Who should not take HMG-CoA (3-hydroxy-3-methylglutaryl-coenzyme A) reductase inhibitors, commonly referred to as statins?

From the Guidelines

Statins should not be taken by individuals with active or chronic liver disease, as indicated by the most recent and highest quality study 1. When considering the use of statins, it is essential to evaluate the potential risks and benefits, particularly in relation to morbidity, mortality, and quality of life. The primary concern with statin use is the potential for liver damage, which can be exacerbated in individuals with pre-existing liver disease.

Key Considerations for Statin Use

• Absolute contraindications: Active or chronic liver disease, as stated in the study 1.
• Relative contraindications: Concomitant use of cyclosporine, gemfibrozil, or niacin, macrolide antibiotics, various anti-fungal agents, and cytochrome P-450 inhibitors, as these can increase the risk of side effects 1.
• Caution in certain medical conditions: Kidney disease, hypothyroidism, or a history of muscle disorders, as these conditions may increase the risk of statin-induced myopathy 1.
• Medication interactions: Specific medications like cyclosporine, erythromycin, clarithromycin, and certain antifungal medications can interact dangerously with statins, increasing the risk of side effects 1.
• Grapefruit juice avoidance: Grapefruit juice should be avoided when taking certain statins like atorvastatin (Lipitor), simvastatin (Zocor), and lovastatin (Mevacor) as it can increase statin concentration in the blood.

Monitoring and Management

• Baseline evaluation: Conduct baseline hepatic panel and CK before initiating treatment, as recommended in the study 1.
• Monitoring for muscle symptoms: If unexplained severe muscle symptoms or fatigue develop during statin therapy, promptly discontinue the statin and address the possibility of rhabdomyolysis, as advised in the study 1.
• Alternative options: Patients with a history of statin-induced myopathy should discuss alternative cholesterol management options with their doctor, considering the potential risks and benefits of statin therapy 1.

From the Research

Patients Who Should Not Take Statins

The following groups of patients may need to avoid or use statins with caution:

• Patients with active liver disease, as statins were previously considered to be contraindicated in these patients 2
• Patients with certain conditions such as chronic disease of the kidney and liver, human immunodeficiency viral infection, and organ transplants, who may require careful consideration and monitoring 3
• Pregnant women, as statins are not typically recommended during pregnancy 3
• Children, as the safety and efficacy of statins in this population are not well established 3
• Patients with a history of myopathy or rhabdomyolysis, as they may be at increased risk of recurrence 4, 5, 6
• Patients taking certain medications that interact with statins, such as fibrates, diltiazem, verapamil, and amiodarone, as these combinations may increase the risk of adverse effects 4, 6
• Patients with increased age, female gender, renal or liver disease, diabetes, hypothyroidism, debilitated status, surgery, trauma, excessive alcohol intake, and heavy exercise, as these factors may predispose to myopathy caused by combination statin-fibrate therapy 4

Special Considerations

• Patients with cerebrovascular disease should be aware that statins may increase the risk of hemorrhagic stroke, although the overall benefit of statin therapy in reducing cardiovascular events may still outweigh this risk 3
• Patients with compromised renal function or those taking medications that interact with statins may require dose adjustments or alternative treatments 5, 6