A patient with ASCVD risk 12.9% who started rosuvastatin 10 mg daily three weeks ago now reports bilateral knee joint aches; recent labs show total cholesterol 229 mg/dL, LDL 150 mg/dL, triglycerides 104 mg/dL, HDL 58 mg/dL and a CMP/lipid panel is scheduled next week. How should I manage his statin therapy and knee pain?

Management of Bilateral Knee Joint Aches in a Patient on Rosuvastatin

Continue rosuvastatin 10 mg daily and evaluate for non-statin causes of knee pain, as bilateral knee arthralgia after only 3 weeks of therapy is unlikely to represent true statin-associated muscle symptoms (SAMS), which typically present as proximal muscle myalgias rather than isolated joint pain.

Immediate Assessment Required

Obtain creatine kinase (CK) level at next week's lab visit to objectively assess for muscle injury, as the ACC/AHA guidelines recommend measuring CK only in patients with severe muscle symptoms or objective weakness 1. However, given the patient's concern and upcoming lab work, this provides objective data to guide management.

• Conduct a thorough symptom assessment focusing on whether the pain is truly muscular (proximal muscle groups, weakness, difficulty climbing stairs) versus articular (joint-specific, worse with weight-bearing, no weakness) 1.
• Evaluate for non-statin causes including recent changes in physical activity, new medications, underlying inflammatory arthritis, or osteoarthritis exacerbation 1.
• Assess for predisposing factors that increase SAMS risk: hypothyroidism, vitamin D deficiency, concurrent medications (fibrates, niacin), renal impairment, or excessive alcohol use 1.

Why This is Likely NOT Statin-Associated Muscle Symptoms

• Location is atypical: True SAMS typically affects proximal muscle groups (thighs, shoulders, back) with diffuse myalgias, not isolated bilateral knee joints 1.
• Timing is early but possible: While SAMS can occur within weeks, the 3-week timeframe with joint-specific symptoms raises suspicion for alternative etiologies 2.
• Rosuvastatin 10 mg is moderate-intensity: This dose has a favorable safety profile with myopathy rates <0.1% in clinical trials 3.

Management Algorithm Based on CK Results

If CK is Normal (<5× Upper Limit Normal) and Symptoms are Mild:

Continue rosuvastatin 10 mg daily without modification, as this patient has a clear indication for statin therapy (12.9% ASCVD risk) and the benefits substantially outweigh risks 1.

• Reassure the patient that isolated knee pain is unlikely statin-related and investigate alternative causes (osteoarthritis, activity-related) 1.
• Emphasize adherence as nonadherence due to misattributed symptoms is a major pitfall that increases cardiovascular risk 1.
• Recheck symptoms in 2-4 weeks while addressing any identified non-statin causes 1.

If CK is Elevated (5-10× ULN) or Symptoms Progress:

Consider a modified statin regimen rather than discontinuation, as the ACC/AHA guidelines emphasize that most patients can tolerate statin rechallenge 1.

• Option 1: Switch to rosuvastatin 10 mg every-other-day, which maintains 70% of patients at LDL-C goal with improved tolerability and 38% cost reduction 4.
• Option 2: Switch to atorvastatin 10 mg daily (equivalent moderate-intensity), as rosuvastatin may have slightly higher ADR rates in some populations 5.
• Option 3: Continue rosuvastatin 10 mg with added coenzyme Q10 supplementation—though not recommended by ACC/AHA guidelines as evidence does not support efficacy for SAMS prevention 1.

If CK is Severely Elevated (>10× ULN):

Immediately discontinue rosuvastatin and evaluate for rhabdomyolysis (check renal function, urine myoglobin) 2.

• After CK normalizes, rechallenge with a different statin at lower intensity or consider non-statin therapy (ezetimibe) given the patient's intermediate ASCVD risk 1.

Addressing the Lipid Management

The patient's current LDL-C of 150 mg/dL requires continued treatment as the target is ≥30% reduction from baseline (from 150 mg/dL to ≤105 mg/dL) with moderate-intensity therapy 1.

• Rosuvastatin 10 mg should achieve 39-48% LDL-C reduction based on clinical trial data, bringing LDL-C to approximately 78-92 mg/dL 3, 4.
• Assess adherence and response at 4-12 weeks (next visit) per ACC/AHA guidelines 1.
• If LDL-C remains ≥100 mg/dL on maximally tolerated statin, consider adding ezetimibe 10 mg daily, which provides additional 15-20% LDL-C reduction 6.

Critical Pitfalls to Avoid

• Do not discontinue statin therapy prematurely based on subjective symptoms without objective evidence (elevated CK) or thorough evaluation of alternative causes, as this increases cardiovascular risk 1.
• Do not ignore the patient's concerns—validate symptoms, investigate thoroughly, but educate that isolated joint pain is unlikely statin-related 1.
• Do not forget concurrent risk factor management—ensure blood pressure control, smoking cessation, diabetes management, and lifestyle modifications are optimized 1.
• Do not prescribe coenzyme Q10 as ACC/AHA guidelines explicitly state it is not recommended for routine use or SAMS treatment 1.

Next Week's Visit Action Plan

1. Review CMP results for renal function, liver enzymes, and glucose 2.
2. Check CK level to objectively assess muscle injury 1.
3. Review lipid panel to assess rosuvastatin efficacy (expect 39-48% LDL-C reduction from baseline 150 mg/dL) 3.
4. Perform focused musculoskeletal exam of knees to differentiate articular versus muscular symptoms 1.
5. If all labs normal and symptoms mild, continue current therapy and address alternative causes of knee pain 1.
6. If symptoms severe or CK elevated, implement modified statin regimen per algorithm above 1.