Statin intolerance can lead to statin discontinuation or suboptimal therapy, thus it is crucial to identify patients that are exhibiting true statin-associated side effects, and address these symptoms accordingly. “The most important thing for identifying statin intolerance is obtaining a very thorough patient history. Statin intolerance or its symptoms can be induced by concurrent medications that the patients are taking; for instance, several cardiovascular drugs and antibiotics can interact with statins, leading to reduced statin elimination, and increasing the risk of statin intolerance. Also, patients on fenofibrates and statins, or with underlying muscle issues, are at an increased risk for statin-associated myalgia. We should ask patients how long after initiating statin therapy they experienced muscle aches or weakness; if they report pain after just one dose than most likely it is not true statin intolerance, but if the pain appears a month after starting statins, is persistent and affects the patients’ quality of life, then we may think about the possibility of true statin intolerance. Therefore, it becomes crystal clear that getting to know the medical history of the patient before stopping or modifying statin therapy is very crucial as there is no simple test or a questionnaire to determine statin intolerance. ” – said Dr. Cho.
Very frequently, in patients with statin intolerance, it may be advisable to change the dose, switch to a different statin, or try an alternate-day regimen.12 “The lipophilicity and hydrophilicity of statins plays an important role, as hydrophilic statins such as rosuvastatin and pravastatin are less likely to cause muscle aches than lipophilic statins such as simvastatin and atorvastatin. In our clinic, we often start with rosuvastatin once a week with the lowest dose, if the patient can tolerate it, we go to twice a week usually Monday and Thursday and then escalate the dose or the frequency depending upon their performance” – said Dr. Cho, while further adding “in our own study at the Cleveland Clinic12 of more than 1600 patients that were intolerant to two or more statins, intermittent dosing was effective to achieve LDL-C goals and keep patients on statins; 72.5% of them could tolerate some form of long-term statin therapy, with 63.2% on a daily regimen, and 9.3% on intermittent dosiing, while 27.5% were statin-intolerant. Remarkably, the GAUSS-3 trial13, which was a statin intolerance study with the PCSK9 inhibitor evolocumab, echoed our findings, reporting that about 40% of patients population had true statin intolerance.”