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Rastegar TF, Khan IA, Christopher-Stine L. Decoding the Intricacies of Statin-Associated Muscle Symptoms. Curr Rheumatol Rep 2024; 26:260-268. [PMID: 38575845 DOI: 10.1007/s11926-024-01143-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/21/2024] [Indexed: 04/06/2024]
Abstract
PURPOSE OF REVIEW Hyperlipidemia is the major cardiovascular morbidity and mortality risk factor. Statins are the first-line treatment for hyperlipidemia. Statin-associated muscle symptoms (SAMS) are the main reason for the discontinuation of statins among patients. The purpose of this review is to guide clinicians to recognize the difference between self-limited and autoimmune statin myopathy in addition to the factors that potentiate them. Finally, treatment strategies will be discussed. This review mostly focuses on new data in the past 3 years. RECENT FINDINGS Recent findings suggest that SAMS is a complex and multifactorial condition that involves mitochondrial dysfunction, oxidative stress, and immune-mediated mechanisms. Effective management of SAMS requires a thorough evaluation of the patient's symptoms, risk factors, and medication history, as well as consideration of alternative treatment options. While statins are effective in reducing the risk of cardiovascular events, their use is associated with a range of adverse effects, including SAMS.
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Affiliation(s)
- Tara Fallah Rastegar
- Johns Hopkins Myositis Center, Division of Rheumatology, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Imtiaz Ahmed Khan
- Department of Internal Medicine, Texas Tech University Health Science Center, Amarillo, TX, USA
| | - Lisa Christopher-Stine
- Johns Hopkins Myositis Center, Division of Rheumatology, Johns Hopkins University School of Medicine, Baltimore, MD, USA.
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2
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Peyrel P, Mauriège P, Frenette J, Laflamme N, Greffard K, Dufresne SS, Huth C, Bergeron J, Joanisse DR. No benefit of vitamin D supplementation on muscle function and health-related quality of life in primary cardiovascular prevention patients with statin-associated muscle symptoms: A randomized controlled trial. J Clin Lipidol 2024; 18:e269-e284. [PMID: 38177036 DOI: 10.1016/j.jacl.2023.12.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/28/2023] [Revised: 12/11/2023] [Accepted: 12/12/2023] [Indexed: 01/06/2024]
Abstract
BACKGROUND Statins are the leading lipid-lowering drugs, reducing blood cholesterol by controlling its synthesis. Side effects are linked to the use of statins, in particular statin-associated muscle symptoms (SAMS). Some data suggest that vitamin D supplementation could reduce SAMS. OBJECTIVE The purpose of this study was to evaluate the potential benefits of vitamin D supplementation in a randomized controlled trial. METHODS Men (n = 23) and women (n = 15) (50.5 ± 7.7 years [mean ± SD]) in primary cardiovascular prevention, self-reporting or not SAMS, were recruited. Following 2 months of statin withdrawal, patients were randomized to supplementation (vitamin D or placebo). After 1 month of supplementation, statins were reintroduced. Before and 2 months after drug reintroduction, muscle damage (creatine kinase and myoglobin) was measured. Force (F), endurance (E) and power (P) of the leg extensors (ext) and flexors (fle) and handgrip strength (FHG) were also measured with isokinetic and handheld dynamometers, respectively. The Short Form 36 Health Survey (SF-36) questionnaire and a visual analog scale (VAS) were administrated to assess participants' self-reported health-related quality of life and SAMS intensity, respectively. Repeated-measures analysis was used to investigate the effects of time, supplementation, and their interaction, according to the presence of SAMS. RESULTS Despite no change for objective measures, subjective measures worsened after reintroduction of statins, independent of supplementation (VAS, SF-36 mental component score, all p < 0.05). However, no interaction between time and supplementation according to the presence of SAMS was observed for any variables. CONCLUSIONS Vitamin D supplementation does not appear to mitigate SAMS.
