Approach to STATIN intolerance

Try to avoid interacting medications (colchicine, fibrates, verapamil, etc), and check for other medications causes of muscle symptoms (steroids,.....

As a pharmacist, you should know how to deal with statin muscle pain. Mounting evidence suggests that statin-associated muscle pain is driven by a patient’s expectation of harm. In fact, statin-intolerant patients often rate muscle symptoms similarly with statin OR placebo. But it’s still how they feel, often leading to poor adherence. Consider this approach for patients with mild to moderate symptoms...

Assess for other causes of muscle pain. For instance, consider fibromyalgia, hypothyroidism, or vitamin D deficiency. Also ask about physical exertion. Differentiate these symptoms from statin-related pain or weakness, which usually affects proximal muscles (back, thighs, etc.) on both sides, often in the first months of use. Try to avoid interacting medications (colchicine, fibrates, verapamil, etc.), and check for other medications causes of muscle symptoms (steroids, etc.). Listen to the patient’s concerns. Consider holding the statin for a few weeks. If symptoms persist, rule out the statin as the cause.

Revisit benefits to get buy-in before restarting. For example, help CV patients understand that statins reduce MI and stroke risk, even if cholesterol isn’t high. Be patient, persistent, and optimistic. Data suggest that over 70% of statin-intolerant patients can find a regimen they tolerate. Discuss options for another attempt. For instance, try a low dose of the same or a different statin, and titrate. Keep in mind, there’s not strong evidence that hydrophilic statins (pravastatin, rosuvastatin) have lower myopathy risk. But they’re worth a try, especially if needed for fewer interactions. Save intermittent dosing, such as alternate-day or twice-weekly rosuvastatin or atorvastatin, as a last resort.

This approach isn’t proven to reduce CV risk, but can lower LDL by over 30% from baseline. Think, “some statin is better than no statin”. Don’t rely on coenzyme Q10. Evidence is mixed on whether it helps. But it’s not likely to harm if patients want to try it and don’t mind the cost. Advise stopping if it doesn’t help in a month or so.

References

Cheeley MK, Saseen JJ, Agarwala A, Ravilla S, Ciffone N, Jacobson TA, Dixon DL, Maki KC. NLA scientific statement on statin intolerance: a new definition and key considerations for ASCVD risk reduction in the statin intolerant patient. J Clin Lipidol. 2022 Jun 9:S1933-2874(22)00167-2. Available at: https://www.lipidjournal.com/article/S1933-2874(22)00167-2/fulltext
Wiggins BS, Backes JM, Hilleman D. Statin-associated muscle symptoms-A review: Individualizing the approach to optimize care. Pharmacotherapy. 2022 May;42(5):428-438. Available at: https://accpjournals.onlinelibrary.wiley.com/doi/10.1002/phar.2681

Toth PP. That Myalgia of Yours Is Not From Statin Intolerance. J Am Coll Cardiol. 2021 Sep 21;78(12):1223-1226. Available at: https://www.sciencedirect.com/science/article/abs/pii/S0735109721057053?via%3Dihub

Grundy SM, Stone NJ, Bailey AL, Beam C, Birtcher KK, Blumenthal RS, Braun LT, de Ferranti S, Faiella-Tommasino J, Forman DE, Goldberg R, Heidenreich PA, Hlatky MA, Jones DW, Lloyd-Jones D, Lopez-Pajares N, Ndumele CE, Orringer CE, Peralta CA, Saseen JJ, Smith SC Jr, Sperling L, Virani SS, Yeboah J. 2018 AHA/ACC/AACVPR/AAPA/ABC/ACPM/ADA/AGS/APhA/ASPC/NLA/PCNA Guideline on the Management of Blood Cholesterol: Executive Summary: A Report of the American College of Cardiology/American Heart Association Task Force on Clinical Practice Guidelines. J Am Coll Cardiol. 2019 Jun 25;73(24):3168-3209. Available at: https://www.sciencedirect.com/science/article/pii/S0735109718390338?via%3Dihub