Suggested clinical approach for the diagnosis and management of ‘statin intolerance’ with an emphasis on muscle‐related side‐effects

Abstract

Hyperlipidaemia is a major risk factor for cardiovascular morbidity and mortality. 3-hydroxy-3-methylglutaryl coenzyme-A reductase inhibitors ('statins') are first-line therapies for hyperlipidaemia. For each 1.0 mmoL/L reduction in low-density lipoprotein (LDL)-cholesterol, statins reduce the risk of major vascular events by 21% and all-cause mortality by 9%. Owing to their clinical effectiveness and excellent safety profile, many Australians are prescribed statins. There has been widespread reporting of possible sideeffects, particularly muscle pains. Conversely, statin cessation relating to possible sideeffects exposes patients to increased risk of vascular events and death. Although there is clinical consensus for diagnosing rare side-effects (e.g. myopathy or rhabdomyolysis), confirming that statins cause other less common side-effects (e.g. memory impairment) is difficult as strong randomised trial evidence related to statins and non-muscle-related side-effects is lacking. A stepwise approach to possible statin intolerance, consistent definitions and a simple flowchart may improve diagnosis and management. An increasing array of potential treatments is emerging, including intermittent statin dosing, new LDLlowering drugs, LDL apheresis and supplements. Optimal statin use and management of statin intolerance should improve cardiovascular care and clinical outcomes.

The effect of preventative cardiovascular therapies on coronary artery disease in people with and without type 2 diabetes: a propensity-matched score study

“…The publication of these large influential studies in the 1990’s and early 2000’s and the further confirmation of the CV benefits of the above approach in later studies has led to a drastic increase in the uptake of statins and anti-hypertensive agents, in particular RAS inhibitors, for both high risk vascular patients with and without T2DM [ 18 – 20 ]. However, over time, some concern about side-effects has been reported regarding the use of statins [ 21 ]. If patients had been ceasing statins due to this concern, we would have expected to see the effect equally across both patient groups with and without diabetes.…”

Potential Role of Natural Plant Medicine Cyclocarya paliurus in the Treatment of Type 2 Diabetes Mellitus

“…Statins are one of the most widely used lipid-lowering drugs, which can effectively reduce blood lipid levels and reduce the occurrence of cardiovascular events [ 77 ]. Nevertheless, a significant number of patients may develop intolerance after receiving statins [ 78 ].…”

Author reply

“…1 Using macrolide antibiotics as a practical example, we cited evidence to highlight the potential significance of variants in some cytochrome P450 enzymes in the pathogenesis of statin-associated rhabdomyolysis. 2 As Hou et al state, there is a significant association between the SLCO1B1 gene T521C polymorphism and statin-related myopathy risk, but the polymorphism is not diagnostic for myopathy. 3 The strongest evidence for the risk of statin-associated muscle symptoms (SAMS) related to this mutation is for simvastatin 4 and is less well studied for other statins.…”

“…We read with interest the articles in the November issue of the Internal Medicine Journal in relation to advances in the treatment of uveitis, focusing on biologic therapies. 1,2 These agents have undoubtedly been a revolution in the treatment of a wide range of inflammatory diseases in neurology, nephrology, rheumatology, gastroenterology and now ophthalmology. These advances have been on the basis of large, often multi-national, clinical trials demonstrating their efficacy.…”