Take a Stepwise Approach to Statin Intolerance

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 large muscles (back, thighs, etc) on both sides, often in the first months of use.

Try to avoid interacting meds (colchicine, fibrates, verapamil, etc)...and check for other med 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 heart attack 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, recommend trying a low dose of the same or a different statin...and titrating.

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.

See our resource, Statin Intolerance, for more tips...such as when to check labs and how to rule out rhabdomyolysis. Brush up on when to consider other meds in our resource, Non-Statin Lipid-Lowering Agents.

Key References

  • J Clin Lipidol. 2022 Jun 9. doi: 10.1016/j.jacl.2022.05.068
  • Pharmacotherapy. 2022 May;42(5):428-438
  • J Am Coll Cardiol. 2021 Sep 21;78(12):1223-1226
  • J Am Coll Cardiol. 2019 Jun 25;73(24):3168-3209
Pharmacist's Letter. August 2022, No. 380801

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