Approach to the Patient Who Is Intolerant of Statin Therapy

• Published in: The journal of clinical endocrinology and metabolism 2010-05, Vol.95 (5), p.2015-2022
• Main Author: Eckel, Robert H.
• Format: Article
• Language: English
• Subjects: Adrenergic beta-Antagonists - therapeutic use; Angiotensin-Converting Enzyme Inhibitors - therapeutic use; Aspirin - therapeutic use; Atorvastatin Calcium; Biological and medical sciences; Coronary Disease - complications; Diltiazem - therapeutic use; Endocrinopathies; Feeding. Feeding behavior; Female; Fundamental and applied biological sciences. Psychology; Heptanoic Acids - adverse effects; Humans; Hydroxymethylglutaryl-CoA Reductase Inhibitors - adverse effects; Hydroxymethylglutaryl-CoA Reductase Inhibitors - pharmacokinetics; Hypertension - complications; Medical sciences; Middle Aged; Pyrroles - adverse effects; Simvastatin - adverse effects; Vertebrates: anatomy and physiology, studies on body, several organs or systems; Vertebrates: endocrinology
• ISSN: 0021-972X; 1945-7197
• DOI: 10.1210/jc.2009-2689

Myopathy occurs in approximately 10% of statin-treated patients and is most commonly manifested by myalgias with or without plasma creatine kinase (CK) elevations. Predisposition exists in patients treated with high doses of potent statins and those who are older, female, have a genetic predisposition, and when statins are coadministered with drugs that compete with or inhibit drug metabolism. In symptomatic patients, CK levels may assist in guiding management. If less than five times the upper limit of normal, the existing statin should be titrated to achieve cholesterol goals and the CK repeated when symptoms appear or worsen. In patients with moderate to severe symptoms and any patient with CK elevated to more than 5-fold the upper limit of normal, the statin should be stopped. Once asymptomatic and CK is reduced (if elevated previously), cholesterol goals can be approached by: 1) a different statin (e.g. fluvastatin or pravastatin), starting with a low dose and titrating up; 2) an alternate daily or weekly more potent statin (e.g. rosuvastatin or atorvastatin); or 3) the combination of the lowest tolerated statin with a cholesterol absorption inhibitor (ezetimibe) and/or bile acid sequestrant. Over-the-counter preparations, e.g. red yeast rice, containing natural statin-like agents, or plant sterols can also lower cholesterol. These, however, have limited efficacy to achieve targeted cholesterol levels for most patients. In patients without CK elevations and symptoms, progress can be followed clinically, but in patients who show CK elevations, CK should be monitored. At present, the superiority of one approach has not been demonstrated, and the need for clinical trials in well-characterized patients with statin intolerance cannot be dismissed. Statin intolerance is a common and sometimes difficult clinical issue with a number of options for management.