From the Guidelines
For patients with hypercholesterolemia who have developed myositis secondary to statin use, the best treatment option is typically a non-statin lipid-lowering therapy, with ezetimibe (10 mg daily) being a first-line alternative, as supported by recent guidelines 1. When considering treatment options for hypercholesterolemia in patients with myositis secondary to statin use, it's crucial to prioritize therapies that minimize the risk of further muscle damage while effectively managing cholesterol levels.
- Key considerations include:
- The use of ezetimibe, which works by blocking intestinal cholesterol absorption and does not affect muscle metabolism, making it a safer option for patients with myositis.
- PCSK9 inhibitors like evolocumab or alirocumab, which are effective in reducing LDL cholesterol and are suitable for patients with high cardiovascular risk or familial hypercholesterolemia.
- Bempedoic acid, which inhibits cholesterol synthesis earlier in the pathway than statins, potentially reducing muscle-related side effects.
- Lifestyle modifications, including a Mediterranean or plant-based diet, regular physical activity, weight management, and smoking cessation, which are essential for overall cardiovascular health. Given the potential for myositis with statin use, as noted in guidelines 1, and the effectiveness of non-statin therapies in managing hypercholesterolemia, ezetimibe stands out as a preferred initial treatment option due to its mechanism of action and safety profile 1.
- The choice of therapy should be individualized based on the severity of hypercholesterolemia, cardiovascular risk, and the degree of muscle inflammation, with ongoing monitoring to adjust treatment as necessary.
- It's also important to consider the findings from studies on managing dyslipidemia in adults with diabetes, which highlight the importance of prioritizing LDL cholesterol lowering and the potential benefits and risks of combining different lipid-lowering therapies 1.
From the FDA Drug Label
Ezetimibe tablets are indicated: • In combination with a statin, or alone when additional low-density lipoprotein cholesterol (LDL-C) lowering therapy is not possible, as an adjunct to diet to reduce elevated LDL-C in adults with primary hyperlipidemia, including heterozygous familial hypercholesterolemia (HeFH)
The best option for treating hypercholesterolemia in patients with myositis secondary to statin use is ezetimibe.
- Ezetimibe can be used alone when additional LDL-C lowering therapy is not possible, making it a suitable alternative for patients who cannot tolerate statins due to myositis.
- The recommended dose of ezetimibe is 10 mg orally once daily, administered with or without food 2.
- It is essential to assess LDL-C when clinically appropriate, as early as 4 weeks after initiating ezetimibe tablets 2.
- Ezetimibe may cause myopathy, and if myopathy is suspected, it is necessary to discontinue ezetimibe and other concomitant medications, as appropriate 2.
From the Research
Treatment Options for Hypercholesterolemia in Myositis Secondary to Statins
The treatment of hypercholesterolemia in patients with myositis secondary to statin use is a complex issue, as statins are a common cause of myositis. The following options are available:
- Discontinuation of statin use: This is the most effective treatment for statin-induced myopathy, as it allows the muscle to recover from the toxic effects of the statin 3.
- Use of alternative lipid-lowering agents: Bile acid sequestrants, ezetimibe, and fibrates are alternative options for lowering LDL-C levels in patients with statin-induced myositis 4, 5.
- Combination therapy: Combination of a bile acid sequestrant with ezetimibe or a fibrate may be effective in reducing LDL-C levels while minimizing the risk of myositis 4, 5.
- Intensification of lifestyle modifications: Dietary changes and increased physical activity can help lower LDL-C levels and reduce the risk of cardiovascular events 6.
Management of Statin Intolerance
Patients with statin intolerance may require alternative treatment strategies, including:
- Changing statins: Switching to a different statin may help reduce the risk of myositis 6.
- Intermittent dosing: Taking statins intermittently may help reduce the risk of myositis while still providing some cardiovascular benefit 6.
- Use of other LDL-C-lowering agents: Ezetimibe, bile acid sequestrants, and LDL apheresis are alternative options for lowering LDL-C levels in patients with statin intolerance 6.