Statin induced myopathy medical therapy
Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-in-Chief: Rim Halaby
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Overview
When symptoms of myopathy or elevation of creatine kinase occur in the setting of a patient taking statins, the majority of patients may safely continue the treatment with statin. The decision on whether the patient can discontinue or continue statin depends on two factors: the severity of the symptoms and the severity of the increase in the creatine kinase level. Statin can be safely continued when the symptoms are tolerable and the creatine kinase is elevated less than 5 times the upper limits of normal. Otherwise, if the creatine kinase level is higher than five times the upper limit of normal or if the symptoms are intolerable regardless of the level of creatine kinse, statins should be stopped for a certain period of time and restarted again with lower doses or with different types of statins. The role of vitamin D and coenzyme Q10 is still controversial in the management of statin induced myopathy.
Treatment
The decision on whether the patient can discontinue or continue statin depends on two factors:
- The severity of the symptoms
- The increase in the creatine kinase level.
Tolerable Symptoms with Absent or Mild Elevation of Creatine Kinase<5ULN
- Continue statin[1]
- Consider lowering the dose of statin, adjust the optimal dose of statin depending on the symptoms of the patient
Tolerable Symptoms with Absent or Mild Elevation of Creatine Kinase>5ULN or with Rhabdomyolysis
- Discontinue statin
- Ensure an appropriate management for rhabdomyolysis if present by good hydration and follow up[2]
- Resume the treatment with statin once the symptoms are resolved. Modify the treatment regimen as follows:
- Monitor creatinine kinase levels.
Intolerable Symptoms
- Discontinue statin regardless of the level of the creatine kinase.[2]
- Resume the treatment with statin once the symptoms are resolved. Modify the treatment regimen as follows:
- Administration of a lower dose statin
- Alternation in the dosing
- Twice weekly dosing with longer half lives statins
- Different type of statin.[2]
- Monitor creatinine kinase levels.
Recurrence of Symptoms
If the symptoms recur despite appropriate management consider:
Multiple statin therapy at multiple doses
- Rosuvastatin: daily, low dose (2.5-5 mg/day) or alternate-day dose or weekly[3]
- Atorvastatin: either alternate-day dose (5-10 mg) or 10 mg twice weekly[4]
- Fluvastatin XL: 80 mg/day[5]
Other lipid lowering drugs[6]
Lifestyle changes including diet and exercise
- Shown below is an image summarizing the management plan for statin induced myopathy.[7]
Vitamin D
Several studies have evaluated the role of vitamin D in statin induced myopathy. The results have shown so far no significant relation between the vitamin D level and statin induced myopathy; however, the results of other studies are still pending. Hence, it is not recommended yet to take vitamin D as part of a treatment for statin induced myopathy. Nevertheless, it is important to check for the vitamin D level as vitamin D deficiency is common and it can cause symptoms of myalgia independently from statin use.[8][9]
Coenzyme Q10
- Coenzyme Q10 is found in complex I or II of the electron transport chain and it plays a role as an antioxidant in mitochondrial lipid membrane. Coenzyme Q10 also inhibits apoptosis induced by statins.
- As [[statin]s] inhibit the synthesis of cholesterol by decreasing the production of mevalonate, a precursor for both cholesterol and coenzyme Q10, they cause coenzyme Q10 deficiency and subsequent mitochondrial dysfunction.[1]
- No current data supports the use of ubiquinone (coenzyme Q10) use for the treatment of statin induced myalgia[10][11]. However, it was proven to be safe to be used but with uncertain efficiency. More evidence based studies are required to recommend its use or not.[12]
References
- ↑ 1.0 1.1 Blaier O, Lishner M, Elis A (2011). "Managing statin-induced muscle toxicity in a lipid clinic". J Clin Pharm Ther. 36 (3): 336–41. doi:10.1111/j.1365-2710.2011.01254.x. PMID 21414023.
- ↑ 2.0 2.1 2.2 2.3 Harper CR, Jacobson TA (2010). "Evidence-based management of statin myopathy". Curr Atheroscler Rep. 12 (5): 322–30. doi:10.1007/s11883-010-0120-9. PMID 20628837.
- ↑ Athyros VG, Tziomalos K, Kakafika AI, et al.: Effectiveness of ezetimibe alone or in combination with twice a week Atorvastatin (10 mg) for statin intolerant high-risk patients. Am J Cardiol 2008, 101:483–485.
- ↑ Rivers SM, Kane MP, Busch RS, et al.: Colesevelam hydrochloride-ezetimibe combination lipid-lowering therapy in patients with diabetes or metabolic syndrome and a history of statin intolerance. Endocr Pract 2007, 13:11–16.
- ↑ Backes JM, Venero CV, Gibson CA, et al.: Effectiveness and tolerability of every-other-day rosuvastatin dosing in patients with prior statin intolerance. Ann Pharmacother 2008, 42:34–346.
- ↑ Lu Z, Kou W, Du B, et al.: Effect of Xuezhikang, an extract from red yeast Chinese rice, on coronary events in a Chinese population with previous myocardial infarction. Am J Cardiol 2008, 101:1689–1693.
- ↑ Jacobson TA: Toward “pain-free” statin prescribing: clinical algorithm for diagnosis and management of myalgia [see comment]. Mayo Clin Proc 2008, 83:687–700.
- ↑ Linde R, Peng L, Desai M, Feldman D (2010). "The role of vitamin D and SLCO1B1*5 gene polymorphism in statin-associated myalgias". Dermatoendocrinol. 2 (2): 77–84. doi:10.4161/derm.2.2.13509. PMC 3081682. PMID 21547103.
- ↑ Calvo MS, Whiting SJ (2003). "Prevalence of vitamin D insufficiency in Canada and the United States: importance to health status and efficacy of current food fortification and dietary supplement use". Nutr Rev. 61 (3): 107–13. PMID 12723644.
- ↑ Schaars CF, Stalenhoef AF (2008). "Effects of ubiquinone (coenzyme Q10) on myopathy in statin users". Curr Opin Lipidol. 19 (6): 553–7. doi:10.1097/MOL.0b013e3283168ecd. PMID 18957876.
- ↑ Levy HB, Kohlhaas HK (2006). "Considerations for supplementing with coenzyme Q10 during statin therapy". Ann Pharmacother. 40 (2): 290–4. doi:10.1345/aph.1G409. PMID 16449543.
- ↑ Wyman M, Leonard M, Morledge T (2010). "Coenzyme Q10: a therapy for hypertension and statin-induced myalgia?". Cleve Clin J Med. 77 (7): 435–42. doi:10.3949/ccjm.77a.09078. PMID 20601617.