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Alternative Statin Regimens Reduce Muscle Pain
04/27/12
EXPERT ANALYSIS FROM THE ANNUAL MEETING OF AMERICAN COLLEGE OF PHYSICIANS
EXPERT ANALYSIS FROM THE ANNUAL MEETING OF AMERICAN COLLEGE OF PHYSICIANS
NEW ORLEANS – Alternative dosing regimens solve the common problem of statin-induced muscle pain in most cases.
Lowering the daily dose of the statin, dropping down
to alternate-day or even once-weekly therapy, or switching to another
statin having a better track record with regard to myalgia all have been
shown to improve tolerability while maintaining reasonably effective
lipid-lowering, according to Dr. Karol E. Watson, codirector of the
University of California, Los Angeles, Program in Preventive Cardiology.
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Dr. Karol E. Watson |
It
must be emphasized, however, that none of the alternative dosing
regimens have proved to reduce cardiovascular events. The issue hasn’t
been studied. That being said, alternative dosing strategies do provide
an option for patients who would otherwise go without the proven
benefits of statin therapy, she noted at the annual meeting of the
American College of Physicians.
Statin-induced muscle pain, cramping, or weakness is
far more common than rates from major clinical trials would suggest.
Statin-induced myalgia occurs in 10%-20% of treated patients in everyday
practice. In contrast, in the landmark clinical trials, where patients
were carefully preselected and there was often an active run-in phase,
myalgia rates were far lower and similar to placebo.
Factors that increase the likelihood of
statin-induced myopathy include advanced age, diabetes, hypothyroidism,
renal insufficiency, alcohol abuse, liver disease, and smaller muscle
mass, as is common in patients of smaller body size, including women.
But people who experience more muscle side effects also tend to get the
biggest lipid responses to statin therapy, Dr. Watson noted.
Of all the statins, rosuvastatin (Crestor) has been
shown to have the most favorable ratio of LDL lowering to creatine
kinase elevation (Cleve. Clin. J. Med. 2011;78:393-403). It’s a good option in patients experiencing problematic myalgia on another statin.
Also, fluvastatin XL performed exceptionally well in
the large French observational Prediction of Muscular Risk in
Observational Conditions (PRIMO) study, the cardiologist continued.
Among nearly 8,000 French patients on high-dose statins for at least 3
months, 10.5% reported muscle-related symptoms. The lowest rate, at
5.1%, was in patients on fluvastatin XL at 80 mg/day. The highest rate,
18.2%, was in patients on simvastatin at 40-80 mg/day. PRIMO
participants on atorvastatin at 40-80 mg/day had a 14.9% incidence of
muscle symptoms, while those on 40 mg/day of pravastatin had a 10.9%
rate (Cardiovasc. Drugs Ther. 2005:19:403-14).
Alternate-day dosing as an answer for
statin-intolerant patients only can be carried out effectively with
rosuvastatin or atorvastatin, drugs with half-lives markedly longer than
the other statins. Alternate-day dosing with 5 or 10 mg of rosuvastatin
was studied in a retrospective analysis involving 51 patients, 37 (73%)
of whom were able to tolerate the regimen. Among those who tolerated
every-other-day dosing, the mean reduction in LDL was 34.5%, enabling
half of them to achieve their LDL target (Ann. Pharmacother. 2008;42:341-6).
In another retrospective study, once-weekly dosing
of rosuvastatin at 2.5-20 mg was introduced to 50 previously
statin-intolerant patients. Thirty-seven patients (74%) were able to
tolerate the once-weekly therapy at a mean dose of 10 mg. They responded
with a 23% reduction in LDL from a baseline of 167 mg/dL (Am. J. Cardiol. 2009;103:393-4).
In a prospective pilot study, 61 consecutive
patients intolerant to other statins were placed on rosuvastatin at 5
mg/day if they were moderately high risk and 10 mg/day if they were at
very high risk. Only 1 of the 61 patients discontinued rosuvastatin
because of muscle pain. From a baseline mean LDL of 177 mg/dL, patients
in the 5-mg/day group dropped their LDL by a mean of 75 mg/dL and those
on 10 mg/day lowered their LDL by 79 mg/dL (Clin. Ther. 2006;28:933-42).
The National Lipid Association advises that it’s not
routinely necessary to get a baseline creatine kinase level before
starting statin therapy, nor is it necessary to obtain one during
treatment in asymptomatic patients, Dr. Watson noted. But patients on
statin therapy need to be counseled about the associated increased risk
of muscle complaints and the importance of contacting their physicians
should they arise (Am. J. Cardiol. 2006;97:89C-94C).
Those who develop tolerable muscle symptoms may
continue with therapy, according to the National Lipid Association
Statin Safety Task Force. But patients who experience intolerable
symptoms with or without a creatine kinase elevation should stop
treatment. Once they’re asymptomatic, the same drug can be restarted at
the same dose, or one of the alternative strategies Dr. Watson described
can be employed.
She reported serving as a consultant to Pfizer and on the Merck clinical trials adjudication committee.
For me the alternative for statin drugs is optimizing your cholesterol levels. In that way, there's no need for a statin. How to do it? You must modify your diet and lifestyle. Optimize your vitamin d levels, reduce or eliminate grains and sugar, get plenty of animal-based omega-3 fats, eat heart-healthy foods, exercise, don't be stress, avoid smoking as well as alcohol and get plenty of sleep.
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