high-intensity statin (Ref).

Dosing: Simvastatin 20 to 40 mg/day is considered a moderate-intensity statin (generally reduces LDL-C by ~30% to 49%). If LDL-C must be lowered ≥50%, select a high-intensity statin (atorvastatin or rosuvastatin). Assess response ~1 to 3 months after therapy initiation or dose adjustment and every 3 to 12 months thereafter (Ref).

Clinical considerations: Use in conjunction with lifestyle modification (eg, diet, exercise). When initiating therapy and selecting dose intensity, consider age, baseline LDL-C, 10-year atherosclerotic cardiovascular disease (ASCVD) risk, risk-enhancing factors, potential adverse effects, and drug interactions (Ref).

Heterozygous familial hypercholesterolemia

Heterozygous familial hypercholesterolemia (alternative agent):

Note: Use of simvastatin should be limited to patients unable to tolerate a high-intensity statin. Multiple lipid-lowering therapies may be needed if statin monotherapy is not effective. Referral to a lipid specialist should be considered if treatment goals are not met (Ref).

Patients unable to tolerate high-intensity therapy (eg, appropriate dose of atorvastatin or rosuvastatin):

Moderate-intensity therapy: Oral: 20 to 40 mg once daily in the evening (Ref).

Homozygous familial hypercholesterolemia

Homozygous familial hypercholesterolemia (alternative agent):

Note: Use of simvastatin should be limited to patients unable to tolerate a high-intensity statin. Multiple lipid-lowering therapies may be needed if statin monotherapy is not effective. Referral to a lipid specialist should be considered if treatment goals are not met (Ref).

Patients unable to tolerate high-intensity therapy (eg, appropriate dose of atorvastatin or rosuvastatin):

Moderate-intensity therapy: Oral: 20 to 40 mg once daily in the evening (Ref).

Prevention of atherosclerotic cardiovascular disease

Prevention of atherosclerotic cardiovascular disease:

Note: If LDL-C goal (eg, percent reduction or absolute goal) is not met with the initial dose, may consider up-titration to a maximum of 40 mg/day based on estimated 10-year ASCVD risk (see ACC/AHA ASCVD Risk Estimator Plus online), LDL-C response, and tolerability. If LDL-C goal is not met with maximally tolerated dose, consider switching to a high-intensity statin (atorvastatin or rosuvastatin); additional lipid-lowering therapy may be warranted (Ref).

Primary prevention:

Patients without diabetes, 40 to 75 years of age, and LDL-C 70 to 189 mg/dL:

ASCVD 10-year risk 5% to <7.5%:

Note: Depending on baseline LDL-C and presence of risk-enhancing factors, consider statin therapy after shared decision-making with patient. Some experts suggest shared decision-making if ASCVD 10-year risk is 5% to 10%; however, in patients with a baseline LDL-C ≥160 mg/dL, statin therapy is usually recommended (Ref).

Moderate-intensity therapy: Oral: 20 to 40 mg once daily in the evening to reduce LDL-C by 30% to 49% (Ref).

ASCVD 10-year risk ≥7.5% to <20%:

Note: Depending on baseline LDL-C and presence of risk-enhancing factors, consider statin therapy after shared decision-making with patient. Some experts suggest initiating moderate-intensity statin therapy in most patients if ASCVD 10-year risk is >10% to <20% and LDL-C is >100 mg/dL (Ref).

Moderate-intensity therapy: Oral: 20 to 40 mg once daily in the evening to reduce LDL-C by 30% to 49%; higher-risk patients with multiple risk-enhancing factors may benefit from high-intensity statin therapy (ie, with atorvastatin or rosuvastatin) to reduce LDL-C by ≥50% (Ref).

ASCVD 10-year risk ≥20% (alternative agent):

Note: Use of simvastatin should be limited to patients unable to tolerate a high-intensity statin (Ref).

Patients unable to tolerate high-intensity therapy (eg, appropriate dose of atorvastatin or rosuvastatin):

Moderate-intensity therapy: Oral: 20 to 40 mg once daily in the evening (Ref).

Patients with diabetes:

Age 40 to 75 years without additional ASCVD risk factors:

Moderate-intensity therapy: Oral: 20 to 40 mg once daily in the evening to reduce LDL-C by 30% to 49% (Ref).

ASCVD 10-year risk ≥7.5% or multiple ASCVD risk factors (alternative agent):

Note: Use of simvastatin should be limited to patients unable to tolerate a high-intensity statin (Ref).

Patients unable to tolerate high-intensity therapy (eg, appropriate dose of atorvastatin or rosuvastatin):

Moderate-intensity therapy: Oral: 20 to 40 mg once daily in the evening (Ref).

Patients with LDL-C ≥190 mg/dL and 20 to 75 years of age (regardless of ASCVD risk estimate or coexisting diabetes mellitus) (alternative agent):

Note: Use of simvastatin should be limited to patients unable to tolerate a high-intensity statin (Ref).

Patients unable to tolerate high-intensity therapy (eg, appropriate dose of atorvastatin or rosuvastatin):

Moderate-intensity therapy: Oral: 20 to 40 mg once daily in the evening (Ref).

Secondary prevention in patients with established ASCVD (eg, coronary heart disease, cerebrovascular disease [ischemic stroke or transient ischemic attack], peripheral arterial disease) (alternative agent):

Note: Use of simvastatin should be limited to patients unable to tolerate a high-intensity statin (Ref). Patients with high-risk ASCVD may require additional therapies to achieve LDL-C goal (eg, <70 mg/dL or <50 mg/dL if very high risk) (Ref).

Patients unable to tolerate high-intensity therapy (eg, appropriate dose of atorvastatin or rosuvastatin):

Moderate-intensity therapy: Oral: 20 to 40 mg once daily in the evening (Ref).

Transplantation, post kidney

Transplantation, post kidney (alternative agent) (off-label use):

Note: The decision to initiate therapy for primary or secondary prevention is similar to the nontransplant population (see the "Prevention of Atherosclerotic Cardiovascular Disease" indication); however, in patients who are 30 to 39 years of age, some experts suggest statin therapy post kidney transplantation for primary prevention of ASCVD. For primary prevention of ASCVD in patients 18 to 29 years of age, use shared decision-making while considering risks and benefits (Ref). Certain immunosuppressive drugs can induce or exacerbate hypercholesterolemia; significant drug interactions between statins and immunosuppressant drugs are frequent; some interactions can increase statin serum concentrations and risk of toxicity (eg, myopathy) (Ref).

Oral: Initial: 20 mg once daily; increase dose based on response, tolerability, and concomitant drugs up to 40 mg once daily (Ref).

Dosage adjustment for concomitant therapy: Significant drug interactions exist, requiring dose/frequency adjustment or avoidance. Consult drug interactions database for more information.

Dosing: Kidney Impairment: Adult

The renal dosing recommendations are based upon the best available evidence and clinical expertise. Senior Editorial Team: Bruce Mueller, PharmD, FCCP, FASN, FNKF; Jason A. Roberts, PhD, BPharm (Hons), B App Sc, FSHP, FISAC; Michael Heung, MD, MS.

Altered kidney function:

Initial: No dosage adjustment necessary for any degree of kidney dysfunction. Maximum dose: 40 mg once daily (Ref).

Hemodialysis, intermittent (thrice weekly): Unlikely to be significantly dialyzed (highly protein bound) (Ref):

Note: Kidney Disease: Improving Global Outcomes (KDIGO) guidelines recommend not initiating a statin in dialysis patients due to lack of benefits shown in this population; however, patients initiated on a statin before progressing to dialysis may continue to receive therapy (Ref).

Daily dosing: No dosage adjustment necessary; maximum dose: 40 mg once daily (Ref).

Three times weekly (post dialysis) dosing: 20 mg 3 times weekly after hemodialysis on dialysis days (Ref).

Peritoneal dialysis: Unlikely to be significantly dialyzed (highly protein bound) (Ref):

Note: KDIGO guidelines recommend not initiating a statin in dialysis patients due to lack of benefits shown in this population; however, patients initiated on a statin before progressing to dialysis may continue to receive therapy (Ref).

No dosage adjustment necessary; maximum dose: 40 mg once daily (Ref).

CRRT: Unlikely to be significantly dialyzed (highly protein bound) (Ref): No dosage adjustment necessary; maximum dose: 40 mg once daily (Ref).

PIRRT (eg, sustained, low-efficiency diafiltration): Unlikely to be significantly dialyzed (highly protein bound) (Ref): No dosage adjustment necessary; maximum dose: 40 mg once daily (Ref).

Dosing: Hepatic Impairment: Adult

The hepatic dosing recommendations are based upon the best available evidence and clinical expertise. Senior Editorial Team: Matt Harris, PharmD, MHS, BCPS, FAST, Jeong Park, PharmD, MS, BCPS, FCCP, FAST, Arun Jesudian, MD, Sasan Sakiani, MD.

Note: Although use is contraindicated in patients with active liver failure or decompensated cirrhosis according to the manufacturer's labeling, baseline elevation in AST/ALT should not preclude use of statins for compelling indications in patients with chronic stable liver disease including compensated cirrhosis (Ref).

Hepatic impairment prior to treatment initiation:

Child-Turcotte-Pugh class A: No dosage adjustment necessary (Ref).

Child-Turcotte-Pugh class B and C: Oral: Initial: 20 mg once daily; if tolerated for ≥14 days may increase to a maximum dose of 40 mg once daily (Ref). Note: Patients with severe decompensated cirrhosis may not tolerate doses >20 mg once daily (Ref).

Acute hepatotoxicity or worsening of hepatic function (eg, progression from Child-Turcotte-Pugh class A to B) during treatment:

Progression from baseline to Child-Turcotte-Pugh class A through C: Although use is contraindicated in patients with active liver failure or decompensated cirrhosis according to the manufacturer’s labeling, if simvastatin-induced toxicity (eg, liver injury, rhabdomyolysis) has been ruled out, may continue current dose for hypercholesterolemia and atherosclerotic cardiovascular disease risk management, not to exceed 40 mg once daily (Ref); however, in patients with decompensated cirrhosis, consider not exceeding 20 mg once daily (Ref). Continued use of statin therapy may be hepatoprotective in patients with decompensated cirrhosis (Ref).

