What are the common side effects of statin therapy and how can they be managed?

From the Guidelines

Statin therapy is generally well-tolerated, but common side effects include muscle pain, liver enzyme elevations, digestive issues, increased blood sugar, and neurological effects, and managing these side effects is crucial to minimize morbidity, mortality, and improve quality of life. Muscle symptoms, which affect 5-10% of patients, range from mild discomfort to severe myopathy 1. To manage these side effects, several strategies can be employed. For muscle pain, reducing the dose, switching to a different statin (like rosuvastatin or pravastatin which are less likely to cause muscle issues), or changing to an alternate-day dosing schedule may help 1. Coenzyme Q10 supplements (100-200 mg daily) might benefit some patients with muscle symptoms, though evidence is mixed 1. For digestive issues like nausea or constipation, taking the medication with food can help. Patients experiencing cognitive effects may benefit from switching to a less lipophilic statin like pravastatin or rosuvastatin that doesn't cross the blood-brain barrier as readily 1. Regular monitoring of liver enzymes and blood glucose is important, especially in the first year of therapy 1. If side effects persist despite these interventions, considering non-statin lipid-lowering medications like ezetimibe (10 mg daily) or PCSK9 inhibitors may be necessary 1.

Some key points to consider when managing statin side effects include:

• Muscle symptoms can be managed by reducing the dose, switching to a different statin, or changing to an alternate-day dosing schedule 1
• Coenzyme Q10 supplements may benefit some patients with muscle symptoms, though evidence is mixed 1
• Digestive issues can be managed by taking the medication with food
• Cognitive effects may be managed by switching to a less lipophilic statin like pravastatin or rosuvastatin 1
• Regular monitoring of liver enzymes and blood glucose is important, especially in the first year of therapy 1
• Non-statin lipid-lowering medications like ezetimibe or PCSK9 inhibitors may be considered if side effects persist despite interventions 1

It's also important to note that statin therapy is associated with a small increased risk of new-onset diabetes, particularly in individuals with risk factors for diabetes 1. However, the benefits of statin therapy in reducing cardiovascular risk generally outweigh the risks, and lifestyle changes such as regular physical activity, healthy dietary patterns, and weight management can help mitigate the risk of diabetes 1.

Overall, the management of statin side effects should prioritize minimizing morbidity, mortality, and improving quality of life, and clinicians should work with patients to develop a personalized plan to manage side effects and optimize the benefits of statin therapy.

From the FDA Drug Label

Rosuvastatin tablets may cause serious side effects, including: Muscle pain, tenderness and weakness (myopathy). Muscle problems, including muscle breakdown, can be serious in some people and rarely cause kidney damage that can lead to death. The most common side effects may include headache, nausea, muscle aches and pains, weakness, and constipation. Atorvastatin calcium tablets may cause serious side effects including: Muscle pain, tenderness and weakness (myopathy). Muscle problems, including muscle breakdown, can be serious in some people and, rarely, cause kidney damage that can lead to death. The most common side effects of atorvastatin calcium tablets include: nasal congestion, sore throat, runny nose diarrhea urinary tract infection nausea muscle spasms throat pain muscle and joint pain pain in extremity upset stomach musculoskeletal pain trouble sleeping

Common side effects of statin therapy include:

• Muscle pain, tenderness, and weakness (myopathy)
• Headache
• Nausea
• Muscle aches and pains
• Weakness
• Constipation
• Nasal congestion
• Sore throat
• Runny nose
• Diarrhea
• Urinary tract infection
• Muscle spasms
• Throat pain
• Muscle and joint pain
• Pain in extremity
• Upset stomach
• Musculoskeletal pain
• Trouble sleeping

Management of side effects:

• Tell your healthcare provider right away if you have unexplained muscle pain, tenderness, or weakness, especially if you have a fever or feel more tired than usual.
• Your healthcare provider may do further tests to diagnose the cause of your muscle problems.
• Your healthcare provider may change your dose of statin tablets if needed.
• Exercise regularly and make healthy food choices to maintain healthy body weight 2 3.

From the Research

Common Side Effects of Statin Therapy

• Muscle symptoms, such as myalgia, are the most common side effect of statin use, with documented rates from 1-10% 4
• Statin-associated muscle symptoms can lead to noncompliance and premature discontinuation of the medication 5
• Uncommon side effects include new-onset diabetes mellitus and elevation in liver enzymes 5
• Rhabdomyolysis is the most serious adverse effect from statin use, though it occurs quite rarely (less than 0.1%) 4

Management of Statin Side Effects

• The appropriate evaluation of the patient before starting statins and proactive utilization of available diagnostic tests to rule out alternate etiologies mimicking adverse effects are essential for accurate diagnosis of statin-associated side effects 5
• In patients with true statin-associated side effects, timely intervention with modified statin or non-statins is beneficial 5
• Exchange of statin may be beneficial, although all statins have been associated with muscle pain 6
• Reduction of dose is worth trying, especially in primary prevention 6

Risk Factors for Statin-Related Myopathy

• Hypothyroidism, polypharmacy, and alcohol abuse are common risk factors for statin-related myopathy 4
• Patients with multiple medical co-morbidities are at increased risk of adverse effects from long-term statin use 4

Cardiovascular Benefits vs. Risks

• The cardiovascular benefits of statins far outweigh the non-cardiovascular harms in patients with cardiovascular risk 7
• Statin therapy has significant mortality and morbidity benefit for both primary and secondary prevention from cardiovascular disease 4
• The small risks of muscle symptoms are much lower than the known cardiovascular benefits 8