What is the significance of elevated Creatine Kinase (CK) levels, currently at 248, in a 70-year-old male who discontinued atorvastatin (Lipitor) 3 weeks ago due to initial elevated CK levels of 217?

From the Guidelines

I strongly advise against restarting atorvastatin at this time, given the patient's CK levels have increased to 248 since discontinuation, indicating a potential ongoing muscle injury. For a 70-year-old male with these findings, it is crucial to investigate other potential causes of the elevated CK beyond statin therapy, as suggested by the 2019 guideline on the management of blood cholesterol 1. Consider checking thyroid function, assessing for recent physical exertion, muscle trauma, or other medications that might cause myopathy. The guideline highlights that myositis/myopathy (CK > ULN) with concerning symptoms or objective weakness is rare but requires prompt statin cessation and evaluation for reversible causes 1.

Key considerations in this case include:

• The patient's age and potential comorbidities that could predispose him to statin-associated muscle symptoms (SAMS) or more severe conditions like myositis or rhabdomyolysis, as outlined in the guideline 1.
• The fact that CK levels have not decreased but instead increased since atorvastatin was stopped, suggesting either a delayed recovery from statin-induced muscle injury or an alternative etiology for the muscle enzyme elevation.
• The importance of a comprehensive evaluation of musculoskeletal symptoms before lipid-lowering therapy with a statin is initiated, including documentation of baseline symptoms and identification of predisposing factors for SAMS, as recommended by the guideline 1.

Once the CK normalizes (typically below 200 U/L), you could consider reintroducing a different statin at a lower dose, such as rosuvastatin 5mg or pravastatin 10mg, which are generally less myotoxic. During this period, maintain cardiovascular risk reduction through other means such as diet modification, exercise as tolerated, and other lipid-lowering medications if indicated. Weekly CK monitoring would be reasonable until levels normalize before considering any statin rechallenge, ensuring that the patient's muscle injury has resolved and minimizing the risk of further complications.

From the FDA Drug Label

Myopathy and Rhabdomyolysis: Risk factors include age 65 years or greater, uncontrolled hypothyroidism, renal impairment, concomitant use with certain other drugs, and higher atorvastatin calcium dosage. Discontinue atorvastatin calcium tablets if markedly elevated CK levels occur or myopathy is diagnosed or suspected Discontinue atorvastatin calcium tablets if markedly elevated CK levels occur or myopathy is diagnosed or suspected

The patient is a 70-year-old male who stopped atorvastatin 3 weeks ago due to a CK level of 217, and today his CK level is 248.

• The patient's age is a risk factor for myopathy.
• The patient's CK levels are elevated, even after stopping atorvastatin. Given the elevated CK levels and the patient's age, it is likely that the patient has myopathy or rhabdomyolysis. Discontinue atorvastatin calcium tablets if markedly elevated CK levels occur or myopathy is diagnosed or suspected 2, 2, 2.

From the Research

Patient's Condition

• The patient is a 70-year-old male who stopped taking atorvastatin 3 weeks ago due to a creatine kinase (CK) level of 217.
• The patient's CK level has increased to 248 after stopping atorvastatin.

Statin Therapy and CK Levels

• A study published in 2009 3 found that high pretreatment CK levels, particularly 1 to 5 times the upper limit of normal (UNL), should not be an impediment to starting or continuing statins to lower low-density lipoprotein cholesterol (LDL-C).
• The study showed that patients with high CK levels (>or=250 but <2500 IU/L) tolerated statins well at doses reducing LDL-C to target, without development of myalgia-myositis.
• Another study published in 2010 4 found that simvastatin use was associated with a higher likelihood of CK elevation (>or =10x ULN) than lovastatin, and high-dose simvastatin conferred a greater risk than lower doses of either simvastatin or lovastatin.

Atorvastatin and Ezetimibe Combination

• A study published in 2019 5 found that the combination of ezetimibe and atorvastatin is effective in reducing atherogenic lipids and is well tolerated.
• Another study published in 2022 6 compared the efficacy and tolerability of a fixed-dose combination of ezetimibe/atorvastatin with atorvastatin monotherapy in Chinese patients with hypercholesterolemia and found that the combination therapy was more effective in reducing LDL-C levels.

Considerations for the Patient

• The patient's increased CK level after stopping atorvastatin may not necessarily be a contraindication for restarting statin therapy, as some studies suggest that high CK levels can be tolerated with statin use 3.
• The combination of ezetimibe and atorvastatin may be a viable option for the patient, considering its efficacy and tolerability in reducing LDL-C levels 5, 6.