Strategies to optimize statin treatment for muscle symptoms

Statins are highly effective for preventing heart attacks by reducing low-density lipoprotein or "bad" cholesterol. However, 10 to 20 percent of patients taking statins report muscle-related symptoms including aches, pains and cramps that prevent the use of recommended doses. Patients who have difficulty taking statins have a high risk of cardiovascular events, resulting in higher health care costs.

To address these concerns, Mount Sinai researchers are providing approaches to optimize cardiovascular risk reduction for these patients. The findings are published in Journal of the American College of Cardiology on Monday, August 28.

Since adverse muscle symptoms are subjective, the research team developed a statin-associated muscle symptom (SAMS) clinical index to evaluate whether the symptoms are consistent with statin-associated muscle symptoms. A low score identifies patients with a very low likelihood that the muscle symptoms are truly due to the statin.

"Muscle symptoms experienced by patients on statin therapy may or not be related to the medication," said the study's lead author, Robert Rosenson, MD, Professor of Medicine and Director of Cardiometabolic Disorders at the Icahn School of Medicine at Mount Sinai. "A different statin may be well tolerated in patients who were unable to tolerate a particular statin."

Rosenson and the research team propose the following strategies for optimizing cholesterol treatment in patients with SAMS:

• Re-challenging as well as switching statins--While switching statins and reducing doses are commonplace, re-challenging patients with the same statin at the same dose is unusual because patients often feel uncomfortable retrying a statin that they perceive has caused intolerable effects. The research team advises clinicians to try the same statin at the same dose again to verify that the muscle symptoms occur again. In patients who have true statin muscle symptoms, other statins may be tolerated because they will experience fewer drug interactions or they have a genetic predisposition that results in more effective metabolism of an alternative statin.
• Adopting healthy lifestyle changes. Eating a healthy diet, maintaining a normal weight, exercising regularly, and avoiding tobacco will help patients lower their LDL cholesterol, which may allow them to take reduced statin doses.
• Non-statin pharmacotherapies. Taking ezetimibe (Zetia) before a PCSK9 inhibitor, a different class of cholesterol-busting drugs, bile acid sequestrants (BAS), or fibric acid medications can also lower LDL cholesterol; these drugs are not linked to adverse muscle complaints.
• Nutraceuticals. Coenzyme Q10 may reduce SAMS, and ingesting turmeric can improve pain in patients with musculoskeletal conditions. Additional trials are needed to evaluate these therapies.
• Evaluation for other diseases affecting the musculoskeletal system.