From the Guidelines
For a patient on statin therapy with muscular pain and normal creatine kinase (CK) levels, the most appropriate management option is to consider a statin holiday of 2-4 weeks to determine if symptoms resolve, followed by rechallenge with the same statin at a lower dose or switching to an alternative statin with different pharmacokinetics, such as rosuvastatin or pravastatin, as recommended by the 2018 AHA/ACC/AACVPR/AAPA/ABC/ACPM/ADA/AGS/APhA/ASPC/NLA/PCNA guideline on the management of blood cholesterol 1.
When managing a patient with muscular pain on statin therapy, it is essential to rule out other causes of myalgia, such as:
- Vitamin D deficiency
- Hypothyroidism
- Drug interactions with medications like gemfibrozil or certain antibiotics
The patient's symptoms should be thoroughly assessed, and predisposing factors for statin-associated muscle symptoms (SAMS) should be identified, including demographics, comorbid conditions, and use of medications that can adversely affect statin metabolism, as outlined in the 2018 AHA/ACC/AACVPR/AAPA/ABC/ACPM/ADA/AGS/APhA/ASPC/NLA/PCNA guideline on the management of blood cholesterol 1.
If the patient's symptoms persist, consider non-statin lipid-lowering therapies like:
- Ezetimibe 10 mg daily
- PCSK9 inhibitors
It is also important to note that coenzyme Q10 supplementation is not recommended for routine use in patients treated with statins or for the treatment of SAMS, as stated in the 2018 AHA/ACC/AACVPR/AAPA/ABC/ACPM/ADA/AGS/APhA/ASPC/NLA/PCNA guideline on the management of blood cholesterol 1.
The goal of management is to maintain lipid-lowering therapy while minimizing side effects, as discontinuation of statin therapy increases the risk of cardiovascular events, as highlighted in the 2018 AHA/ACC/AACVPR/AAPA/ABC/ACPM/ADA/AGS/APhA/ASPC/NLA/PCNA guideline on the management of blood cholesterol 1.
From the FDA Drug Label
Myopathy and Rhabdomyolysis Simvastatin may cause myopathy and rhabdomyolysis. Discontinue simvastatin if markedly elevated CK levels occur or if myopathy is either diagnosed or suspected. Muscle symptoms and CK increases may resolve if simvastatin is discontinued.
For a patient on statin therapy with muscular pain and normal creatine kinase (CK) levels, the management options include:
- Monitoring: Continue to monitor the patient's CK levels and muscle symptoms.
- Dose adjustment: Consider reducing the dose of simvastatin or switching to a different statin.
- Alternative causes: Investigate alternative causes of muscular pain, such as other medications or underlying medical conditions.
- Discontinuation: If muscle symptoms persist or worsen, consider discontinuing simvastatin temporarily or permanently 2.
- Patient education: Instruct patients to promptly report any unexplained muscle pain, tenderness or weakness, particularly if accompanied by malaise or fever 3.
From the Research
Management Options for Patients on Statin Therapy with Muscular Pain and Normal CK Levels
- The evidence suggests that statin-associated muscle symptoms (SAMS) are common, but the relationship between SAMS and biomarkers of muscle damage is not well established 4.
- A study found that simvastatin use, BMI, and CK-MB were independent markers of SAMS, but this study had high CK values, not normal CK levels like in the patient's case 4.
- Another study found that statin therapy yielded a small, clinically insignificant increase in median creatine kinase values, and most (>90%) of all reports of muscle symptoms by participants allocated statin therapy were not due to the statin 5.
- For patients with muscular pain and normal CK levels, the management options may include:
- Exchange of statin, as all statins have been associated with muscle pain, but some may be more likely to cause muscle symptoms than others 6, 7.
- Reduction of dose, which may be worth trying, especially in primary prevention 6.
- Close monitoring of muscle symptoms and CK levels, as early recognition of muscle symptoms is required to prevent rhabdomyolysis 7.
- It is essential to weigh the benefits of statin therapy against the potential risks and to use clinical judgment to manage potential side effects on an individual basis 6, 5.
- A practical approach to diagnosing and managing patients with statin-associated myalgias and muscle injury has been proposed, which includes recognizing and managing both while still lowering the low-density lipoprotein 8.