Mr. S has not had a cardiovascular event but is at high risk for an MI or CVA. Statins are the drug of first choice and should be used for primary and secondary prevention of MI and stroke. Some clinicians would add coenzyme Q-10, but data is limited to the effectiveness of this strategy and it would increase costs.
A study by Turchin and colleagues evaluated charts of 107,835 patients on statins between 2000-2008. Of these patients, 11,124 or approximately 10% stopped statins because of side effects. Of those 11,000, 90% were able to restart the same or another statin within a year and continue with long-term therapy.1
Mr. S was started on another statin 4 weeks later and he did not have a recurrence of muscle aches. His LDL is at goal.
Certain statins such as lovastatin and simvastatin have a higher risk of myopathy especially at higher doses. Atorvastatin and rosuvastatin have the greatest potential to reduce LDL cholesterol and have an intermediate risk of myopathy. Pravastatin and fluvastatin are less potent LDL reducing statins but are considered the lowest risk for inducing myopathy.
The ALERT study (Assessment of Lescol in renal transplantation) was conducted in over 2,000 patients who had renal transplant. Patients were given cyclosporine and about half also received fluvastatin. The patients receiving cyclosporin and fluvastatin did not have a higher risk of myopathy then the patients on cyclosporin and placebo.
BS did well switching from a statin with a higher myopathy risk to a statin with a lower myopathy risk. He was also instructed to remain hydrated especially when exercising. His LDL continues to be at goal, at one year follow-up and he is symptom free.
1. Zhang H, Plutzky J, Skentzos S, et al. Discontinuation of statins in routine care settings. Ann Intern Med 2013; available at: https://annals.org/article.aspx?articleid=1671715. Accessed April 30, 2013