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Affiliation(s)
- Paul Peyrel
- Department of Kinesiology, Université Laval, Québec, QC G1V 0A6, Canada (Peyrel, Mauriège, Huth, and Joanisse); Research Center of the University Institute of Cardiology and Pulmonology of Quebec, Québec, QC G1V 4G5, Canada (Peyrel, Mauriège, Huth, and Joanisse)
| | - Pascale Mauriège
- Department of Kinesiology, Université Laval, Québec, QC G1V 0A6, Canada (Peyrel, Mauriège, Huth, and Joanisse); Research Center of the University Institute of Cardiology and Pulmonology of Quebec, Québec, QC G1V 4G5, Canada (Peyrel, Mauriège, Huth, and Joanisse)
| | - Jérôme Frenette
- CHU de Québec - Université Laval Research Center, Québec, QC G1V 4G2, Canada (Frenette, Laflamme, Greffard, and Bergeron); Department of Rehabilitation, Université Laval, Québec, QC G1V 0A6, Canada (Frenette)
| | - Nathalie Laflamme
- CHU de Québec - Université Laval Research Center, Québec, QC G1V 4G2, Canada (Frenette, Laflamme, Greffard, and Bergeron)
| | - Karine Greffard
- CHU de Québec - Université Laval Research Center, Québec, QC G1V 4G2, Canada (Frenette, Laflamme, Greffard, and Bergeron)
| | - Sébastien S Dufresne
- Department of Health Sciences, Université du Québec à Chicoutimi, Saguenay, QC G7H 2B1, Canada (Dufresne)
| | - Claire Huth
- Department of Kinesiology, Université Laval, Québec, QC G1V 0A6, Canada (Peyrel, Mauriège, Huth, and Joanisse); Research Center of the University Institute of Cardiology and Pulmonology of Quebec, Québec, QC G1V 4G5, Canada (Peyrel, Mauriège, Huth, and Joanisse)
| | - Jean Bergeron
- CHU de Québec - Université Laval Research Center, Québec, QC G1V 4G2, Canada (Frenette, Laflamme, Greffard, and Bergeron); Departments of Laboratory Medicine and of Specialized Medicine, Université Laval, Québec, QC G1V 0A6, Canada (Bergeron)
| | - Denis R Joanisse
- Department of Kinesiology, Université Laval, Québec, QC G1V 0A6, Canada (Peyrel, Mauriège, Huth, and Joanisse); Research Center of the University Institute of Cardiology and Pulmonology of Quebec, Québec, QC G1V 4G5, Canada (Peyrel, Mauriège, Huth, and Joanisse).
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Carallo C, Capozza A, Gnasso A. Effects of Vitamin D Supplementation in Patients with Statin-Associated Muscle Symptoms and Low Vitamin D Levels. Metab Syndr Relat Disord 2022; 20:567-575. [PMID: 36346279 DOI: 10.1089/met.2021.0127] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022] Open
Abstract
Background: Statin therapy is a cornerstone of cardiovascular disease treatment and prevention. Unfortunately, 7%-29% of statin-treated patients complain of muscular fatigue, cramps, and/or pain (statin-associated muscle symptoms [SAMS]). In recent years, the important role of vitamin D in muscle health maintenance has been highlighted. In addition, hypovitaminosis D is very prevalent, and might be a reversible risk factor for SAMS occurrence. Methods: In our controlled intervention study, patients suffering from both SAMS and hypovitaminosis D underwent vitamin D replacement for 6 months. SAMS intensity and its impact on the quality of life were evaluated with a questionnaire during follow-up. A subgroup of patients who were not at the low-density lipoprotein cholesterol (LDL-C) target attempted a statin rechallenge after 3 months. Control subjects, with SAMS only, were not treated. Results: Blood vitamin D levels reached 261% of baseline values. Pain intensity was reduced by 63%, and all life quality indicators improved. At follow-up, percentage variations in SAMS intensity and in vitamin D levels were inversely related (r = 0.57, P = 0.002). In a multiple regression analysis, this association was found to be independent. Among the rechallenge subgroup, 75% successfully tolerated high-intensity statins during the follow-up. The parameters of interest were unchanged in control subjects. Conclusions: In our findings, the amount of increase in vitamin D concentrations is directly related to SAMS improvement. Although randomized studies are needed, 25(OH)D levels can be measured, and eventually supplemented, in all patients suffering from SAMS, and this can be done together with a statin rechallenge after 3 months for patients who are not at the LDL-C target. Register: The study protocol was registered with the EudraCT clinical trial register [ID: 2019-003250-83] in date April 8, 2020.
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Affiliation(s)
- Claudio Carallo
- Metabolic Diseases Unit, Department of Clinical and Experimental Medicine, "Magna Graecia" University, Catanzaro, Italy
| | - Alessandro Capozza
- Metabolic Diseases Unit, Department of Clinical and Experimental Medicine, "Magna Graecia" University, Catanzaro, Italy
| | - Agostino Gnasso
- Metabolic Diseases Unit, Department of Clinical and Experimental Medicine, "Magna Graecia" University, Catanzaro, Italy
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Triple Jeopardy: Rapidly Progressive Glomerulonephritis Induced by Triple Seropositive Disease—A Rare Case. Case Rep Med 2022; 2022:2032525. [PMID: 36419545 PMCID: PMC9678450 DOI: 10.1155/2022/2032525] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/25/2022] [Revised: 10/22/2022] [Accepted: 11/04/2022] [Indexed: 11/15/2022] Open
Abstract
The double-positive disease is the co-occurrence of antiglomerular basement membrane (anti-GBM) disease and antineutrophil cytoplasmic antibodies (ANCAs) and is an uncommon cause of renal failure. Our case of triple-positive disease is an even rarer cause of isolated renal failure, as it includes anti-GBM, antimyeloperoxidase (MPO), and antiproteinase 3 (PR3). We present a case of a 62-year-old Caucasian male with a history of multiple comorbidities, who presented to the emergency department (ED) with worsening dyspnea on exertion that started about one month prior to admission. He was found to be in renal failure secondary to triple-positive disease. We believe that the likely mechanism of our patient's triple-positive disease was a drug-induced ANCA vasculitis overlapping with Goodpasture's syndrome. We believe our case to be a valuable addition to the literature as it is a rare overlap syndrome without a previously established disease course or etiology.
