What is the recommended time to wait after discontinuing (dc) statin therapy before restarting it after completing daptomycin therapy?

Timing for Restarting Statin Therapy After Daptomycin Discontinuation

After discontinuing daptomycin therapy due to elevated creatine phosphokinase (CK) levels, statins should be restarted only after CK levels have normalized, typically within 7 days of daptomycin discontinuation. 1

Understanding Statin-Daptomycin Interaction

• Daptomycin is associated with myopathy in 2-14% of patients, with rhabdomyolysis being a known adverse effect 1
• Statin coadministration with daptomycin has been identified as an independent risk factor for both myopathy (odds ratio 2.60) and rhabdomyolysis (odds ratio 4.67) 1
• The mechanism involves disruption of sarcolemma membrane integrity, which can be exacerbated when both medications are used concurrently 2

Monitoring and Management During Daptomycin Therapy

• When initiating daptomycin in patients on statins, consider the following options:

  • Continue statin with weekly CK monitoring (especially important for patients receiving statins for secondary prevention of cardiovascular disease) 3
  • Temporarily discontinue statin during daptomycin therapy if the patient is at lower cardiovascular risk 1

• Monitor CK levels:

  • Baseline CK measurement before starting therapy 4
  • Weekly monitoring during concomitant therapy 5, 3
  • Immediate testing if muscle symptoms develop 4

Management of CK Elevations

• For asymptomatic CK elevations (3-10 times upper limit of normal):

  • Follow CK levels weekly until there is no longer medical concern 4
  • Consider withholding a single daptomycin dose and resuming 24 hours later if CK elevations are mild 2

• For significant CK elevations (>10 times upper limit of normal) or symptomatic myopathy:

  • Discontinue both daptomycin and statin therapy immediately 4
  • Monitor CK levels until normalization 4, 1

Restarting Statin Therapy After Daptomycin

• Wait for CK levels to normalize before restarting statin therapy 1
• Most cases of daptomycin-induced CK elevation resolve within 1 week of discontinuation 6
• When restarting statins:
  • Consider starting at a lower dose and titrating up as tolerated 4
  • Monitor for recurrence of muscle symptoms 4
  • Measure CK if symptoms recur 4

Special Considerations

• Patients at higher risk for statin-daptomycin myopathy include:

  • Obese patients (odds ratio 3.28 for rhabdomyolysis) 1
  • Patients receiving antihistamines (odds ratio 3.50 for myopathy) 1
  • Patients being treated for deep abscesses (odds ratio 2.80 for myopathy) 1

• For patients who absolutely require both medications:

  • Consider a "daptomycin holiday" approach for asymptomatic CK elevations - temporarily withholding daptomycin until CK trends downward before resuming therapy 6
  • Resume statin therapy only after completing full daptomycin course and confirming normal CK levels 1

Practical Algorithm for Restarting Statins

1. Complete daptomycin therapy course
2. Measure CK levels after completion
3. If CK is normal (or returned to baseline): restart statin at previous dose
4. If CK remains elevated: wait additional 3-7 days and recheck
5. Once CK normalizes: restart statin with follow-up CK measurement in 1-2 weeks