An Evidence-Based Guideline for Treating Dyslipidemia in Statin-Intolerant Patients

Abstract

The purpose of this report is to inform nurse practitioners and other health care providers about how to treat dyslipidemia in the statin-intolerant patient while simultaneously achieving optimal cardiovascular outcomes for this patient population. This report will briefly explain how to rechallenge the statin-intolerant patient and the secondary therapies that are available to decrease cardiovascular morbidity and mortality. Algorithms for rechallenging the statin-intolerant patient and secondary therapies are also provided.

Pharmacotherapeutics for dyslipidemia management

“…14 In cases of muscle symptoms accompanied by signifi cant CK elevation or rhabdomyolysis, immediate discontinuation of the statin is necessary; exploration of nonstatin lipid-lowering therapy may be necessary. 11 For a patient with muscle pain in the absence of CK elevation, it may be adequate to temporarily stop the statin and then rechallenge with a diff erent statin; in these instances, providers should consider shift ing from a lipophilic to a hydrophilic statin, as hydrophilic statins are associated with a lower risk of these symptoms. 12,114 Statins are primarily metabolized in the liver, and elevations of liver enzymes, including AST and ALT, have been reported.…”

“…Adverse reactions to statin therapy can include myalgia, myotoxicity, elevations in hemoglobin A1C (A1C) and fasting glucose levels, and insulin resistance, any or all of which may result in patients or prescribers opting to discontinue therapy 11. It is important to advise patients that, in most cases, intolerance to one statin does not necessarily signify intolerance to other statins 11.…”

“…In cases of suspected or confirmed myopathy, muscular injury induced by statins, or rhabdomyolysis (which typically entails serum creatine kinase [CK] levels approximately 10 times higher than the upper limit of normal), CK and myoglobin levels should be checked 14. In cases of muscle symptoms accompanied by significant CK elevation or rhabdomyolysis, immediate discontinuation of the statin is necessary; exploration of nonstatin lipid-lowering therapy may be necessary 11. For a patient with muscle pain in the absence of CK elevation, it may be adequate to temporarily stop the statin and then rechallenge with a different statin; in these instances, providers should consider shifting from a lipophilic to a hydrophilic statin, as hydrophilic statins are associated with a lower risk of these symptoms 12,.…”

“…Statins are 3-hydroxy-3-methylglutaryl-coenzyme A ( HMG-CoA) reductase inhibitors that are proven to manage dyslipidemia and reduce adverse CV outcomes, making them a fi rst-line drug for dyslipidemia. 11 Statins contain the analogue of HMG-CoA and a structure that binds the statin molecule to HMG-CoA reductase; inhibiting this enzyme is the mechanism by which statins inhibit cholesterol synthesis, reducing LDL-C levels. 12 Statins can be classifi ed by their solubility-lipophilic (simvastatin, fl uvastatin, pitavastatin, lovastatin, and atorvastatin) or hydrophilic (rosuvastatin and pravastatin).…”

“…12,13 Adverse reactions to statin therapy can include myalgia, myotoxicity, elevations in hemoglobin A1C (A1C) and fasting glucose levels, and insulin resistance, any or all of which may result in patients or prescribers opting to discontinue therapy. 11 It is important to advise patients that, in most cases, intolerance to one statin does not necessarily signify intolerance to other statins. 11 In cases of suspected or confi rmed myopathy, muscular injury induced by statins, or rhabdomyolysis (which typically entails serum creatine kinase [CK] levels approximately 10 times higher than the upper limit of normal), CK and myoglobin levels should be checked.…”