From the Guidelines
A statin might be held inpatient due to potential drug-drug interactions, acute illness, or elevated liver enzymes, as recommended by the American Heart Association in 2016 1. When considering holding a statin in an inpatient setting, several factors come into play. These include:
- Potential drug-drug interactions with other medications that the patient is taking, which can increase the risk of adverse effects such as myopathy and rhabdomyolysis
- Acute illness, which can also increase the risk of statin-associated adverse effects
- Elevated liver enzymes, such as ALT or AST greater than 3 times the upper limit of normal, which may require temporary discontinuation of statins
- Acute kidney injury or symptoms of myopathy, such as muscle pain, weakness, or tenderness with elevated creatine kinase levels
- Starting medications with significant interaction potential, such as certain antifungals, macrolide antibiotics, or immunosuppressants The decision to hold a statin should be based on a thorough review of the patient's medications and medical history, as well as careful consideration of the potential risks and benefits, as outlined in the American Heart Association's 2016 scientific statement 1. Key considerations include:
- The dose limits and adverse effects associated with statin drug-drug interactions
- The monitoring parameters necessary to minimize toxicity
- The potential need for dose adjustments, changing to a safer statin medication, or discontinuing statins when necessary Ultimately, the goal is to balance the short-term risks against the long-term cardiovascular benefits of statin therapy, with plans to resume therapy once the acute condition resolves or interacting medications are discontinued, as recommended by the American Heart Association 1.
From the Research
Reasons for Holding Statin Therapy Inpatient
- Adverse effects, such as liver enzyme abnormalities or muscle toxicity, may necessitate holding statin therapy inpatient for close monitoring and management 2, 3.
- Patients with certain underlying conditions, such as liver disease or chronic kidney disease, may require careful consideration and potential adjustment of statin therapy, which can be done in an inpatient setting 4, 2.
- In cases of severe statin-associated muscle symptoms (SAMSs), such as rhabdomyolysis, inpatient management may be necessary to ensure prompt treatment and prevent further complications 3, 5.
- Drug interactions with other medications, such as fibrates, diltiazem, verapamil, and amiodarone, can increase the risk of adverse effects and may require inpatient monitoring and adjustment of statin therapy 2.
- Patients undergoing vascular surgery or with acute coronary syndromes may require peri-operative statin therapy, which can be initiated and monitored in an inpatient setting 6.