How to handle statin muscle pain?

This simple note will discuss steps that the pharmacist can follow to handle statin muscle pain...
Abdelwahab Ward, BS Pharm, PharmD

As a pharmacist, you may know that up to 30% of statin patients get muscle pain, cramps, or weakness, usually in the larger muscles such as the thighs. You should suggest these strategies to help patients stay on the statin...

Lowering the dose is often enough to reduce symptoms. Changing the statin to fluvastatin, pravastatin, or low-dose rosuvastatin can help, probably because of fewer drug interactions. Pitavastatin also has few interactions, but there's no proof it's less likely to cause muscle pain. Avoiding interacting drugs, especially with simvastatin, lovastatin, or atorvastatin. Explain that adding a 3A4 inhibitor (clarithromycin, etc) to these statins increases risk.

Trying alternate day dosing if needed to improve tolerability. But explain there's no proof this strategy improves CV outcomes. Suggest using rosuvastatin or atorvastatin because they're longer acting. Advise giving a low dose every second or third day or just once a week, based on tolerability and the LDL goal. Adding another LDL-lowering drug if needed to reach the LDL goal. Suggest a bile acid sequestrant, ezetimibe, or niacin. But keep in mind, these have less evidence of improving CV outcomes.

Correcting low vitamin D or hypothyroidism can help muscle pain. Trying CoQ10 might help, but it's not "evidence-based". Many patients and cardiologists swear by it and it's not likely to harm. If patients want to try it, suggest 100 to 200 mg/day. Keep in mind, creatine kinase levels should be checked if patients complain of muscle pain. Explain to patients their prescriber will stop the statin for very high levels or if symptoms are intolerable.

References

Abdelwahab Ward, BS Pharm, PharmD