Expert opinion: the therapeutic challenges faced by statin intolerance

ABSTRACT

Introduction: Statin intolerance is largely defined by muscle related symptoms, leading to intolerability and cessation. The nocebo effect coupled with the challenges of diagnosing statin myopathy undermines drug adherence that is critical for achieving the benefits of lipid-lowering and cardiovascular risk reduction. A temporal relationship should be made between the initiation of therapy and development of symptoms to aid in diagnosis. The mainstay of treatment is statin cessation or statin dose reduction and evaluation of alternative causes for muscle related symptoms. Most symptoms usually resolve within 2 weeks of discontinuing therapy. The patient can be re-challenged with the same statin at a lower dose or an alternative statin. Non-statin lipid lowering therapies offer an alternative to patients who cannot tolerate statins.

Areas covered: We discuss current guideline-focused management of patients with statin intolerance.

Expert opinion: When initiating statin therapy, attention to risk factors for statin intolerance is strongly recommended. Most patients will tolerate some degree of statin therapy; thus statin re-challenge is advisable. If alternative dosing regimens are not tolerated, non-statin medications are acceptable alternatives. To limit errors in the diagnosis of statin intolerance, improvements in clinician-patient communication about the side effects and benefits of statins should be attempted.

KEYWORDS:

• Intolerance
• myopathy
• statin
• cardiovascular
• prevention

Article highlights

• Statin intolerance is the inability to tolerate at least two different statins - one statin at the lowest starting daily dose and a second statin at any dose.

• Contraindications and drug interactions should be assessed prior to initiating statin therapy.

• Lower dose, alternative, or intermittent statin dosing regimens is advisable in statin intolerance.

• Ezetimibe is recommended as a non-statin based option in statin intolerance.

• PCSK9 inhibitors may be a potential alternative for patients with persistent intolerance.

• Effective patient-provider communication will improve statin adherence and outcomes.This box summarizes key points contained in this article.

Declaration of interest

S.S. Martin reports grants from the PJ Schafer Cardiovascular Research Fund, American Heart Association, Aetna Foundation, and Google, outside the submitted work. He has received honoraria from the American College of Cardiology for dyslipidemia-related educational activities. In addition, S.S Martin is listed as a co-inventor on a pending patent filed by Johns Hopkins University for a novel method of LDL-C estimation. M. Banach has given lectures, received honoraria, and participated in conferences, advisory boards and clinical trials sponsored by Abbott, Abbott Vascular, Amgen, Daiichi-Sankyo, Esperion, KRKA, Merck Sharp & Dohme, Resverlogix Cooperation, and Sanofi-Regeneron. He has also received the grant support from Pfizer and Valeant. The authors have no other relevant affiliations or financial involvement with any organization or entity with a financial interest in or financial conflict with the subject matter or materials discussed in the manuscript apart from those disclosed.