management of statin induced myopathy
Last edited 08/2020 and last reviewed 06/2023
- undertake diagnostic workup as described
- if the workup suggests a neurologic, rheumatolic or metabolic aetiology, a referral to a specialist is indicated
- if myopathy with multiple statin challenges then specialist advice should be sought
- use of a statin holiday
- a 6-week 'statin holiday' may be used to see if symptoms of myopathy
resolve
- some give these patient supplements of 600 mg daily of a bioavailable source of coenzyme Q10 and fish oil during this statin holiday (1)
- if symptoms persist or if resolution is unclear at 6 weeks, extend
the holiday for an additional 6 weeks, except in patients with recent
unstable coronary disease:
- for these patients, unless there is evidence of rhabdomyolysis, we believe that the benefits of continued statin therapy exceed the risks (1)
- a 6-week 'statin holiday' may be used to see if symptoms of myopathy
resolve
- once the myopathy symptoms have abated or are controlled, a rechallenge
of statin therapy is in order for those whose risk profile suggests greater
benefit from statin therapy (note a statin rechallenge is not appropriate
if there has been evidence of statin-induced rhabdomyolysis)
- long acting fluvastatin or a statin with less cytochrome P 450 dependence, such as pravastatin, are often the first line if previous statin-induced myopathy
- if myopathy has recurred with multiple statin rechallenges or whose
lipid-lowering goal requires a more potent therapy, rosuvastatin in alternate-day
or once- or twice-a-week schedules is efficacious and well tolerated in
many patients
- however, although such alternate-day therapies may produce excellent reductions in cholesterol levels, these regimens have not been proven to reduce cardiovascular end points
- alternative therapies may require seeking specialist advice but include:
- ezetimibe
- bile sequestrants
- fibrates
- nicotinic acid
- PCSK9 inhibitors
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