Dosing: Adjustment for Toxicity: Adult

Severe muscle symptoms or fatigue: Promptly discontinue use; evaluate CPK, creatinine, and urinalysis for myoglobinuria (Ref).

Mild to moderate muscle symptoms: Discontinue use until symptoms can be evaluated; evaluate patient for conditions that may increase the risk for muscle symptoms (eg, hypothyroidism, reduced renal or hepatic function, rheumatologic disorders such as polymyalgia rheumatica, steroid myopathy, vitamin D deficiency, or primary muscle diseases). Upon resolution, resume the original or lower dose of simvastatin. If muscle symptoms recur, discontinue simvastatin use. After muscle symptom resolution, may then use a low dose of a different statin; gradually increase if tolerated. In the absence of continued statin use, if muscle symptoms or elevated CPK continues after 2 months, consider other causes of muscle symptoms. If determined to be due to another condition aside from statin use, may resume statin therapy at the original dose (Ref).

Dosing: Older Adult

Refer to adult dosing.

Dosing: Pediatric

(For additional information see "Simvastatin: Pediatric drug information")

Dosage guidance:

Dosing: A lower, conservative dosing regimen may be necessary in patient populations predisposed to myopathy. Dosage should be individualized according to the baseline LDL-C level, the recommended goal of therapy, and patient response; adjustments should be made at intervals of 4 weeks.

Clinical considerations: Lifestyle changes are recommended to be implemented for at least 6 to 12 months before beginning pharmacotherapy (Ref).

Hyperlipidemia or heterozygous familial hypercholesterolemia and nonfamilial hypercholesterolemia

Hyperlipidemia or heterozygous familial hypercholesterolemia (HeFH) and nonfamilial hypercholesterolemia: Note: Limited data available for nonfamilial hypercholesterolemia or other forms of non-HeFH hyperlipidemia.

Begin treatment if, after adequate trial (6 to 12 months) of intensive lifestyle modification emphasizing body weight normalization and diet, the following are present (Ref):

LDL-C ≥190 mg/dL or

LDL-C remains ≥160 mg/dL and two or more cardiovascular risk factors: Family history of premature atherosclerotic cardiovascular disease (<55 years of age), overweight, obesity, or other elements of insulin resistance syndrome or

LDL-C ≥130 mg/dL and diabetes mellitus (Ref).

Therapy may also be considered for children 8 to 9 years of age meeting the above criteria or for children with diabetes mellitus and LDL-C ≥130 mg/dL (Ref).

Children ≥4 years and <10 years: Very limited data available: Oral: Initial: 5 mg once daily in the evening increasing to 10 mg once daily after 4 weeks and to 20 mg once daily after another 4 weeks as tolerated; maximum daily dose: 20 mg/day; most experience is with children at least 8 years of age; in trials, the youngest reported patient was 4 years of age (Ref).

Children ≥10 years and Adolescents: Oral: Initial: 10 mg once daily in the evening increasing to 20 mg once daily after 6 weeks and to 40 mg once daily after another 6 weeks as tolerated; maximum daily dose: 40 mg/day.

Dosage adjustment for concomitant therapy: Significant drug interactions exist, requiring dose/frequency adjustment or avoidance. Consult drug interactions database for more information.

Dosing adjustment for toxicity: Muscle symptoms (potential myopathy): Children ≥4 years and Adolescents: Discontinue use until symptoms can be evaluated; check CPK level; based on experience in adult patients, also evaluate patient for conditions that may increase the risk for muscle symptoms (eg, hypothyroidism, reduced renal or hepatic function, rheumatologic disorders such as polymyalgia rheumatica, steroid myopathy, vitamin D deficiency, or primary muscle diseases). Upon resolution (symptoms and any associated CPK abnormalities), resume the original or consider a lower dose of simvastatin and retitrate. If muscle symptoms recur, discontinue simvastatin use. After muscle symptom resolution, may then reinitiate a different statin at an initial low dose; gradually increase if tolerated. Based on experience in adult patients, if muscle symptoms or elevated CPK persists for 2 months in the absence of continued statin use, consider other causes of muscle symptoms. If determined to be due to another condition aside from statin use, may resume statin therapy at the original dose (Ref).

Dosing: Kidney Impairment: Pediatric

There are no pediatric specific recommendations. Simvastatin does not undergo significant renal excretion. Based on experience in adult patients with mild-to-moderate renal impairment, no dosage adjustment necessary; in severe impairment, use with caution.

Dosing: Hepatic Impairment: Pediatric

Contraindicated in patients with active liver disease, including unexplained persistent elevations in hepatic transaminases.

Adverse Reactions (Significant): Considerations
Hepatic effects

Statins are associated with increased serum transaminases and hepatotoxicity (Ref). Asymptomatic transient or persistent increases both <3 or >3 times the ULN in serum transaminases may occur with all statins; the increase in alanine aminotransferase (ALT) is typically greater than the increase in aspartate aminotransferase (AST) (Ref). Acute hepatotoxicity, rarely presenting as a drug-induced autoimmune hepatitis, has been reported (Ref).

Upon dose reduction or discontinuation, transaminase levels return to or near pretreatment levels; although, mild elevations resolve with continued use in some cases (Ref). Chronic liver injury (defined as liver biochemical or histological abnormalities that persisted for 6 months or more after onset) has been reported (Ref).

Mechanism: Unclear; inhibition of the CYP450 system leading to increased plasma concentrations of statins has been postulated (Ref). Changes in the lipid components of the hepatocyte membrane may lead to increased permeability and leakage of liver enzymes (Ref).

Onset: Varied; most cases occur within the first 3 months of statin initiation or dose escalation (Ref). Duration of simvastatin prior to hepatotoxicity has been reported from approximately 1 to 9 months (Ref).

Risk factors:

• Higher doses may increase the risk of liver injury (Ref)

• Concurrent medication with statin drug-drug interactions or hepatotoxic properties (Ref)

• Hepatotoxicity is more commonly associated with atorvastatin than pravastatin, rosuvastatin, and simvastatin (Ref). Fluvastatin is associated with the greatest risk of developing hepatotoxicity (Ref)

• Cross-reactivity between different statins and the susceptibility to hepatotoxicity is unknown as data have shown conflicting results (Ref)

• Chronic hepatitis B and alcohol consumption are independent risk factors for hepatic aminotransferase elevation associated with statins in patients 80 years of age or older (Ref)

Muscle-related effects

Statins are associated with several muscle-related effects, including:

Myalgia (muscle symptoms without significant creatine kinase [CK] elevations; also known as statin-associated muscle symptoms) (Ref)

Myopathy (defined as unexplained muscle pain or weakness accompanied by a CK concentration >10 times the ULN) (Ref)

Rhabdomyolysis (CK >40 times the ULN) (Ref) often with acute renal failure secondary to myoglobinuria (Ref)

Immune-mediated necrotizing myopathy (IMNM) (elevated CK plus the presence of antibodies against HMG-CoA) (Ref)

Mechanism: Uncertain; alterations in the mevalonate pathway and changes in the electrical and structural characteristics of the sarcolemma related to calcium ion flux possibly contribute (Ref). Decreased ubiquinone, which is essential for energy production in skeletal muscle, may also contribute (Ref). Myopathy/rhabdomyolysis risk is related to circulating active drug concentrations (Ref). IMNM is considered an immune-mediated process; autoantibodies against HMG-CoA reductase (anti-HMG-CoA) have been identified (Ref).

Onset: Delayed; often presents within a few months after starting therapy (highest risk within first year of use), when the dose of the statin is increased, or when introducing an interacting drug (Ref). Muscle symptoms often appear more promptly when patients are reexposed to the same statin (Ref). Duration of statin use prior to development of IMNM is ~2 to 3 years (Ref).

Risk factors:

• First year of therapy (Ref)

• Dose increase (for myopathy and rhabdomyolysis, but not IMNM) (Ref)

• Addition of an interacting drug (eg, concurrent use of medications associated with myopathy [eg, gemfibrozil] or concurrent use of strong CYP3A4 inhibitors) (Ref)

• Older patients (Ref)

• Hypothyroidism (Ref)

• Preexisting muscle disease (Ref)

• Kidney impairment, especially with simvastatin 80 mg/day (Ref)

• Females (Ref)

• Low body mass index (Ref)

• Heavy exercise (Ref)

• Surgery (Ref)

• Higher HMG-COA reductase inhibitory activity (Ref), rosuvastatin > atorvastatin > simvastatin > pravastatin ≈ lovastatin (Ref)

• Asian population: Data are conflicting regarding increased susceptibility to myopathy with simvastatin in patients of Chinese origin (Ref)

Adverse Reactions

The following adverse drug reactions and incidences are derived from product labeling unless otherwise specified. Adverse reaction incidence reported in adults.

