Scenario = 55M IHD with stents, trialed simvastatin, atorvastatin and pravastatin, all causing myalgia, without CK rise
Question = what to do?
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