From the Guidelines
Rosuvastatin is generally considered the most tolerated statin for patients with statin intolerance, with lower rates of muscle-related side effects compared to other statins. When managing statin-intolerant patients, it is essential to consider the approach outlined in the 2022 ACC expert consensus decision pathway 1. This involves a systematic evaluation of statin-associated side effects, including statin-associated muscle symptoms, which may occur in 5% to 20% of patients.
Key Considerations for Statin-Intolerant Patients
- A careful history can help determine whether symptoms are consistent with statin-related effects, which tend to be symmetric myalgias or weakness in large proximal muscle groups 1.
- Other causes of muscle symptoms must be ruled out, such as hypothyroidism, vitamin D deficiency, and recent exercise, and drug–drug interactions that can increase systemic statin exposure must be considered 1.
- Some patients, such as women, individuals of Asian descent, and the elderly, may be at increased risk for statin-associated muscle symptoms, but they may be able to tolerate a lower statin intensity, an alternative statin, or alternative dosing strategies 1.
Alternative Statin Regimens
- For patients who experience statin-associated muscle symptoms, alternative statin regimens may include alternate-day dosing with a long half-life statin, such as atorvastatin or rosuvastatin, or de-escalation dosing, reducing the daily dose of a statin 1.
- The predominantly hydrophilic statins, rosuvastatin and pravastatin, may be better tolerated than lipophilic statins, such as simvastatin, fluvastatin, pitavastatin, lovastatin, and atorvastatin 1.
Non-Statin Therapies
- Non-statin therapies, such as ezetimibe or PCSK9 inhibitors, may be considered for patients who have failed at least 2 (and preferably 3) statins, including a trial of 1 attempt at the lowest approved dose or using alternative statin dosing 1.
- These therapies should only be considered after a systematic and rigorous evaluation of statin-associated side effects has been conducted, and the patient has been found to be truly statin-intolerant 1.
From the Research
Statin Intolerance
- Statin intolerance is defined as one or more adverse effects associated with statin therapy which resolves or improves with dose reduction or discontinuation 2
- It can be classified as a complete inability to tolerate any dose of a statin or partial intolerance with inability to tolerate the dose necessary to achieve the patient-specific therapeutic objective 2
Tolerable Statin Regimens
- To identify a tolerable statin regimen, clinicians should consider using several different strategies, such as different statin, dose, and/or dosing frequency 2
- Non-statin therapy may be required for patients who cannot reach therapeutic objectives with lifestyle and maximal tolerated statin therapy 2
Most Tolerated Statin
- There is no specific statin that is identified as the most tolerated in the provided studies
- However, studies suggest that using a different statin, dose, or dosing frequency may help identify a tolerable statin regimen for patients with statin intolerance 2
Alternative Therapies
- For patients who are statin intolerant, alternative therapies such as ezetimibe, PCSK9 inhibitors, or a combination of these may be considered 3, 4, 5, 6
- These therapies have been shown to reduce LDL-C levels and cardiovascular risk in patients who are statin intolerant or have not achieved their treatment goals with statin therapy 3, 4, 5, 6