1% to 10%:

Cardiovascular: Atrial fibrillation (6%), edema (≤3%)

Dermatologic: Eczema (5%)

Gastrointestinal: Abdominal pain (7%), constipation (7%), gastritis (5%), nausea (5%)

Genitourinary: Cystitis (interstitial; Huang 2015)

Hepatic: Increased serum transaminases (≤2%)

Nervous system: Headache (3% to 7%), vertigo (5%)

Neuromuscular & skeletal: Increased creatine phosphokinase in blood specimen (>3 × normal: 5%), myalgia (4%) (table 1)

Simvastatin: Adverse Reaction: Myalgia

Drug (Simvastatin)

Placebo

Population

Dosage Form

Number of Patients (Simvastatin)

Number of Patients (Placebo)

4%

3%

Adults

Tablets

2,221

2,223

Respiratory: Bronchitis (7%), upper respiratory infection (9%)

Miscellaneous: Swelling (≤3%)

Frequency not defined:

Dermatologic: Skin rash

Endocrine & metabolic: Increased gamma-glutamyl transferase

Gastrointestinal: Diarrhea, dyspepsia, flatulence

Hepatic: Increased serum alkaline phosphatase

Nervous system: Asthenia

Postmarketing:

Cardiovascular: Flushing, vasculitis

Dermatologic: Alopecia, changes in nails, changes of hair, cutaneous nodule, erythema multiforme, lichen planus, pruritus, skin discoloration, skin photosensitivity (Morimoto 1995), Stevens-Johnson syndrome, toxic epidermal necrolysis, urticaria, xeroderma

Endocrine & metabolic: Elevated glycosylated hemoglobin, increase in fasting plasma glucose

Gastrointestinal: Dry mucous membranes, dysgeusia (Tuccori 2011), pancreatitis (Johnson 2006), vomiting

Genitourinary: Erectile dysfunction

Hematologic & oncologic: Anemia, eosinophilia (de las Marinas Alvarez 2018), hemolytic anemia, increased erythrocyte sedimentation rate, leukopenia, positive ANA titer, purpuric disease, thrombocytopenia (Groneberg 2001)

Hepatic: Autoimmune hepatitis (Russo 2014), hepatic failure, hepatitis, jaundice

Hypersensitivity: Anaphylaxis, angioedema, hypersensitivity reaction

Immunologic: Dermatomyositis (Chemello 2017)

Nervous system: Chills, cognitive dysfunction (including amnesia, confusion, forgetfulness, memory impairment) (Suraweera 2016), depression, dizziness, malaise, paresthesia, peripheral neuropathy (Phan 1995)

Neuromuscular & skeletal: Arthralgia (Campion 2008), arthritis, immune-mediated necrotizing myopathy (Essers 2019), lupus-like syndrome (Ahmad 2000), muscle cramps, myopathy (Newman 2019), polymyalgia rheumatica, rhabdomyolysis (Kariyanna 2019)

Respiratory: Dyspnea, interstitial pulmonary disease (De Groot 1996)

Miscellaneous: Fever

Contraindications

Hypersensitivity to simvastatin or any component of the formulation; acute liver disease or decompensated cirrhosis; concomitant use of strong CYP3A4 inhibitors (select azole antifungals [eg, itraconazole, ketoconazole, posaconazole, voriconazole], select macrolide antibiotics [eg, erythromycin and clarithromycin], select HIV protease inhibitors [eg, nelfinavir, ritonavir, darunavir/ritonavir], select hepatitis C virus protease inhibitors [eg, boceprevir, telaprevir], cobicistat-containing products, and nefazodone), cyclosporine, danazol, or gemfibrozil.

Significant drug interactions exist, requiring dose/frequency adjustment or avoidance. Consult drug interactions database for more information.

Canadian labeling: Additional contraindications (not in the US labeling): Persistent elevated transaminases; breastfeeding; pregnancy.

Warnings/Precautions

Concerns related to adverse effects:

• Diabetes mellitus: Increases in HbA1c and fasting blood glucose have been reported; however, the benefits of statin therapy far outweigh the risk of dysglycemia.

Disease-related concerns:

• Hepatic impairment: Use with caution in patients who consume large amounts of ethanol and/or have a history of liver disease; may require dosage adjustment in some patients with hepatic impairment.

• Myasthenia gravis: May rarely worsen or precipitate myasthenia gravis (MG); monitor for worsening MG if treatment is initiated (AAN [Narayanaswami 2021]).

• Renal impairment: Use with caution in patients with severe renal impairment (creatinine clearance not defined); monitor closely.

Dosage form specific issues:

• Propylene glycol: Some dosage forms may contain propylene glycol; large amounts are potentially toxic and have been associated hyperosmolality, lactic acidosis, seizures and respiratory depression; use caution (AAP 1997; Zar 2007). See manufacturer's labeling.

Special Populations:

• Elderly: Use with caution in patients ≥65 years of age; these patients are predisposed to myopathy.

• Surgical patients: Based on current research and clinical guidelines, HMG-CoA reductase inhibitors should be continued in the perioperative period for noncardiac and cardiac surgery (ACC/AHA [Fleisher 2014]; ACC/AHA [Hillis 2011]). Perioperative discontinuation of statin therapy is associated with an increased risk of cardiac morbidity and mortality.

Dosage Forms: US

Excipient information presented when available (limited, particularly for generics); consult specific product labeling. [DSC] = Discontinued product

Suspension, Oral:

FloLipid: 20 mg/5 mL (150 mL); 40 mg/5 mL (150 mL) [contains ethylparaben, methylparaben, propylene glycol, propylparaben]

Generic: 20 mg/5 mL (75 mL [DSC])

Tablet, Oral:

Zocor: 5 mg [DSC], 10 mg, 20 mg, 40 mg, 80 mg [DSC]

Generic: 5 mg, 10 mg, 20 mg, 40 mg, 80 mg

Generic Equivalent Available: US

Yes

Pricing: US

Tablets (Simvastatin Oral)

5 mg (per each): $0.10 - $2.81

10 mg (per each): $0.13 - $2.82

20 mg (per each): $0.14 - $4.92

40 mg (per each): $0.15 - $4.92

80 mg (per each): $0.17 - $4.92

Tablets (Zocor Oral)

10 mg (per each): $6.37

20 mg (per each): $11.12

40 mg (per each): $11.12

Disclaimer: A representative AWP (Average Wholesale Price) price or price range is provided as reference price only. A range is provided when more than one manufacturer's AWP price is available and uses the low and high price reported by the manufacturers to determine the range. The pricing data should be used for benchmarking purposes only, and as such should not be used alone to set or adjudicate any prices for reimbursement or purchasing functions or considered to be an exact price for a single product and/or manufacturer. Medi-Span expressly disclaims all warranties of any kind or nature, whether express or implied, and assumes no liability with respect to accuracy of price or price range data published in its solutions. In no event shall Medi-Span be liable for special, indirect, incidental, or consequential damages arising from use of price or price range data. Pricing data is updated monthly.

Dosage Forms: Canada

Excipient information presented when available (limited, particularly for generics); consult specific product labeling.

Tablet, Oral:

Zocor: 10 mg, 20 mg, 40 mg

Generic: 5 mg, 10 mg, 20 mg, 40 mg, 80 mg

Administration: Adult

Oral:

Suspension: Administer in the evening on an empty stomach. Shake well for at least 20 seconds before administering dose.

Tablets: Administered without regard to meals. Administer in the evening for maximal efficacy.

Administration: Pediatric

Oral: May be taken without regard to meals. Administration with the evening meal or at bedtime has been associated with somewhat greater LDL-C reduction

Use: Labeled Indications

Heterozygous familial hypercholesterolemia: To reduce elevated total cholesterol (total-C), LDL-C, apoB, and triglyceride levels, and to increase HDL-C in patients with primary hypercholesterolemia.

Heterozygous familial hypercholesterolemia (pediatrics): To reduce total-C, LDL-C, and apoB levels in boys and postmenarche girls 10 to 17 years of age with heterozygous familial hypercholesterolemia with either LDL-C ≥190 mg/dL, LDL-C ≥160 mg/dL with positive family history of premature cardiovascular disease (CVD), or LDL-C ≥160 mg/dL with 2 or more other CVD risk factors.

Homozygous familial hypercholesterolemia: To reduce total-C and LDL-C in patients with homozygous familial hypercholesterolemia as an adjunct to other lipid-lowering treatments (eg, LDL apheresis) or if such treatments are unavailable.

Prevention of atherosclerotic cardiovascular disease:

Primary prevention of atherosclerotic cardiovascular disease: To reduce the risk of myocardial infarction (MI), stroke, revascularization procedures, and angina in adults without a history of coronary heart disease (CHD) but who have multiple CHD risk factors.

Secondary prevention in patients with established atherosclerotic cardiovascular disease: To reduce the risk of MI, stroke, revascularization procedures, and angina in patients with a history of CHD.

Use: Off-Label: Adult

Transplantation, post kidney

Medication Safety Issues
Sound-alike/look-alike issues:

Simvastatin may be confused with atorvastatin, nystatin, pitavastatin

Zocor may be confused with Cozaar, Lipitor, Zoloft, ZyrTEC

International issues:

Cardin [Poland] may be confused with Cardem brand name for celiprolol [Spain]; Cardene brand name for nicardipine [US, Great Britain, Netherlands]

Metabolism/Transport Effects

Substrate of CYP3A4 (major), OATP1B1/1B3 (SLCO1B1/1B3); Note: Assignment of Major/Minor substrate status based on clinically relevant drug interaction potential

Drug Interactions

Note: Interacting drugs may not be individually listed below if they are part of a group interaction (eg, individual drugs within “CYP3A4 Inducers [Strong]” are NOT listed). For a complete list of drug interactions by individual drug name and detailed management recommendations, use the Lexicomp drug interactions program by clicking on the “Launch drug interactions program” link above.

