Management of statin induced myopathy

• undertake diagnostic workup as described
• if the workup suggests a neurologic, rheumatolic or metabolic aetiology, a referral to a specialist is indicated
• if myopathy with multiple statin challenges then specialist advice should be sought
• use of a statin holiday
  • a 6-week 'statin holiday' may be used to see if symptoms of myopathy resolve
    • some give these patient supplements of 600 mg daily of a bioavailable source of coenzyme Q10 and fish oil during this statin holiday (1)
    • if symptoms persist or if resolution is unclear at 6 weeks, extend the holiday for an additional 6 weeks, except in patients with recent unstable coronary disease:
      • for these patients, unless there is evidence of rhabdomyolysis, we believe that the benefits of continued statin therapy exceed the risks (1)
• once the myopathy symptoms have abated or are controlled, a rechallenge of statin therapy is in order for those whose risk profile suggests greater benefit from statin therapy (note a statin rechallenge is not appropriate if there has been evidence of statin-induced rhabdomyolysis)
  • long acting fluvastatin or a statin with less cytochrome P 450 dependence, such as pravastatin, are often the first line if previous statin-induced myopathy
  • if myopathy has recurred with multiple statin rechallenges or whose lipid-lowering goal requires a more potent therapy, rosuvastatin in alternate-day or once- or twice-a-week schedules is efficacious and well tolerated in many patients
    • however, although such alternate-day therapies may produce excellent reductions in cholesterol levels, these regimens have not been proven to reduce cardiovascular end points
  • alternative therapies may require seeking specialist advice but include:
    • ezetimibe
    • bile sequestrants
    • fibrates
    • nicotinic acid
    • PCSK9 inhibitors

Reference:

• 1) Fernandez G et al. Statin myopathy: a common dilemma not reflected in clinical trials. Cleve Clin J Med. 2011 Jun;78(6):393-403