From the Guidelines
Pitavastatin has the least myopathic effects among the statins.
Key Points
- Pitavastatin is a potent inhibitor of HMG-coenzyme A reductase, reducing LDL-C effectively by a mean of 43–47% 1.
- It has a lower incidence of myopathy, especially when used in persons without multi-system disease or multiple medications, similar to other statins when used with fibrate 1.
- The 2018 AHA/ACC/AACVPR/AAPA/ABC/ACPM/ADA/AGS/APhA/ASPC/NLA/PCNA guideline lists pitavastatin as a low-intensity statin therapy option, with an LDL-C lowering of less than 30% 1.
- Statin-associated muscle symptoms (SAMS), including myalgias, myositis, and rhabdomyolysis, are rare but require prompt statin cessation and evaluation for reversible causes 1.
- All currently marketed statins, including lovastatin, simvastatin, pravastatin, fluvastatin, and atorvastatin, appear to have a similar potential for causing myopathy, with an incidence of severe myopathy reported to be around 0.08% to 0.09% 1.
- However, pitavastatin has been shown to have a lower risk of myopathy, with muscle-related symptoms occurring in 2.3% of patients in the REPRIVE trial 1.
From the Research
Statin-Associated Myopathy
The risk of myopathic effects varies among different statins, with some having a lower risk than others.
- Pravastatin and fluvastatin are considered to have a lower risk of myopathy compared to other statins, as they are not metabolized by the cytochrome P-450 (CYP) 3A4 pathway 2.
- The risk of myopathy is also influenced by individual demographic features, genetic factors, and co-morbidities, as well as physicochemical properties of statins and pharmacokinetic interactions with concomitant medications 3.
Comparison of Statins
While all statins can cause myopathic effects, the incidence and severity of these effects vary among different statins.
- Cerivastatin, which was withdrawn from the market, had a higher risk of rhabdomyolysis compared to other statins 2.
- Other statins, such as pravastatin and fluvastatin, are considered to have a lower risk of myopathy, but the exact incidence and severity of myopathic effects can vary depending on individual patient factors and concomitant medications 2, 3.
Management of Statin-Associated Myopathy
The management of statin-associated myopathy involves identifying patients at high risk of myopathy, monitoring for signs and symptoms of myopathy, and adjusting statin therapy as needed.
- Patients who experience muscle symptoms or elevated creatine kinase levels should be evaluated for myopathy, and statin therapy should be adjusted or discontinued if necessary 4, 5.
- In some cases, alternative lipid-lowering therapies may be necessary to manage cholesterol levels while minimizing the risk of myopathy 4, 5.