An Update on Statin Alternatives and Adjuncts

Matthew J Sorrentino


Clin Lipidology. 2012;7(6):721-730. 

In This Article

Use of Statins in Patients With Myalgias

Myalgias are the most common adverse effect causing discontinuation of statins. Before abandoning statin therapy, it is important to determine if muscle complaints are due to the statin medication. It is useful to obtain a muscle and joint pain history prior to prescribing a statin. Subsequent muscle complaints can then be compared with the initial report to determine if new symptoms have developed. Many patients complain of joint aches, which are unlikely to be due to the statin. Likewise, muscle cramps, especially cramping in the legs that typically occur at night, are not likely due to the statin drugs. A drug-free holiday for a few weeks followed by reintroduction of the statin can be an effective way to determine if the muscle complaints are likely to be due to the statin medication.

Changing statin types may improve tolerability of the statins. A statin metabolized by a different enzymatic system may be better tolerated. Lovastatin, simvastatin and atorvastatin are metabolized by the CYP450 3A4 system in the liver, whereas pravastatin, rosuvastatin and pitivastatin are metabolized by alternate pathways. Choosing a statin that has a different mechanism of metabolism, especially if other medications are being used that utilize the same metabolic pathways, may lead to reduced muscle symptoms. The hydrophilicity or lipophilicity of statins may correlate with muscle symptoms. Highly lipophilic statins, such as simvastatin and lovastatin, may increase the risk for CK elevations compared with low lipophilic statins, such as pravastatin and rosuvastatin.[5] Finally, genome-wide association studies have identified a strong association of myopathy with a single nucleotide polymorphism, suggesting that genetic variation in the population may be linked to the risk of myopathy.[6] Genotyping of patients may prove useful in identifying individuals at the highest risk of toxicity.