Atorvastatin Safety Reappraised: From Pharmacogenomic Mechanisms to Personalized Risk Management

Atorvastatin remains a cornerstone of lipid-lowering therapy and cardiovascular prevention, but concerns about adverse effects continue to undermine adherence and long-term clinical benefit. This structured narrative review critically reappraises its safety profile by integrating evidence from randomized trials, meta-analyses, observational studies, pharmacovigilance analyses, case reports, and preclinical models. Evidence is interpreted according to study design, with controlled and synthesized human data guiding clinical conclusions and lower level evidence treated as supportive or hypothesis-generating. Overall, atorvastatin provides substantial cardiovascular protection, whereas serious adverse reactions are uncommon. The principal clinical concerns are statin-associated muscle symptoms, hepatic laboratory abnormalities, drug-drug interactions, and a small dose- and susceptibility-dependent increase in new-onset diabetes. Safety is shaped by dose, comorbidities, interacting medicines, pharmacokinetic variability, and transporter variants, particularly SLCO1B1, although the clinical actionability of other pharmacogenomic markers remains limited. We, therefore, emphasize individualized risk assessment, interaction review, appropriate monitoring, dechallenge and rechallenge, dose adjustment, alternative statins, and nonstatin combination therapy when needed. Experimental delivery systems and mechanistic findings may inform future strategies but do not yet establish improved clinical safety. Taken together, the evidence supports a benefit-centered, evidence-stratified framework that addresses genuine toxicity without overstating uncertain safety signals or unnecessarily discontinuing effective therapy.