Abiraterone Acetate: May enhance the myopathic (rhabdomyolysis) effect of HMG-CoA Reductase Inhibitors (Statins). Risk C: Monitor therapy

Acipimox: May enhance the myopathic (rhabdomyolysis) effect of HMG-CoA Reductase Inhibitors (Statins). Risk C: Monitor therapy

Amiodarone: May increase serum concentrations of the active metabolite(s) of Simvastatin. Amiodarone may increase the serum concentration of Simvastatin. Management: Consider using a non-interacting statin (pravastatin) in patients on amiodarone. If combined, limit the adult simvastatin dose to 20 mg daily and monitor for evidence of simvastatin toxicities (eg, myalgia, liver function test elevations, rhabdomyolysis). Risk D: Consider therapy modification

AmLODIPine: May increase the serum concentration of Simvastatin. Management: Dose of simvastatin should not exceed 20 mg daily if coadministering with amlodipine. If coadministering with simvastatin and amlodipine, close laboratory and clinical monitoring for signs and symptoms of rhabdomyolysis is warranted. Risk D: Consider therapy modification

Asunaprevir: May increase the serum concentration of HMG-CoA Reductase Inhibitors (Statins). Risk C: Monitor therapy

Azithromycin (Systemic): May enhance the myopathic (rhabdomyolysis) effect of Simvastatin. Risk C: Monitor therapy

Bempedoic Acid: May increase the serum concentration of Simvastatin. Management: Avoid coadministration of bempedoic acid with simvastatin doses greater than 20 mg due to the potential for increased simvastatin concentrations and simvastatin-related myopathy. Risk D: Consider therapy modification

Bezafibrate: May enhance the myopathic (rhabdomyolysis) effect of HMG-CoA Reductase Inhibitors (Statins). Bezafibrate may increase the serum concentration of HMG-CoA Reductase Inhibitors (Statins). More specifically, bezafibrate may increase the serum concentration of fluvastatin Management: Avoid use of bezafibrate and HMG-CoA reductase inhibitors (statins) unless strictly indicated due to the increased of muscle toxicity (including rhabdomyolysis). In patients who may be predisposed to myopathy, concomitant use is contraindicated. Risk D: Consider therapy modification

Ciprofibrate: May enhance the adverse/toxic effect of HMG-CoA Reductase Inhibitors (Statins). Management: Avoid the use of HMG-CoA reductase inhibitors and ciprofibrate if possible. If concomitant therapy is considered, benefits should be carefully weighed against the risks, and patients should be monitored closely for signs/symptoms of muscle toxicity. Risk D: Consider therapy modification

Ciprofloxacin (Systemic): May enhance the myopathic (rhabdomyolysis) effect of Simvastatin. Ciprofloxacin (Systemic) may increase the serum concentration of Simvastatin. Risk C: Monitor therapy

Clofazimine: May increase the serum concentration of CYP3A4 Substrates (High risk with Inhibitors). Risk C: Monitor therapy

Colchicine: May enhance the myopathic (rhabdomyolysis) effect of HMG-CoA Reductase Inhibitors (Statins). Colchicine may increase the serum concentration of HMG-CoA Reductase Inhibitors (Statins). HMG-CoA Reductase Inhibitors (Statins) may increase the serum concentration of Colchicine. Risk C: Monitor therapy

CycloSPORINE (Systemic): May increase the serum concentration of Simvastatin. Risk X: Avoid combination

CYP3A4 Inducers (Moderate): May decrease the serum concentration of Simvastatin. Risk C: Monitor therapy

CYP3A4 Inducers (Strong): May decrease the serum concentration of Simvastatin. Risk C: Monitor therapy

CYP3A4 Inhibitors (Moderate): May increase serum concentrations of the active metabolite(s) of Simvastatin. CYP3A4 Inhibitors (Moderate) may increase the serum concentration of Simvastatin. Risk C: Monitor therapy

CYP3A4 Inhibitors (Strong): May increase serum concentrations of the active metabolite(s) of Simvastatin. CYP3A4 Inhibitors (Strong) may increase the serum concentration of Simvastatin. Risk X: Avoid combination

CYP3A4 Inhibitors (Weak): May increase serum concentrations of the active metabolite(s) of Simvastatin. CYP3A4 Inhibitors (Weak) may increase the serum concentration of Simvastatin. Risk C: Monitor therapy

Cyproterone: May increase the serum concentration of HMG-CoA Reductase Inhibitors (Statins). Risk C: Monitor therapy

Dabigatran Etexilate: Simvastatin may enhance the anticoagulant effect of Dabigatran Etexilate. Risk C: Monitor therapy

Daclatasvir: May increase the serum concentration of HMG-CoA Reductase Inhibitors (Statins). Risk C: Monitor therapy

Danazol: May increase the serum concentration of Simvastatin. Risk X: Avoid combination

DAPTOmycin: Simvastatin may enhance the adverse/toxic effect of DAPTOmycin. Risk X: Avoid combination

Darolutamide: May increase the serum concentration of OATP1B1/1B3 (SLCO1B1/1B3) Substrates (Clinically Relevant with Inhibitors). Risk C: Monitor therapy

Digoxin: Simvastatin may increase the serum concentration of Digoxin. Risk C: Monitor therapy

DilTIAZem: Simvastatin may decrease the serum concentration of DilTIAZem. DilTIAZem may increase the serum concentration of Simvastatin. Management: Avoid concurrent use of diltiazem with simvastatin when possible. If used together, limit adult doses to simvastatin 10 mg daily and diltiazem 240 mg per day; monitor closely for signs of simvastatin toxicity (eg, myositis, rhabdomyolysis). Risk D: Consider therapy modification

Dronedarone: May increase serum concentrations of the active metabolite(s) of Simvastatin. Dronedarone may increase the serum concentration of Simvastatin. Management: Carefully consider the potential risks and benefits of this combination. If coadministered, limit adult simvastatin dose to 10 mg daily, and monitor closely for signs of simvastatin toxicity (eg, myositis, rhabdomyolysis). Risk D: Consider therapy modification

Elbasvir and Grazoprevir: May increase the serum concentration of Simvastatin. Risk C: Monitor therapy

Elranatamab: May increase the serum concentration of CYP Substrates (Narrow Therapeutic Index/Sensitive with Inhibitors). Risk C: Monitor therapy

Eltrombopag: May increase the serum concentration of OATP1B1/1B3 (SLCO1B1/1B3) Substrates (Clinically Relevant with Inhibitors). Risk C: Monitor therapy

Encorafenib: May increase the serum concentration of OATP1B1/1B3 (SLCO1B1/1B3) Substrates (Clinically Relevant with Inhibitors). Risk C: Monitor therapy

Erdafitinib: May increase the serum concentration of CYP3A4 Substrates (Narrow Therapeutic Index/Sensitive with Inhibitors). Risk X: Avoid combination

Erythromycin (Systemic): May increase serum concentrations of the active metabolite(s) of Simvastatin. Erythromycin (Systemic) may increase the serum concentration of Simvastatin. Risk X: Avoid combination

Etravirine: May decrease the serum concentration of HMG-CoA Reductase Inhibitors (Statins). This applies to atorvastatin, lovastatin and simvastatin. Risk C: Monitor therapy

Fenofibrate and Derivatives: May enhance the adverse/toxic effect of HMG-CoA Reductase Inhibitors (Statins). Risk C: Monitor therapy

Fexinidazole: May increase the serum concentration of CYP3A4 Substrates (High risk with Inhibitors). Risk X: Avoid combination

Fosamprenavir: May increase the serum concentration of Simvastatin. Risk X: Avoid combination

Fostamatinib: May increase the serum concentration of Simvastatin. Risk C: Monitor therapy

Fostemsavir: May increase the serum concentration of HMG-CoA Reductase Inhibitors (Statins). Management: Use the lowest possible starting statin dose and monitor patients closely for statin-related adverse effects (eg, muscle aches and pains) during coadministration with fostemsavir. Risk D: Consider therapy modification

Fusidic Acid (Systemic): May enhance the adverse/toxic effect of HMG-CoA Reductase Inhibitors (Statins). Specifically, the risk for muscle toxicities, including rhabdomyolysis may be significantly increased. Management: Avoid concurrent use whenever possible. Use is listed as contraindicated in product characteristic summaries in several countries, although UK labeling suggests that use could be considered under exceptional circumstances and with close supervision. Risk X: Avoid combination

Fusidic Acid (Systemic): May increase the serum concentration of CYP3A4 Substrates (High risk with Inhibitors). Risk X: Avoid combination

Gemfibrozil: May enhance the myopathic (rhabdomyolysis) effect of Simvastatin. Gemfibrozil may increase the serum concentration of Simvastatin. Concentrations of the active simvastatin acid metabolite may also be increased by gemfibrozil. Risk X: Avoid combination

Glecaprevir and Pibrentasvir: May increase the serum concentration of Simvastatin. Risk X: Avoid combination

Glofitamab: May increase the serum concentration of CYP Substrates (Narrow Therapeutic Index/Sensitive with Inhibitors). Risk C: Monitor therapy

Grapefruit Juice: May increase the serum concentration of Simvastatin. Risk X: Avoid combination

Interleukin-6 (IL-6) Inhibiting Therapies: May decrease the serum concentration of HMG-CoA Reductase Inhibitors (Statins). Risk C: Monitor therapy

Itraconazole: May increase the serum concentration of Simvastatin. Risk X: Avoid combination

Lacidipine: May increase the serum concentration of Simvastatin. Risk C: Monitor therapy

Lanthanum: May decrease the serum concentration of HMG-CoA Reductase Inhibitors (Statins). Management: Administer HMG-CoA reductase inhibitors (eg, statins) at least two hours before or after lanthanum. Risk D: Consider therapy modification

Leflunomide: May increase the serum concentration of OATP1B1/1B3 (SLCO1B1/1B3) Substrates (Clinically Relevant with Inhibitors). Risk C: Monitor therapy

Leniolisib: May increase the serum concentration of OATP1B1/1B3 (SLCO1B1/1B3) Substrates (Clinically Relevant with Inhibitors). Risk X: Avoid combination

Lercanidipine: May increase the serum concentration of Simvastatin. Management: Administer lercanidipine in the morning and simvastatin in the evening in patients receiving these drugs in combination. Risk D: Consider therapy modification

Letermovir: May increase the serum concentration of Simvastatin. Risk X: Avoid combination

Levamlodipine: May increase the serum concentration of Simvastatin. Management: Limit simvastatin dose to 20 mg daily and monitor closely for signs and symptoms of rhabdomyolysis (eg, creatinine phosphokinase, muscle aches and pains) if coadministering with levamlodipine. Risk D: Consider therapy modification

