From the Guidelines
The patient is at greatest risk for myopathy (muscle damage) if he starts high-intensity rosuvastatin therapy. According to the 2013 ACC/AHA guideline on the treatment of blood cholesterol to reduce atherosclerotic cardiovascular risk in adults 1, statins, particularly at high doses, can cause muscle-related adverse effects ranging from mild myalgia (muscle pain) to severe rhabdomyolysis. This risk is increased in this 62-year-old patient due to several factors, including his age, potential drug interactions between rosuvastatin and amlodipine, and obesity (BMI 33 kg/m²).
Key Factors Increasing Risk
- Age over 60 years increases statin-related muscle toxicity risk
- Potential drug interactions between rosuvastatin and amlodipine may increase statin blood levels
- Obesity (BMI 33 kg/m²) may contribute to increased risk
Presentation and Monitoring
Myopathy typically presents as muscle pain, tenderness, or weakness, sometimes accompanied by elevated creatine kinase levels. If the patient experiences these symptoms after starting rosuvastatin, dose reduction or switching to a different statin might be necessary. Regular monitoring of muscle symptoms and liver function tests is important during the initial months of therapy and after any dose increases, as recommended by the guideline 1.
Additional Considerations
The guideline also suggests that baseline measurement of hepatic transaminase levels (ALT) should be performed before initiation of statin therapy, and during statin therapy, it is reasonable to measure hepatic function if symptoms suggesting hepatotoxicity arise 1. However, myopathy remains the primary concern in this patient given the factors mentioned.
From the FDA Drug Label
Risk Factors for Myopathy Risk factors for myopathy include age 65 years or greater, uncontrolled hypothyroidism, renal impairment, concomitant use with certain other drugs (including other lipid-lowering therapies), and higher rosuvastatin dosage. The myopathy risk is greater in patients taking rosuvastatin 40 mg daily compared with lower rosuvastatin dosages.
The patient is at greatest risk for myopathy if he starts high-intensity rosuvastatin therapy, as he is 62 years old, which is close to the age of 65 or greater that is considered a risk factor for myopathy. Although his age is not exactly 65 or greater, it is still a consideration, and other factors such as the high-intensity dosage may contribute to the risk. 2
From the Research
Adverse Effects of Rosuvastatin Therapy
The patient is at greatest risk for the following adverse effects if he starts high-intensity rosuvastatin therapy:
- Myopathy, ranging from common but clinically benign myalgia to rare but life-threatening rhabdomyolysis 3, 4, 5, 6
- Renal failure, as higher doses of rosuvastatin have been associated with cases of renal failure 7
- Asymptomatic liver enzyme elevations, which occur with rosuvastatin at a similarly low incidence as with other statins 7
- Adverse effects related to the gastrointestinal tract and central nervous system, which are also commonly observed with many other drugs 7
- Proteinuria induced by rosuvastatin, likely associated with a statin-provoked inhibition of low-molecular-weight protein reabsorption by the renal tubules 7
Risk Factors for Adverse Effects
The patient's risk factors for adverse effects include:
- Advanced age, as statin-induced myopathy appears to be more common in older patients 3, 6
- High dosage of rosuvastatin, as the risk of myopathy and renal failure is dose-dependent 3, 6, 7
- Potential drug-drug interactions, as the patient is taking other medications that may increase the risk of rosuvastatin-associated toxicity 7