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Teo CB, Tan PY, Tay RYK, Khoo J, Watts GF, Loh WJ. Association Between Vitamin D Supplementation and Statin-Associated Muscle Symptoms: A Systematic Review. High Blood Press Cardiovasc Prev 2022; 29:337-351. [PMID: 35768686 DOI: 10.1007/s40292-022-00526-5] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/03/2022] [Accepted: 05/11/2022] [Indexed: 11/29/2022] Open
Abstract
INTRODUCTION Although low vitamin D levels are associated with statin-associated muscle symptoms (SAMS), it remains unclear if vitamin D supplementation leads to symptom improvement. AIM We performed a systematic review to evaluate the association of vitamin D supplementation with resolution of SAMS. METHODS We searched Medline (PubMed), Embase and Cochrane Library till 12 December 2021. Full length articles that reported on the association between vitamin D supplementation in adult patients with SAMS were included. RESULTS We identified 8 interventional studies comprising 669 participants. Majority of the participants were of Caucasian ethnicity and the mean age of participants ranged from 59.5 to 64.8 years old. The studies recruited patients with initial mean pre-treatment vitamin D levels ranging from 17.8 to 22.0ng/mL. Follow up duration ranged from 2 to 24 months and mean post-treatment vitamin D levels ranged from 34.3 to 56.0ng/mL. We found that vitamin D supplementation was associated with improved statin tolerance in 509 out of 606 (83.9%) patients across the 7 studies which reported patient numbers after supplementation (95% CI = 0.81-0.87, I2 = 72% n = 7). None of the studies were randomized controlled trials (RCTs) and hence placebo effect of vitamin D could not be ruled out. Nocebo effect of statin was also not assessed by any of the studies. CONCLUSION Vitamin D supplementation in patients with mild-moderate vitamin D insufficiency was associated with improvement of SAMS. However, quantitative efficacy analysis was not possible and this observed association is likely confounded by nocebo and placebo effects. RCTs are required to conclusively assess the utility of vitamin D supplementation in improving SAMS.
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Affiliation(s)
- Chong Boon Teo
- Yong Loo Lin School of Medicine, National University of Singapore, Singapore, Singapore
| | - Pek Yan Tan
- Yong Loo Lin School of Medicine, National University of Singapore, Singapore, Singapore
| | - Ryan Yong Kiat Tay
- Yong Loo Lin School of Medicine, National University of Singapore, Singapore, Singapore
| | - Joan Khoo
- Department of Endocrinology, Changi General Hospital, Singapore, Singapore
| | - Gerald F Watts
- School of Medicine, University of Western Australia, Perth, Australia.,Department of Cardiology, Royal Perth Hospital, Perth, Australia
| | - Wann Jia Loh
- Department of Endocrinology, Changi General Hospital, Singapore, Singapore.
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Hou Q, Pang C, Chen Y. Association Between Vitamin D and Statin-Related Myopathy: A Meta-analysis. Am J Cardiovasc Drugs 2022; 22:183-193. [PMID: 34296397 DOI: 10.1007/s40256-021-00492-8] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 07/06/2021] [Indexed: 02/03/2023]
Abstract
BACKGROUND Myopathy is the most widely reported statin-associated adverse event. Several studies have linked vitamin D deficiency with statin-related myopathy. OBJECTIVE This meta-analysis aimed to investigate whether adult patients with statin-related myopathy have a lower 25-hydroxyvitamin D (25OHD) level than patients without myopathy and whether statin-related myopathy in vitamin D-deficient patients can be improved by vitamin D supplementation. METHODS PubMed, EMBASE, and the Cochrane Central Register of Controlled Trials were searched until 28 September 2020. Original studies comparing the 25OHD levels of patients with and without myopathy or detecting the impact of vitamin D supplementation on statin-related muscular intolerance were included. Subgroup analyses based on the sample size and baseline 25OHD level were conducted. RESULTS This meta-analysis, based on nine cohort studies with a total of 2906 patients, revealed that the 25OHD level of patients with statin-related myopathy was significantly lower than that of patients without myopathy [weighted mean difference - 4.17 ng/mL; 95% confidence interval (CI) - 7.70 to - 0.63; p = 0.021]. The overall analysis from another four studies with 446 patients who were previously vitamin D deficient and reported statin-related muscular intolerance showed that the pooled tolerance rate of statins improved to 89% (95% CI 8692; p < 0.001) after vitamin D supplementation. CONCLUSIONS The present meta-analysis provides evidence that low 25OHD level is associated with statin-related myopathy and that exogenous vitamin D supplementation can improve statin-related muscular intolerance associated with low 25OHD level in most cases. Our findings may provide useful insight for the prevention and treatment of statin-related myopathy.
