CLINICAL COMME TARY STATINS AS A CAUSE OF MYOPATHY: KEY CONSIDERATIONS FOR THE CLINICIAN

Abstract

The current gold standard of managing the patient at high risk for cardiovascular (CV) disease risk is
reduction of low density lipoprotein (LDL) to <70 mg/dl. Statin therapy is currently the treatment of choice
to achieve and maintain this level. There is, however, some evidence that statins may be associated with
myopathy. The incidence of statin-related myopathy has been difficult to determine due to varying clinical
definitions, but up to 10.5% appears to be an appropriate estimate. What we do know is that short-term
randomized controlled clinical trials generally report a lower incidence of myopathy than long-term trials.
Also, the incidence of myopathy tends to be less with lower statin dosages. This is important since the LDL
goal can be achieved in many cases with statins at safer, lower doses. For example, ezetimibe can contribute
significantly to LDL reduction in the average at-risk patient. Note, however, that there is one clinical
situation, acute coronary syndrome, in which initial use of a high statin dose is backed by clinical evidence
(e.g., controlled clinical trials with atorvastatin). Genetics may playa role in the risk of myopathy, as studies
have shown that certain patients are more genetically predisposed to developing myopathy. This may assume
importance in future management of patients as the realm of genetics advances. While a myopathy may
occur with one statin, it may not occur with other statins. When myopathy has been a problem, a useful
approach is to administer rosuvastatin in a low dose twice a week or every three days, as supported by clinical
evidence. Statins have been shown to interfere with the cellular functional role of coenzyme QI0 and also to
contribute to its depletion. Coenzyme QI0 may decrease or prevent statin myopathy, and may even provide
some benefit, although this has not been clearly established by controlled trials. The occurrence of the most
serious complication of myopathy-rhabdomyolysis-is rare. When it does occur, awareness of the problem,
its risks, and careful preventive follow-up of the patient are indicated.