Lomitapide: May increase serum concentrations of the active metabolite(s) of Simvastatin. Lomitapide may increase the serum concentration of Simvastatin. Management: Reduce the recommended simvastatin dose by 50%. Generally, limit the maximum adult simvastatin dose to 20 mg/day. A 40 mg/day dose can be considered in patients who previously received 80 mg/day for at least a year without evidence of muscle toxicity. Risk D: Consider therapy modification

Lonafarnib: May increase the serum concentration of Simvastatin. Risk X: Avoid combination

Mosunetuzumab: May increase the serum concentration of CYP Substrates (Narrow Therapeutic Index/Sensitive with Inhibitors). Risk C: Monitor therapy

Niacin: May enhance the myopathic (rhabdomyolysis) effect of Simvastatin. Niacin may increase the serum concentration of Simvastatin. Management: Avoid this combination in Chinese patients; some non-US labeling state this combination is not recommended in any Asian patients. If coadministered, consider simvastatin dose reductions and monitor closely for signs and symptoms of muscle toxicity. Risk D: Consider therapy modification

Nirmatrelvir and Ritonavir: May increase the serum concentration of Simvastatin. Management: Discontinue simvastatin at least 12 hours prior to initiating nirmatrelvir and ritonavir, and do not restart simvastatin until 5 days after completing nirmatrelvir and ritonavir treatment. Risk X: Avoid combination

Pacritinib: May increase the serum concentration of CYP3A4 Substrates (Narrow Therapeutic Index/Sensitive with Inhibitors). Risk X: Avoid combination

Pretomanid: May increase the serum concentration of OATP1B1/1B3 (SLCO1B1/1B3) Substrates (Clinically Relevant with Inhibitors). Risk C: Monitor therapy

QuiNINE: May increase the serum concentration of HMG-CoA Reductase Inhibitors (Statins). Risk C: Monitor therapy

Raltegravir: May enhance the myopathic (rhabdomyolysis) effect of HMG-CoA Reductase Inhibitors (Statins). Risk C: Monitor therapy

Ranolazine: May increase the serum concentration of Simvastatin. Management: Carefully consider the potential benefits and risks of this combination. Limit simvastatin to 20 mg daily if coadministered, and monitor closely for signs and symptoms of myopathy or rhabdomyolysis. Risk D: Consider therapy modification

Red Yeast Rice: May enhance the adverse/toxic effect of HMG-CoA Reductase Inhibitors (Statins). Risk X: Avoid combination

Repaglinide: HMG-CoA Reductase Inhibitors (Statins) may increase the serum concentration of Repaglinide. Risk C: Monitor therapy

Ritlecitinib: May increase the serum concentration of CYP3A4 Substrates (Narrow Therapeutic Index/Sensitive with Inhibitors). Risk C: Monitor therapy

Roxadustat: May increase the serum concentration of HMG-CoA Reductase Inhibitors (Statins). Risk C: Monitor therapy

Rupatadine: May enhance the adverse/toxic effect of HMG-CoA Reductase Inhibitors (Statins). Specifically, the risk for increased CPK and/or other muscle toxicities may be increased. Risk C: Monitor therapy

Simeprevir: May increase the serum concentration of Simvastatin. Risk C: Monitor therapy

Spironolactone: May increase the serum concentration of CYP3A4 Substrates (Narrow Therapeutic Index/Sensitive with Inhibitors). Risk C: Monitor therapy

St John's Wort: May decrease serum concentrations of the active metabolite(s) of HMG-CoA Reductase Inhibitors (Statins). Management: Consider avoiding the concomitant administration of St John's Wort with atorvastatin, lovastatin and simvastatin in order to avoid the potential for decreased effects statins. If coadministered, monitor for decreased statin efficacy. Risk D: Consider therapy modification

Talquetamab: May increase the serum concentration of CYP Substrates (Narrow Therapeutic Index/Sensitive with Inhibitors). Risk C: Monitor therapy

Teclistamab: May increase the serum concentration of CYP Substrates (Narrow Therapeutic Index/Sensitive with Inhibitors). Risk C: Monitor therapy

Teriflunomide: May increase the serum concentration of OATP1B1/1B3 (SLCO1B1/1B3) Substrates (Clinically Relevant with Inhibitors). Risk C: Monitor therapy

Ticagrelor: May increase the serum concentration of Simvastatin. Management: Avoid using doses of simvastatin greater than 40 mg/day with ticagrelor. Monitor for increased systemic effects of simvastatin in patients receiving concurrent ticagrelor. Risk D: Consider therapy modification

Tipranavir: May increase the serum concentration of Simvastatin. Risk X: Avoid combination

Trabectedin: HMG-CoA Reductase Inhibitors (Statins) may enhance the myopathic (rhabdomyolysis) effect of Trabectedin. Risk C: Monitor therapy

Treosulfan: May increase the serum concentration of CYP3A4 Substrates (Narrow Therapeutic Index/Sensitive with Inhibitors). Risk X: Avoid combination

Trofinetide: May increase the serum concentration of OATP1B1/1B3 (SLCO1B1/1B3) Substrates (Clinically Relevant with Inhibitors). Management: Avoid concurrent use with OATP1B1/1B3 substrates for which small changes in exposure may be associated with serious toxicities. Monitor for evidence of an altered response to any OATP1B1/1B3 substrate if used together with trofinetide. Risk D: Consider therapy modification

Verapamil: May increase serum concentrations of the active metabolite(s) of Simvastatin. Verapamil may increase the serum concentration of Simvastatin. Management: Carefully consider the potential risks and benefits of this combination. If coadministered, limit adult simvastatin dose to 10 mg daily, and monitor closely for signs of simvastatin toxicity (eg, myositis, rhabdomyolysis). Risk D: Consider therapy modification

Vitamin K Antagonists (eg, warfarin): HMG-CoA Reductase Inhibitors (Statins) may enhance the anticoagulant effect of Vitamin K Antagonists. Risk C: Monitor therapy

Voclosporin: May increase the serum concentration of OATP1B1/1B3 (SLCO1B1/1B3) Substrates (Clinically Relevant with Inhibitors). Risk C: Monitor therapy

Voxilaprevir: May increase the serum concentration of HMG-CoA Reductase Inhibitors (Statins). Management: Use the lowest statin dose possible if combined with voxilaprevir and monitor patients for increased statin effects/toxicities. Avoid concomitant use of voxilaprevir with rosuvastatin or pitavastatin, and limit pravastatin doses to 40 mg daily. Risk D: Consider therapy modification

Food Interactions

Simvastatin serum concentration may be increased when taken with grapefruit juice. Management: Avoid combination.

Reproductive Considerations

Adequate contraception is recommended if an HMG-CoA reductase inhibitor (statin) is required in patients who may become pregnant (AHA/ACC [Grundy 2019]; CCS [Pearson 2021]). Nonhormonal contraception is preferred for patients at high risk of atherosclerotic cardiovascular disease and those with familial hypercholesterolemia (Balla 2020). Patients planning to become pregnant should discuss their lifetime risk of cardiovascular disease, as well as risks and benefits of statin therapy with their health care team (CCS [Pearson 2021]). When appropriate, statins can be discontinued 1 to 2 months prior to conception (AHA/ACC [Grundy 2019]).

When a statin is needed in a patient of reproductive potential, a more hydrophilic option (eg, pravastatin, rosuvastatin) may be preferred to limit placental transfer (CCS [Pearson 2021]).

Pregnancy Considerations

In healthy pregnancies, changes in lipid synthesis occur that are required for normal placental and fetal growth. Low-density lipoprotein cholesterol and triglycerides increase as pregnancy progresses and decline postpartum. HMG-CoA reductase inhibitors (statins) decrease the synthesis of cholesterol and substances derived from cholesterol. Therefore, based on the mechanism of action, in utero exposure may cause fetal harm (Lecarpentier 2012); however, data from available studies have not shown an increased risk of major congenital anomalies following first trimester exposure (Bateman 2015; Chang 2021; Vahedian-Azimi 2021a). Additional data are needed to evaluate other pregnancy outcomes, such as miscarriage (Vahedian-Azimi 2021b).

Because there is potential for fetal harm, statins should be discontinued once pregnancy is recognized (AHA/ACC [Grundy 2019]; Brunham 2018). If lipid-lowering therapy during pregnancy is required, it should be individualized based on the therapeutic needs of the patient, considering the lifetime risk of untreated disease, use of nonstatin therapies, as well as the known risks and benefits of statins. Based on limited data, when a statin is needed in a pregnant patient, a more hydrophilic option (eg, pravastatin, rosuvastatin) may be preferred. Lipophilic statins (eg, atorvastatin, fluvastatin, lovastatin, simvastatin, pitavastatin) may be more likely to cross the placenta and increase the risk of congenital malformations (AHA/ACC [Grundy 2019]; CCS [Pearson 2021]; Lecarpentier 2012).

Additional data are needed to clarify the role of statins for the prevention of atherosclerotic cardiovascular disease in at-risk pregnant patients (AHA/ACC [Grundy 2019]; CCS [Pearson 2021]; Parikh 2021).

Breastfeeding Considerations

It is not known if simvastatin is present in breast milk.

HMG-CoA reductase inhibitors (statins) decrease the synthesis of cholesterol and substances derived from cholesterol. Normal concentrations of cholesterol in breast milk are required for infant development (Holmsen 2017; Lecarpentier 2012). Due to the potential for adverse events in the breastfed infant, breastfeeding is not recommended by the manufacturer. Available guidelines recommend resuming statin therapy once breastfeeding is completed (AHA/ACC [Grundy 2019]; CCS [Pearson 2021]).

Dietary Considerations

Generally, patients should be placed on a standard cholesterol-lowering diet and other lifestyle modifications for 3 to 6 months prior to the initiation of drug therapy. The diet should be continued during drug therapy. However, for patients with advanced risk factors (eg, known coronary heart disease), drug therapy may be initiated concurrently with diet modification. Simvastatin serum concentration may be increased when taken with grapefruit juice; avoid concurrent intake of grapefruit juice.

