Statin Intolerance - the 2015 Approach

Scenario = 55M IHD with stents, trialed simvastatin, atorvastatin and pravastatin, all causing myalgia, without CK rise

Question = what to do?

Atorvastatin - cardiologist's "friend"

Atorvastatin - cardiologist's "friend"

Statin intolerance - consider these:

  • Vitamin D level - low vitamin D level has been associated with statin induced myalgia
  • Drug interactions
    • amiodarone - increases statin toxicity, especially for simvastatin lovastatin
    • erythromycin and clarithromycin, but not azithromycin
    • verapamil and diltiazem, but less likely with amlodipine
    • protease inhibitors, especially ritonavir
    • fibrates - significantly increases the risk of statin toxicity, more frequently with gemfibrozil
  • Other statins
    • Twice-weekly or every-other-day schedule Rosuvastatin (or Atorvastatin)
      • Retrospective studies in lipid clinics have had some success in using twice-weekly or every other day dosing of rosuvastatin. (Ref)  The dosage is usually 5 mg twice weekly 5 mg every other day.  In the two studies, 80% and 72% of patients managed to stay on statin. 
      • It is of note that there is no outcome study examining such dosing regimen.
    • Pravastatin is metabolised differently from other statins.  Most statins are metabolised by the cytochrome P-450 isoenzyme.  Instead, pravastatin is significantly renally excreted.

References:

Gadarla M, Kearns AK, Thompson PD. Efficacy of rosuvastatin (5 mg and 10 mg) twice a week in patients intolerant to daily statins. Am J Cardiol. 2008;101:1747-1748.

Backes JM, Venero CV, Gibson CA, et al. Effectiveness and tolerability of every-other-day rosuvastatin dosing in patients with prior statin intolerance. Ann Pharmacother. 2008;42:341-346. 

 

Author:

Dr Andrew To