From the Guidelines
Rosuvastatin is preferred over pravastatin for patients with muscle ache concerns due to its lower propensity for causing muscle-related side effects, as evidenced by its hydrophilic properties and lower tissue penetration 1. When considering the addition of an oral statin to a patient already on Repatha (evolocumab), it's crucial to weigh the benefits of further lowering LDL cholesterol against the potential for increased muscle symptoms. Key factors to consider include:
- The patient's individual cholesterol goals and cardiovascular risk profile
- The presence of predisposing factors for statin-associated muscle symptoms (SAMS), such as age, female sex, low body mass index, and comorbidities like renal or liver disease 1
- The potential for drug interactions, particularly with medications that inhibit CYP3A4 or OATP1B1, which can increase statin levels and exacerbate muscle symptoms 1 If a statin is deemed necessary, initiating therapy with a low dose of rosuvastatin (5-10mg) taken every other day or twice weekly can help minimize muscle symptoms while still providing lipid-lowering benefits 1. Regular monitoring of muscle symptoms, creatine kinase levels, and lipid profiles is essential when combining these medications to promptly identify and address any adverse effects. Ultimately, the decision to add a statin to Repatha therapy should be highly individualized, taking into account the patient's unique clinical profile, history of statin tolerance, and specific cardiovascular risk factors 1.
From the FDA Drug Label
Adverse reactions (regardless of causality) reported in ≥2% of pravastatin-treated patients in placebo-controlled trials of up to 8 months duration are identified in Table 1: ... Myalgia 1.2 2.3 ... Adverse Reactions (regardless of causality) ... Table 2: Adverse Reactions in ≥5% of Patients Treated with Pravastatin 40 mg and at an Incidence Greater than Placebo in Long-Term Placebo-Controlled Trials ... Musculoskeletal Pain 24.4 24. 9 ... Muscle Cramp 4.6 5. 1
The FDA drug label does not provide a direct comparison between pravastatin and rosuvastatin regarding muscle aches.
- Myalgia was reported in 2.3% of patients treated with pravastatin.
- Musculoskeletal Pain was reported in 24.9% of patients treated with pravastatin.
- Muscle Cramp was reported in 5.1% of patients treated with pravastatin. There is no information about the use of oral statin as needed in patients on Repatha 2.
From the Research
Comparison of Pravastatin and Rosuvastatin
- Pravastatin and rosuvastatin are both statins used to lower cholesterol levels, but they have different potencies and side effect profiles 3.
- Rosuvastatin is considered a more potent statin than pravastatin, with a greater ability to lower LDL cholesterol levels 4.
- However, the choice between pravastatin and rosuvastatin should be based on individual patient factors, such as tolerance to side effects and specific cholesterol-lowering needs.
Muscle Aches and Statin Therapy
- Muscle aches are a common side effect of statin therapy, but the risk varies among different statins 3.
- Pravastatin is generally considered to have a lower risk of muscle aches compared to other statins, including rosuvastatin 3.
- However, the exact comparison of muscle ache risk between pravastatin and rosuvastatin is not clearly established in the provided studies.
Use of Oral Statin with Repatha
- Repatha (evolocumab) is a PCSK9 inhibitor that can be used in combination with statin therapy to further lower LDL cholesterol levels 5, 4, 6, 7.
- The use of oral statin with Repatha is common, and the combination has been shown to be effective in reducing cardiovascular events 6, 7.
- However, the decision to use an oral statin with Repatha should be based on individual patient factors, such as cholesterol-lowering needs and tolerance to side effects.