Red yeast rice contains variable amounts of several compounds that are structurally similar to HMG-CoA reductase inhibitors, primarily monacolin K (or mevinolin) which is structurally identical to lovastatin; concurrent use of red yeast rice with HMG-CoA reductase inhibitors may increase the incidence of adverse and toxic effects (Lapi 2008; Smith 2003).

Monitoring Parameters

ACC/AHA Blood Cholesterol Guideline recommendations ( ACC/AHA [Grundy 2019]):

Lipid panel (total cholesterol, HDL, LDL, triglycerides): Lipid profile (fasting or nonfasting) before initiating treatment. Fasting lipid profile should be rechecked 4 to 12 weeks after starting therapy and every 3 to 12 months thereafter. If 2 consecutive LDL levels are <40 mg/dL, consider decreasing the dose.

Hepatic transaminase levels: Baseline measurement of hepatic transaminase levels (AST and ALT); measure AST, ALT, total bilirubin, and alkaline phosphatase if symptoms suggest hepatotoxicity (eg, unusual fatigue or weakness, loss of appetite, abdominal pain, dark-colored urine or yellowing of skin or sclera) during therapy.

CPK: CPK should not be routinely measured. Baseline CPK measurement is reasonable for some individuals (eg, family history of statin intolerance or muscle disease, clinical presentation, concomitant drug therapy that may increase risk of myopathy). May measure CPK in any patient with symptoms suggestive of myopathy (pain, tenderness, stiffness, cramping, weakness, or generalized fatigue).

Evaluate for new-onset diabetes mellitus during therapy; if diabetes develops, continue statin therapy and encourage adherence to a heart-healthy diet, physical activity, a healthy body weight, and tobacco cessation. Monitor for signs and symptoms of myopathy or rhabdomyolysis (especially in patients with renal impairment).

If patient develops a confusional state or memory impairment, may evaluate patient for nonstatin causes (eg, exposure to other drugs), systemic and neuropsychiatric causes, and the possibility of adverse effects associated with statin therapy.

Manufacturer's labeling: Consider neuromuscular and serologic testing if immune-mediated necrotizing myopathy is suspected.

Mechanism of Action

Simvastatin is a methylated derivative of lovastatin that acts by competitively inhibiting 3-hydroxy-3-methylglutaryl-coenzyme A (HMG-CoA) reductase, the enzyme that catalyzes the rate-limiting step in cholesterol biosynthesis. In addition to the ability of HMG-CoA reductase inhibitors to decrease levels of high-sensitivity C-reactive protein (hsCRP), they also possess pleiotropic properties including improved endothelial function, reduced inflammation at the site of the coronary plaque, inhibition of platelet aggregation, and anticoagulant effects (de Denus 2002; Ray 2005).

Pharmacokinetics (Adult Data Unless Noted)

Onset of action: >3 days.

Peak effect: 2 weeks.

LDL-C reduction: 20 to 40 mg/day: 35% to 41%.

Average HDL-C increase: 5% to 15%.

Average triglyceride reduction: 7% to 30%.

Absorption: Although 85% is absorbed following administration, <5% reaches the general circulation due to an extensive first-pass effect.

Protein binding: ~95%.

Metabolism: Hepatic via CYP3A4; extensive first-pass effect.

Bioavailability: <5%.

Half-life elimination: Unknown.

Time to peak: 1.3 to 2.4 hours.

Excretion: Feces (60%); urine (13%).

Pharmacokinetics: Additional Considerations (Adult Data Unless Noted)

Altered kidney function: Higher systemic exposure may be achieved in patients with severe renal insufficiency.

Older adult: Mean plasma level of HMG-CoA reductase inhibitory activity is increased approximately 45%.

Brand Names: International
International Brand Names by Country
For country code abbreviations (show table)

