Can pitavastatin (pitavastatin) cause myalgias (muscle pain)?

Pitavastatin Can Cause Myalgias, Though Less Frequently Than Other Statins

Yes, pitavastatin can cause myalgias (muscle pain), though it appears to have a lower risk profile compared to other statins. According to the FDA drug label, myalgia is one of the most common adverse reactions reported with pitavastatin, occurring in 3.1% of patients taking the 4 mg dose compared to 1.4% in placebo groups 1.

Evidence of Muscle-Related Side Effects

The FDA label clearly states that pitavastatin may cause:

• Myopathy (muscle pain, tenderness, or weakness associated with elevated creatine kinase)
• Rhabdomyolysis (in rare cases)
• Acute kidney injury secondary to myoglobinuria 1

In the REPRIVE trial involving 7,769 participants with HIV infection, muscle-related symptoms occurred in 2.3% of patients in the pitavastatin group compared to 1.4% in the placebo group 2.

Risk Factors for Pitavastatin-Induced Myalgias

Several factors increase the risk of developing muscle symptoms with pitavastatin:

• Age ≥65 years
• Uncontrolled hypothyroidism
• Renal impairment
• Concomitant use of certain drugs (especially other lipid-lowering therapies)
• Higher pitavastatin dosage 1
• Female sex
• Low body mass index
• Asian ancestry
• Excess alcohol consumption
• High levels of physical activity 3

Pitavastatin vs. Other Statins

Interestingly, pitavastatin appears to have a more favorable muscle side effect profile compared to other statins:

• The 2024 International Lipid Expert Panel (ILEP) position paper notes that "the prevalence of pitavastatin intolerance is similar to placebo" 2
• Case reports suggest pitavastatin may be better tolerated than fluvastatin and pravastatin, which were traditionally considered the most tolerable statins 4

Management of Pitavastatin-Induced Myalgias

If myalgias develop while on pitavastatin:

1. Assess severity:

   • Measure creatine kinase (CK) levels if symptoms are severe or objective weakness is present 3
   • Discontinue pitavastatin if markedly elevated CK levels occur or if myopathy is diagnosed/suspected 1

2. Intervention options:

   • Temporarily discontinue pitavastatin until symptoms improve 3
   • Consider dose reduction (starting with lowest effective dose)
   • Try alternate-day dosing
   • Switch to a different statin if necessary 3

3. Monitor for rare complications:

   • Be vigilant for signs of immune-mediated necrotizing myopathy (IMNM), characterized by persistent proximal muscle weakness and elevated CK despite discontinuation 1

Important Caveats

1. Nocebo effect: Statin-associated myalgia is often overestimated. A systematic analysis of 26 statin clinical trials showed an incidence of myalgia of 12.7% in statin-treated patients versus 12.4% in placebo groups 3.

2. Baseline assessment: Pre-statin assessments of myopathy, myalgias, and other constitutional symptoms should be performed to ensure baseline symptoms aren't erroneously attributed to statin therapy 3.

3. Risk-benefit consideration: Despite potential muscle symptoms, the cardiovascular benefits of statin therapy generally outweigh the risks for most patients 3.

4. Patient education: Patients should be informed about the risk of myopathy and rhabdomyolysis when starting pitavastatin and instructed to promptly report any unexplained muscle pain, tenderness, or weakness, particularly if accompanied by malaise or fever 1.

In conclusion, while pitavastatin can cause myalgias like other statins, evidence suggests it may have a more favorable muscle side effect profile, making it a potentially good option for patients who have experienced muscle symptoms with other statins.