March 28, 2023

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Today we’re going to be talking about statins and the possible adverse reaction of my algebra and why it’s so important to know about this average reaction is because standards are going to be given all the time especially used in the primary and secondary prevention of coronary disease now statins are also going to be the only lipid lowering medication that

Has proven reduction in the patient’s mortality they work by inhibiting hmg coa to mevalonic acid now the reason or the thought as to why muscular injury occurs are really going to be three schools of thoughts here this one is going to be the reduction or the inhibition of the synthesis of coq10 decreased mitochondrial function and finally altered muscle protein

Degradation now these are the three theories as to why muscular injury occurs but again it’s not really known as to why this exactly occurs all right now let’s go over a few definitions here now myalgia means that we have muscular discomfort with or soon after exercise so we’re going to have soreness cramping things of that nature and we normally or we should have

A normal ck level myopathy means we have muscular weakness with or without increased ck levels myositis means muscle inflammation myonecrosis means we have an elevation in ck levels and there’s going to be varying degrees here mild is going to be when we have a 3 to 10 x elevation of ck moderate is when we have 10 to 50 times elevation and a severe myonecrosis is

Going to be we have over 50 times the elevation of ck finally we have rhabdomyolysis this is going to be myonecrosis with myoglobinuria or acute renal failure now the reason why there’s so much controversy as to whether this actually exists or not is because when we look at all the studies when we look at all the trials there is no evidence that statins actually

Cause muscular injury the problem is a lot of clinicians will report that their patients complain of muscular injury such as soreness tenderness weakness cramping when placed on a statin so the evidence doesn’t really show this but we have anecdotal evidence that says otherwise so this is why there’s a debate as to whether they do or do not cause muscular injury

Now there are certain things that are going to increase the risk of having this and really when we look at muscular disorders we’re going to be noticing that they’re going to be exacerbation of symptoms when placed on a statin and we also noticed that when we have elevated cholesterol levels for example when talking about diseases like als we actually have a

Prolonged lifespan in als when we have elevated levels of cholesterol which is why it’s often recommended to take patients off a statin when they have these types of neuromuscular disease processes now when looking at all the data pravastatin and fluvastatin are probably going to be those that are associated with the least amount of risk of developing muscular

Injury we also have to look out for other disease processes like hypothyroidism vitamin d deficiency obstructive pulmonary disease chronic and acute renal failure and medications that inhibit cytochrome p450 and or combining statins with fibroids these are all going to increase the risk of developing muscular injury myalgia myopathy and things of that nature now

When looking at this clinically patients are often going to report muscular weakness or soreness in the proximal large muscle groups such as the legs they can also report feeling a difficulty of getting up from a seated position pain or weakness when raising the arms and or climbing stairs now we have to be careful about ck levels ck levels can really be elevated

In patients with hypothyroidism and in regular muscular injury that can occur with exercise so after running playing sports things of that nature we can have increased levels of ck and obviously we can have muscle soreness as well when this occurs can really happen at any time when the patient is on a statin but for the most part it’s going to be within a few

Weeks of initiating therapy to a few months and the likelihood of this being a statin related event really decreases after six months of therapy now if the patient is presenting with these symptoms and you feel like it might be statin induced then at this point we want to take the patient off the medication and do a trial run now if for whatever reason you also

Drew ck levels they happen to be 10 times the upper limit of normal but the patient is asymptomatic this is also an indication to take the patient off a stand and then recheck the ck levels down the road and see if they revert back to normal so if the patient is feeling this we take them off and then we reassess now if for whatever reason we notice that this is

Statin induced but the patient has to be on the standard for other pas for uh for other diseases like diabetes or they’ve had a previous mi and we really want to see if there’s something we can alter in their regimen to place them right back on the stand so things we might look at are going to be first drug drug interactions are they taking another medication that

Is going to increase the risk of myalgia or muscular injury if so we might want to change that medication if they’re on a fibrate like gem fibrazil then we might want to switch to phenofibrate because that’s going to be a better medication it’s going to decrease statin levels and decrease the risk of having muscular injury we’re also going to want to correct

Any hypothyroidism if the patient has hypothyroid that in itself is also going to cause my algebra muscular pain muscular weakness so we want to correct the tsh level we want to check for vitamin d deficiency patients with vitamin d vitamin d deficiency are going to be more at risk of developing muscular injury so replace with vitamin d and finally if all of

This you know has been done there’s still nothing we can try changing the medication to previous that and flusten because like we said these have the less likelihood of developing muscular injury let’s say we’ve done all this and the patient still has muscular pain well at that point then we can try doing alternate day dosing so instead of giving the statin every

Single day we alternate days where we do one day yes when they know one day yes the only problem with doing this alternate day regimen is if this actually changes the possibility of decreasing mortality all the studies normally do once a day dosing every single day dosing and this is what’s been proven in the studies to decrease mortality if we do alternate

Regimen day dosing we’re not sure if this is going to affect the patient’s mortality or not but if the patient has to be on a statin this is acceptable as well all right so that was today’s lecture on statins the adverse reaction of myalgia and how we can go about working this up and changing the regimen to decrease the incidence of having muscular injury

Transcribed from video
Do statins REALLY cause myalgia? By Medgeeks