  • (AE) United Arab Emirates: Alistim | Normolip | Simcard | Simva | Simvagen | Simvast | Simvaten | Simvor | Sivacor | Vasta | Viscor | Zocor;
  • (AR) Argentina: Coledis | Coleflux | Colesterminol | Dosavastatin | Fada simvastatina | Gemistatin | Klonastin | Labistatin | Lipoblock | Lisac | Nivelipol | Redusterol | Sevacol | Several | Simvastatin gen med | Simvastatin vannier | Simvastatina Fabra | Simvastatina lepetit | Simvastatina northia | Simvastec | Sincolvastatin | Sistatin | Tanavat | Vasotenal | Zocor;
  • (AT) Austria: Gerosim | Nyzoc | Simvarcana | Simvastad | Simvastatin +pharma | Simvastatin 1a pharma gmbh | Simvastatin Actavis | Simvastatin alternoca arzneimittel | Simvastatin bluefish | Simvastatin genericon pharma | Simvastatin hexal pharma | Simvastatin interpharm | Simvastatin merck | Simvastatin Pfizer | Simvastatin ranbaxy | Simvastatin ratiopharm | Simvastatin sandoz | Simvastatin teva | Simvatin | Zocord;
  • (AU) Australia: Apo simvastatin | Auro simvastatin | Genrx simvastatin | Lipex | Pharmacor simvastatin | Ransim | Simvabell | Simvacor | Simvar | Simvastatin an | Simvastatin drla | Simvastatin Generic Health | Simvastatin generichealth | Simvastatin Pfizer | Simvastatin RL | Simvastatin sandoz | Simvastatin Winthrop | Simvastatin-dp | Simvastatin-Spirit | Simvasyn | Simvatrust | Synthon simvastatin | Zimstat | Zocor;
  • (BD) Bangladesh: Avastin | Recol | Simacor | Simplaqor | Simvatin | Vastocor | Zostin;
  • (BE) Belgium: Cholemed | Docsimvasta | Simvafour | Simvastaphar | Simvastatin ab | Simvastatin bepb | Simvastatine | Simvastatine Aaxl | Simvastatine arrow | Simvastatine bexal | Simvastatine EG | Simvastatine eurogenerics | Simvastatine merck-generics | Simvastatine pfizer | Simvastatine ratiopharm | Simvastatine Sandoz | Simvastatine teva generics belgium | Zocor;
  • (BF) Burkina Faso: Civastine | Minolip | Simva denk | Sinvaz;
  • (BG) Bulgaria: Actalipid | Hollesta | Neosimva | Simgal | Simvacor | Simvastatin Medica | Simvastatin teva | Vasilip | Zeplan | Zocor | Zostatin;
  • (BR) Brazil: Androlip | Clinfar | Cordiron | Genocardil | Lipistatina | Lipotex | Liptrat | Lovacor | Menocol | Mevilip | Mivalen | Revastin | Sinstiphar | Sinvalip | Sinvane | Sinvascor | Sinvasmax | Sinvastacor | Sinvastamed | Sinvastamil | Sinvastatina | Sinvastatina biolab gen | Sinvastin | Sinvaston | Sinvatrox | Sinvax | Sinvaz | Sivastin | Unak | Vaslip | Vastatil | Zocor;
  • (CH) Switzerland: Simcora | Simvasin | Simvasin Spirig | Simvasin spirig hc | Simvastatin - 1 A Pharma | Simvastatin Actavis | Simvastatin mepha | Simvastatin Pfizer | Simvastatin Streuli | Simvastatin teva | Simvastin-Mepha | Zocor;
  • (CI) Côte d'Ivoire: Minolip | Sinvas | Zocor | Zovatin;
  • (CL) Chile: Arterosan | Nimicor | Simvass | Vasomed | Vasotenal | Zocor;
  • (CN) China: Hai zhi shu | Jian zhi ting | Jing bi shu xin | Li zhi shu | Xi zhi da | Xin xi yue | Yi Kang Shou | Yi xin | Zheng zhi | Zocor;
  • (CO) Colombia: Arianel | Colastatina | Colvast | Labistatin | Simlo | Simplaqor | Simvastan | Simvastatina | Simvastatina Colmed | Simvastatina mk | Statin | Zerocoler | Zocor | Zolaphen;
  • (CZ) Czech Republic: Apo simva | Corsim | Egilipid | Gensi | Sim | Simbela | Simgal | Simirex | Simvacard | Simvastatin bluefish | Simvastatin Orion | Simvax | Simvor | Vasilip | Zocor;
  • (DE) Germany: BeL Simvastatin | Denan | Lipiduc | Sigalip | Simva | Simva Aristo | Simva denk | Simvaaps | Simvabeta | Simvacard | Simvacor | Simvadoc | Simvadura | Simvagamma | Simvahexal | Simvalip | Simvaliquid geriasan | Simvastatin accedo | Simvastatin accord | Simvastatin Acis | Simvastatin Actavis | Simvastatin al | Simvastatin Aristo | Simvastatin Atid | Simvastatin Aurobindo | Simvastatin Aurus | Simvastatin axcount | Simvastatin Axsan | Simvastatin Biomo | Simvastatin bluefish | Simvastatin CT | Simvastatin Dexcel | Simvastatin Dura | Simvastatin Heumann | Simvastatin Hormosan | Simvastatin Isis | Simvastatin Krewel | Simvastatin Ksk | Simvastatin Pfizer | Simvastatin Q-Pharm | Simvastatin ratiopharm | Simvastatin Real | Simvastatin sandoz | Simvastatin stada | Simvastatin Volkspharma | Simvastatin Wolff | Simvastatin-1a pharma | Simvastatin-corax | Simvastatin-isis | Simvastatin-ratiopharm | Simvastatin-saar | Simvastatin-Teva | Simvastatinx | Zemox | Zocor;
  • (DK) Denmark: Perichol | Simvastatin Actavis | Simvastatin Copyfarm | Simvastatin hexal | Zocolip;
  • (DO) Dominican Republic: Inegan | Kavelor | Lipigran | Menosterol | Normicor | Rowestin | Simvast | Simvastatina | Simvastatina Cinfa | Simvastatina Exels | Simvor | Zimvastin | Zocor | Zorlec;
  • (EC) Ecuador: Ecuvas | Rowestin | Simvast | Simvastatina | Simvastatina genamerica | Simvastatina Mepha | Simvastatina Nifa | Simvor | Sinvalip | Vasotenal | Zetina | Zocor;
  • (EE) Estonia: Simgal | Simvacor | Simvastatin accord | Simvastatin Pfizer | Simvastatin-ratiopharm | Simvor | Vasilip | Zocor;
  • (EG) Egypt: Alkor | Amristatin | Corvast | Low-Sterol | Minalip | Simvacor | Simvaged | Simvast | Simvastat | Simvastin | Vastan | Zocor;
  • (ES) Spain: Alcosin | Arudel | Belmalip | Colemin | Glutasey | Histop | Lipociden | Pantok | Simvastatina | Simvastatina acost | Simvastatina Actavis | Simvastatina Almus | Simvastatina alter | Simvastatina apotex | Simvastatina Asol | Simvastatina Aurobindo | Simvastatina bayvit | Simvastatina Bexal | Simvastatina Bluefish | Simvastatina Cinfa | Simvastatina combino | Simvastatina Combino Pharm | Simvastatina combix | Simvastatina cuve | Simvastatina Davur | Simvastatina Decrox | Simvastatina desgen | Simvastatina edigen | Simvastatina grapa | Simvastatina juventus | Simvastatina Kern | Simvastatina Korhispana | Simvastatina Lareq | Simvastatina mabo | Simvastatina merck | Simvastatina normon | Simvastatina pharma combix | Simvastatina pharmacia | Simvastatina pliva | Simvastatina ranbaxy | Simvastatina ratiopharm | Simvastatina rimafar | Simvastatina Sandoz | Simvastatina Stada | Simvastatina sumol | Simvastatina Syntelabo | Simvastatina tarbis | Simvastatina Tecnigen | Simvastatina teva rimafar | Simvastatina ur | Simvastatina vir | Simvastatina Winthrop | Teylor | Zocor;
  • (FI) Finland: Corolin | Lipcut | Simvastatiini ennapharma | Simvastatin Actavis | Simvastatin alpharma | Simvastatin alternova | Simvastatin arrow | Simvastatin avanso | Simvastatin bluefish | Simvastatin gener | Simvastatin Genthon | Simvastatin IVAX | Simvastatin krka | Simvastatin Merck NM | Simvastatin Orion | Simvastatin Pfizer | Simvastatin ranbaxy | Simvastatin ratiopharm | Simvastatin sandoz | Simvastatin sanoswiss | Simvastatin teva | Zocolip | Zocor;
  • (FR) France: Lodales | Simvastatine | Simvastatine accord healthcare | Simvastatine Almus | Simvastatine Alter | Simvastatine arrow | Simvastatine Biogaran | Simvastatine bluefish | Simvastatine Bouchara recordati | Simvastatine EG | Simvastatine evolugen | Simvastatine Gerda | Simvastatine hexal | Simvastatine Isomed | Simvastatine merck | Simvastatine phr lab | Simvastatine Qualimed | Simvastatine Ranbaxy | Simvastatine ratiopharm | Simvastatine rpg | Simvastatine Sandoz | Simvastatine teva | Simvastatine zydus | Zocor;
  • (GB) United Kingdom: Ranzolont | Simvador | Simvastatin almus | Simvastatin arrow | Simvastatin cox | Simvastatin focus | Simvastatin kent | Simvastatin sandoz | Zocor | Zocor heart;
  • (GR) Greece: Antichol | Bevostatin | Christatin | Doctiverine | Extrastatin | Fluitin | Glipal | Goldastatin | Iamastatin | Ipramid | Kymazol | Lepur | Lipexal | Lipomin | Liporex | Lipozid | Lowcholid | Nezatin | Nitastin | Normotherine | Placol | Prizelip | Raptor | Ravostan | Redusterol | Simvachol | Simvacor | Simvalid | Simvanox | Simvaprol | Simvastatin Generics | Simvastatin teva | Simvastatin/mylan | Simvasterol | Simvastil | Simvatin | Sivinar | Sotovastin | Starezin | Stasiva | Statinal | Statinum | Stativer | Statosan | Stazor | Sterylip | Tremital | Vassor | Vastatin | Veristin | Veritrat | Zocor | Zurocid;
  • (HK) Hong Kong: Apo simvastatin | Apo-Simvastatin | Avastinee | Cholestat | Corstat | Covastin | Pms-simvastatin | Qualicor | Simcard | Simgal | Simlofil | Simplaqor | Simstatin | Simtas | Simtin | Simvacor | Simvastatin gp | Simvastatin-Teva | Simvastatina Cinfa | Simvatin | Simvell | Simvoget | Sinvastatina Farmoz | Stavid | Vas | Vasilip | Vick-Zocostatin | Vidastat | Zocor | Zostatin;
  • (HR) Croatia: Astax | Lipex | Lipterra | Protecta | Simvastatin Genera | Simvastatin Genericon | Simvastatin Lek | Simvastatin PharmaS | Simvastatin sandoz | Simvax | Statex | Vasilip | Vaslip;
  • (HU) Hungary: Andever | Awestatin | Sicor | Simvacol | Simvagamma | Simvalip | Simvastatin bluefish | Simvastatin Pfizer | Simvastatin teva | Simvastatin-ratiopharm | Simvep | Simvor | Vasilip | Zocor;
  • (ID) Indonesia: Cholestat | Cholexin | Detrovel | Esvat | Ethicol | Lesvatin | Lipinorm | Mersivas | Normofat | Phalol | Pontizoc | Preschol | Rechol | Rendapid | Rocoz | Selvim | Simbado | Simchol | Simcor | Simvastatin promed | Sinova | Sintrol | Stimpid | Svt | Valansim | Valemia | Vaster | Vazim | Vidastat | Zocor | Zovast;
  • (IE) Ireland: Ritechol | Simator | Simcovas | Simtan | Simvastatin bluefish | Simvastatin teva | Simzor | Sivatin | Zocor;
  • (IL) Israel: Simovil | Simvacor | Simvastatin teva | Simvaxon;
  • (IN) India: Biosim | Femella | Ifistatin | Sim | Simcard | Simchol | Simi | Simlip | Simlo | Simstat | Simvas | Simvaslim | Simvastol | Simvax | Simvin | Simvo | Simvofix | Simvotin | Starstat | Svt | Vastatin | Zocor | Zosta;
