Are there any contraindications to using statins (HMG-CoA reductase inhibitors) in patients with a history of multiple sclerosis (MS)?

Statins Are Not Contraindicated in Multiple Sclerosis Patients

There are no contraindications to using statins in patients with multiple sclerosis—prescribe statins based solely on cardiovascular risk factors, treating MS patients identically to those without MS. 1

Primary Clinical Approach

Assess Cardiovascular Indications First

The decision to use statins in MS patients should be driven entirely by cardiovascular risk, not by MS status. 1 Apply standard cardiovascular guidelines:

• For established atherosclerotic cardiovascular disease: Initiate high-intensity statin therapy regardless of MS diagnosis 1
• For diabetes mellitus: Use moderate to high-intensity statins based on cardiovascular risk factors, with MS having no bearing on this decision 1, 2
• For stroke prevention: Prescribe intensive statin therapy in patients with non-cardioembolic ischemic stroke or TIA, even with concurrent MS 1
• For primary prevention: Apply standard risk calculators and treat according to cardiovascular guidelines 1

Do Not Use Statins to Treat MS Itself

Critically important: Do not prescribe statins to "treat" the MS itself outside of clinical trials, as evidence shows no benefit and possible harm in relapsing-remitting disease. 1 The evidence is clear:

• Meta-analysis of RRMS trials showed no significant effect of statin add-on to interferon-beta therapy 3
• A concerning trend toward increased disease activity was observed in the statin group regarding new T2 lesions, proportion of patients with relapse, and whole brain atrophy 3
• Cochrane review of 458 participants found no convincing evidence to support atorvastatin or simvastatin as adjunctive therapy in MS 4

Standard Monitoring Protocol

Apply the same monitoring used for all statin patients, with no special modifications for MS: 1

• Baseline: Obtain lipid panel, liver function tests (ALT/AST), and consider baseline CK measurement 5
• Follow-up: Recheck lipid panel 4-12 weeks after initiation, then annually 1, 2
• Symptom monitoring: Evaluate for muscle soreness, tenderness, or pain at each visit 5

Critical Caveats for MS Patients

Age and Frailty Considerations

MS patients, particularly older women, may have additional myopathy risk factors: 5

• Advanced age (especially >80 years), with women at higher risk than men 5
• Small body frame and frailty 5
• Multisystem disease 5

Drug Interaction Vigilance

Exercise heightened caution with medications that may be used in MS management: 1

• Avoid CYP3A4 inhibitors with simvastatin or atorvastatin 1
• Exercise caution with cyclosporine if used for MS, as this significantly increases myopathy risk 1

Cognitive Concerns Are Unfounded

Do not withhold statins based on concerns about cognitive worsening—statins do not cause cognitive dysfunction or worsen dementia, and this concern should not deter use in MS patients. 1 This is particularly important given that MS patients may already have cognitive symptoms.

Management of Statin-Related Myopathy

If muscle symptoms develop, follow standard protocols: 5

• Obtain CK measurement and compare to baseline 5
• Check thyroid-stimulating hormone level, as hypothyroidism predisposes to myopathy 5
• Discontinue statin if CK >10 times upper limit of normal with muscle symptoms 5
• For moderate CK elevation (3-10 times ULN) with symptoms, follow weekly until resolution or worsening 5

Common Pitfalls to Avoid

• Do not withhold statins from MS patients with clear cardiovascular indications based on unfounded concerns about MS worsening 1
• Do not discontinue statins perioperatively in MS patients undergoing surgery, as withdrawal increases mortality risk 1
• Do not routinely monitor CK in asymptomatic patients 5
• Do not interpret modest transaminase elevations (<3 times ULN) as contraindication to continuing therapy 5