When to recheck creatine kinase (CK) levels in patients taking Crestor (rosuvastatin) with hyperckemia (elevated creatine kinase levels)?

From the Guidelines

Patients taking Crestor (rosuvastatin) with elevated creatine kinase (CK) levels should have their CK levels rechecked after discontinuing the medication if levels are significantly elevated (>10 times the upper limit of normal) or if the patient is experiencing muscle symptoms. For asymptomatic patients with mild to moderate CK elevations (<10 times upper limit of normal), continued monitoring without medication discontinuation is generally appropriate, with follow-up CK measurements in 2-4 weeks, as suggested by the 2016 ESC/EAS guidelines for the management of dyslipidaemias 1. If a patient has been taken off Crestor due to elevated CK levels, rechecking should occur approximately 2-4 weeks after discontinuation to confirm normalization. Once CK levels normalize, a different statin at a lower dose may be considered with close monitoring. The timing of CK rechecks is important because rosuvastatin has a relatively long half-life (approximately 19 hours) and complete clearance from the body can take several days. CK elevations occur due to statin-induced muscle damage, which is dose-dependent and more common in patients with certain risk factors including advanced age, female gender, small body frame, kidney dysfunction, hypothyroidism, and certain medication interactions, as noted in the 2013 ACC/AHA guideline on the treatment of blood cholesterol to reduce atherosclerotic cardiovascular risk in adults 1. It is also reasonable to evaluate and treat muscle symptoms, including pain, tenderness, stiffness, cramping, weakness, or fatigue, in statin-treated patients according to the management algorithm provided in the 2013 ACC/AHA guideline 1. Additionally, the 2013 ACC/AHA guideline recommends that during statin therapy, it is reasonable to measure CK in individuals with muscle symptoms, including pain, tenderness, stiffness, cramping, weakness, or generalized fatigue 1. Some key points to consider when monitoring CK levels in patients taking lipid-lowering drugs include being alert regarding myopathy and CK elevation in patients at risk, such as elderly patients, concomitant interfering therapy, multiple medications, liver or renal disease, or sport athletes, as highlighted in the 2016 ESC/EAS guidelines 1. Overall, the management of elevated CK levels in patients taking Crestor (rosuvastatin) requires careful consideration of the patient's individual risk factors, symptoms, and laboratory results, as well as close monitoring and follow-up to minimize the risk of adverse effects and optimize treatment outcomes.

From the Research

Rechecking CK Levels in Patients Taking Crestor (Rosuvastatin) with Hyperckemia

• The decision to recheck creatine kinase (CK) levels in patients taking Crestor (rosuvastatin) with hyperckemia should be guided by the severity of symptoms and the degree of CK elevation 2.
• If CK levels are less than five times the upper limit of normal, the existing statin should be titrated to achieve cholesterol goals, and CK levels should be repeated when symptoms appear or worsen 2.
• In patients with moderate to severe symptoms or CK elevations greater than five times the upper limit of normal, the statin should be stopped, and alternative treatments should be considered 2.
• CK levels should be monitored in patients who show CK elevations, and progress can be followed clinically in patients without CK elevations and symptoms 2.
• The risk of significant CK elevation with statins is low, but it may be higher in "real-world" settings, and potential risk factors should be identified and evaluated to quantify the risk for CK elevation with statins 3.

Factors Influencing CK Levels

• High-dose simvastatin appears to confer a greater risk of CK elevation than lower doses of either simvastatin or lovastatin 3.
• The use of interacting medications, such as those that inhibit cytochrome P450 3A4, may increase the risk of CK elevation with statins 4.
• Patients with underlying myopathy or those who are older, female, or have a genetic predisposition may be more susceptible to CK elevations with statin therapy 2.

Management of Hyperckemia

• Asymptomatic patients with high CK levels (>or=250 but <2500 IU/L) can tolerate statins well, and CK levels may actually decrease with statin therapy 5.
• In patients with high CK levels, alternative treatments, such as ezetimibe or bile acid sequestrants, may be considered, and CK levels should be monitored closely 2, 5.