  • (IT) Italy: Clinart | Krustat | Lipenil | Liponorm | Medipo | Omistat | Quibus | Setorilin | Simbatrix | Simvastatina | Simvastatina abc | Simvastatina actavis ptc | Simvastatina Alm | Simvastatina alter | Simvastatina Angenerico | Simvastatina Arrow | Simvastatina Aurob | Simvastatina Awp | Simvastatina Bluefish | Simvastatina Doc | Simvastatina eg | Simvastatina Fg | Simvastatina Fidia | Simvastatina hexal | Simvastatina Pfizer | Simvastatina ranbaxy | Simvastatina ratiopharm | Simvastatina Sandoz | Simvastatina teva | Simvastatina Winthrop | Sincol | Sinvacor | Sinvalip | Sinvat | Sivastin | Turstat | Vastgen | Vastin | Xipocol | Zocor;
  • (JO) Jordan: Cholastin | Lipomid | Losterol | Simvatin | Simver | Sivacor | Syvast | Vasta | Zocor;
  • (JP) Japan: Lipo off | Lipoaut | Lipoblock | Lipodown | Lipodown sawai | Lipokoban | Lipovas | Lipovatol | Lipozart | Ramian | Silovastin | Simvamerck | Simvastatin amel | Simvastatin Emec | Simvastatin Kobayashi | Simvastatin kyorin | Simvastatin maruko | Simvastatin meiji | Simvastatin nichiiko | Simvastatin ohara | Simvastatin takata | Sinstatin | Sinstatin chemiphar | Sinstatin yoshindo;
  • (KR) Korea, Republic of: Cholesnon | Cholesnone | Cholestine | Cholsterol | Elvasta | F-Simva | Hanlim Simvastatin | Huco | Husimva | Ilyangbio simvastatin | Jovastin | K simva | Liporecol | Lipostar | Livastatin | Low-LD | Neustatin | Newsimvad | Newvastin | Ripeco | Ripidatine | Ripidu | Roco | Samsung simvastatin | Simbarod | Simbidan | Simcol | Simpex | Simrox | Simstar | Simstatin | Simstin | Simsva | Simva | Simva v | Simvac | Simvaclin | Simvaco | Simvacotin | Simvagen | Simvahexal | Simvalord | Simvalow | Simvamax | Simvamedi | Simvanex | Simvaran | Simvaro | Simvarol | Simvaromin | Simvarotin | Simvas | Simvaslotec | Simvaspo | Simvast | Simvast cr | Simvastar | Simvastatin dongsung | Simvasterol | Simvastin | Simvat | Simvata | Simvatadin | Simvatan | Simvatatine | Simvatec | Simvaterol | Simvatidin | Simvatin | Simvazotin | Sistar | Sivas | Unisimva | Vast | Yuhan simvastatin | Zobacor | Zobatin | Zocona | Zocor | Zostin | Zovaco | Zovatin;
  • (KW) Kuwait: Simvagen | Simvaten | Vasta | Zocor;
  • (LB) Lebanon: Amristatin | Apo simvastatin | Belmalip | Lipomid | Liporex | Simgal | Simvahexal | Simvarem | Simvast | Simvastatine | Sincol | Stavine | Vascor | Zocor;
  • (LT) Lithuania: Simgal | Simvacor | Simvastatin accord | Simvastatin Aurobindo | Simvastatin-ratiopharm | Simvor | Vasilip | Zocor;
  • (LU) Luxembourg: Docsimvasta | Simvahexal | Simvastatin ratiopharm | Simvastatine EG | Simvastatine Sandoz | Zocor;
  • (LV) Latvia: Simcard | Simgal | Simvacor | Simvagamma | Simvalimit | Simvastatin accord | Simvastatin Aurobindo | Simvastatin ratiopharm | Simvor | Vasilip | Zocor;
  • (MA) Morocco: Cholestin | Civastine | Ransimva | Redlip | Simvastatine | Simvastatine win | Zocor;
  • (MX) Mexico: Apomastina | Colesken | Cotritev | Diskolestina | Fansia | Gecor | Imbistad | Josken | Nafatab | Nodolip | Pulsarat | Ranvor | Simlo | Simplaqor | Simvastatin landsteiner | Simvastatin teva | Simvastatina | Simvastatina nafar | Sinccord | Tulip | Xanterok | Xintilan | Zimbat | Zocor | Zorced;
  • (MY) Malaysia: Covastin | Kardak | Kovaco | Lipaco | Priacin | Simcard | Simcard-10 | Simlo | Simvacip | Simvacor | Simvastatin liconsa | Simvastatin Pharmaniaga | Simvaterol | Simvaz | Simvor | Sivacol | Stavid | Vascor | Vasilip | Zimmex | Zocor;
  • (NG) Nigeria: Mosten | Shinfield simvastatin | Simbaf | Simnest | Simvor | Vasolipin;
  • (NL) Netherlands: Bozara | Simvastatine | Simvastatine A | Simvastatine Accord | Simvastatine actavis | Simvastatine Alpharma | Simvastatine Gf | Simvastatine jubilant | Simvastatine Katwijk | Simvastatine merck | Simvastatine Ranbaxy | Simvastatine ratiopharm | Simvastatine Sandoz | Zocor | Zocor-spf;
  • (NO) Norway: Pantok | Simvastatin arrow | Simvastatin Aurobindo | Simvastatin bluefish | Simvastatin hexal | Simvastatin krka | Simvastatin nycomed | Simvastatin Pfizer | Simvastatin ranbaxy | Simvastatin sandoz | Simvastatin teva | Zocor;
  • (NZ) New Zealand: Arrow Simva | Lipex | Simvarex | Simvastatin mylan | Zocor;
  • (OM) Oman: Viscor;
  • (PE) Peru: Kavelor | Lipidozilo | Modutrol | Penzal | Simtas | Simvalip | Simvas | Simvastatina | Simvastatina genfar | Simvor | Vasotenal | Viaxal | Zocor;
  • (PH) Philippines: Afordel | Altovast | Astin | Buztin | Cardiosim | Cholestad | Cholestrol | Endovaz | Eurocor | Euvasten | Ezesim | Forcad | Lipinorm | Lipivas | Lochol | Normastin | Novovast | Orovas | Philstat | Provast | Qualistat | Ravenar | Reduscole | Regumet | Ritemed Simvastatin | Simbathree | Simlip | Simpex | Simvacare | Simvacor | Simvagen | Simvahex | Simvas | Simvastatin sandoz | Simvastin | Simvasyn | Simvoget | Sistat | Sivatin | Stasim | Stavid | Stilz | Vamstat | Vasclor | Vastichol | Vastilan | Vastincol | Vazz | Vidastat | Winthrop Simvastatin | Zimcor | Zimvacor | Zimvast | Zivas | Zocor | Zolvastin | Zostatin | Zovast;
  • (PK) Pakistan: Antichol | Atcol | Athenil | Cardiovastin | Colocard | Eglocard | Fatrid | L Col | Limitrol | Lioponorm | Lipaxin | Lipix | Liplow | Lipodec | Lipomed | Lokestrol | Mavest | Mistin | Modlip | Neutrachol | Novicor | Nuista | Recol | Saista | Sichor | Silser | Sim-Stat | Simatin | Simcam | Simpill | Simplacor | Sims | Simtat | Simva | Simvacor | Simvascot | Simvastin | Simvazaf | Smartin | Survive | Vastin | Zocor;
  • (PL) Poland: Angiolip | Apo simva | Cardin | Corr | Simcovas | Simgal | Simorion | Simratio | Simredin | Simvacard | Simvachol | Simvacor | Simvagamma | Simvahexal | Simvalip | Simvastatin 1A Pharma | Simvastatin Aurobindo | Simvastatin bluefish | Simvastatin genoptim | Simvastatin krka | Simvastatin Pfizer | Simvastatin teva | Simvastatinum accord | Simvasterol | Simvateva | Simvor | Sistat | Symwastatyna Jelfa | Vasilip | Ximve | Zifam | Zocor;
  • (PR) Puerto Rico: Flolipid | Zocor;
  • (PT) Portugal: Actalipid | Biolipe | Dislipina | Jabastatina | Lipaz | Simvacol | Simvasim | Simvastatin Medineo | Sinpor | Sinvasta Lipaz | Sinvastatina | Sinvastatina Accord | Sinvastatina almus | Sinvastatina APceuticals | Sinvastatina Aurobindo | Sinvastatina aurovitas | Sinvastatina bluefish | Sinvastatina Bluepharma Industria Farmaceutic | Sinvastatina bluesar | Sinvastatina Cinfa | Sinvastatina daquimed | Sinvastatina Frosst | Sinvastatina limeg | Sinvastatina Mepha | Sinvastatina Ratiopharm | Sinvastatina wynn | Sinvastatina Zentiva | Sinvastil | Sivales | Sumaclina | Vascorim | Wensan | Zera | Zocor;
  • (PY) Paraguay: Antex | Simvastatin icu vita | Simvastatina genfar | Sintiodal | Vasotenal | Vastatin;
  • (RO) Romania: Ranvor | Simgal | Simvastatina teva | Sintenal | Vabadin | Vasilip | Zaredil | Zeplan | Zocor;
  • (RU) Russian Federation: Actalipid | Aries | Aterostat | Avestatin | Awestatin | Cholvasim | Holvasim | Simgal | Simlo | Simplacor | Simvacard | Simvacol | Simvahexal | Simvalimit | Simvastatin alkaloid | Simvastatin ferein | Simvastatin sanofi | Simvastatin sz | Simvastatin teva | Simvastatin zentiva | Simvastol | Simvor | Synkard | Vasilip | Vero simvastatin | Zocor | Zorstat | Zovatin;
  • (SA) Saudi Arabia: Apo simvastatin | Pms-simvastatin | Simva | Simvagen | Simvahexal | Simvast | Simvastatin sandoz | Simvaten | Vasta | Viscor | Zocor;
  • (SE) Sweden: Simidon | Simvastatin aco | Simvastatin Actavis | Simvastatin arrow | Simvastatin bluefish | Simvastatin brown | Simvastatin Copyfarm | Simvastatin ebb | Simvastatin gevita | Simvastatin hexal | Simvastatin IVAX | Simvastatin krka | Simvastatin Merck NM | Simvastatin nycomed | Simvastatin Orion | Simvastatin pensa | Simvastatin ranbaxy | Simvastatin sandoz | Simvastatin stada | Simvastatin teva;
  • (SG) Singapore: Apo simvastatin | Covastin | Ifistatin | Priacin | Simcard | Simlo | Simtin | Simvacor | Simvas | Simvor | Simzal | Vascor | Vasilip | Zocor;
  • (SI) Slovenia: Actalipid | Simvastatin teva | Sinvacor | Sinvacor forte | Vasilip;
  • (SK) Slovakia: Aterexa | Medilip | Simgal | Simva | Simvacard | Simvastatin bluefish | Simvastatin Galex | Simvastatin Orion | Simvor | Vasilip | Zocor;
  • (SV) El Salvador: Colestop;
  • (TH) Thailand: Bestatin | Eucor | Lochol | Simvastatin Pfizer | Simvor | Torio | Vascor | Zimmex | Zimva | Zocor;
  • (TN) Tunisia: Lipicard | Redulip | Simvastatine winthrop | Simvax | Sivastyn | Vascor | Zocor | Zovatin;
  • (TR) Turkey: Lipovas | Simvakol | Zocor | Zovatin;
  • (TW) Taiwan: Bezostatin | Kezhi | Lipidoff | Simatin | Simgal | Simpotin | Simva | Simvahexal | Simvatenin | Simvatin | Sinty | Sivasin | So. H. F. C. | Vatatin | Zocor | Zolotin | Zostatin | Zova | Zysim;
  • (UA) Ukraine: Allesta | Cardac | Simgal | Simvacard | Simvacor | Simvahexal | Simvasandoz | Simvastat | Simvastatin alkaloid | Simvastatin apo | Simvastatin sandoz | Simvastatin zentiva | Simvastin | Simvatin | Simvatyn | Simvostat | Vabadin | Vasilip | Vasostat | Vastatin | Vazostat | Zocor | Zosta | Zovatin;
  • (UG) Uganda: Simva denk;
  • (UY) Uruguay: Afat | Ateroclar | Saventrine | Simvastatina | Simvastatina Donier | Simvestol | Vasotenal | Zocor;
  • (VE) Venezuela, Bolivarian Republic of: Cynt | Hisplenil | Kavelor | Rowestin | Simplaqor | Simtatin | Simvastatina | Simvastatina Elter | Simvastatina Kern | Simvastin | Simvor | Tavor | Tinasin | Vasotenal | Vastan | Zocor | Zorlec;
  • (VN) Viet Nam: Lipisim | Simtor vpc;
  • (ZA) South Africa: Adco-Simvastatin | Aspen Simvastatin | Austell Simvastatin | Bio simvastatin | Biovac simvastatin | Choleste | Choleste 10 | Cipla-simvastatin | Michol | Novatin | Redicor | Simaspen | Simayla simvastatin | Simcard | Simvacor | Simvotin | Simzor | Zocor | Zysim;
  • (ZM) Zambia: Simcard | Simva denk | Simvastol | Simvax | Simvor;
  • (ZW) Zimbabwe: Simlo 10 | Simlo 20
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