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Vinci P, Panizon E, Tosoni LM, Cerrato C, Pellicori F, Mearelli F, Biasinutto C, Fiotti N, Di Girolamo FG, Biolo G. Statin-Associated Myopathy: Emphasis on Mechanisms and Targeted Therapy. Int J Mol Sci 2021; 22:11687. [PMID: 34769118 PMCID: PMC8583847 DOI: 10.3390/ijms222111687] [Citation(s) in RCA: 42] [Impact Index Per Article: 14.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/08/2021] [Revised: 10/10/2021] [Accepted: 10/13/2021] [Indexed: 12/25/2022] Open
Abstract
Hyperlipidemia is a major risk factor for cardiovascular morbidity and mortality. Statins are the first-choice therapy for dyslipidemias and are considered the cornerstone of atherosclerotic cardiovascular disease (ASCVD) in both primary and secondary prevention. Despite the statin-therapy-mediated positive effects on cardiovascular events, patient compliance is often poor. Statin-associated muscle symptoms (SAMS) are the most common side effect associated with treatment discontinuation. SAMS, which range from mild-to-moderate muscle pain, weakness, or fatigue to potentially life-threatening rhabdomyolysis, are reported by 10% to 25% of patients receiving statin therapy. There are many risk factors associated with patient features and hypolipidemic agents that seem to increase the risk of developing SAMS. Due to the lack of a "gold standard", the diagnostic test for SAMS is based on a clinical criteria score, which is independent of creatine kinase (CK) elevation. Mechanisms that underlie the pathogenesis of SAMS remain almost unclear, though a high number of risk factors may increase the probability of myotoxicity induced by statin therapy. Some of these, related to pharmacokinetic properties of statins and to concomitant therapies or patient characteristics, may affect statin bioavailability and increase vulnerability to high-dose statins.
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Affiliation(s)
- Pierandrea Vinci
- Clinica Medica, Cattinara Hospital, Department of Medical Surgical ad Health Science, University of Trieste, 34149 Trieste, Italy; (E.P.); (L.M.T.); (C.C.); (F.P.); (F.M.); (N.F.); (F.G.D.G.); (G.B.)
| | - Emiliano Panizon
- Clinica Medica, Cattinara Hospital, Department of Medical Surgical ad Health Science, University of Trieste, 34149 Trieste, Italy; (E.P.); (L.M.T.); (C.C.); (F.P.); (F.M.); (N.F.); (F.G.D.G.); (G.B.)
| | - Letizia Maria Tosoni
- Clinica Medica, Cattinara Hospital, Department of Medical Surgical ad Health Science, University of Trieste, 34149 Trieste, Italy; (E.P.); (L.M.T.); (C.C.); (F.P.); (F.M.); (N.F.); (F.G.D.G.); (G.B.)
| | - Carla Cerrato
- Clinica Medica, Cattinara Hospital, Department of Medical Surgical ad Health Science, University of Trieste, 34149 Trieste, Italy; (E.P.); (L.M.T.); (C.C.); (F.P.); (F.M.); (N.F.); (F.G.D.G.); (G.B.)
| | - Federica Pellicori
- Clinica Medica, Cattinara Hospital, Department of Medical Surgical ad Health Science, University of Trieste, 34149 Trieste, Italy; (E.P.); (L.M.T.); (C.C.); (F.P.); (F.M.); (N.F.); (F.G.D.G.); (G.B.)
| | - Filippo Mearelli
- Clinica Medica, Cattinara Hospital, Department of Medical Surgical ad Health Science, University of Trieste, 34149 Trieste, Italy; (E.P.); (L.M.T.); (C.C.); (F.P.); (F.M.); (N.F.); (F.G.D.G.); (G.B.)
| | - Chiara Biasinutto
- SC Assistenza Farmaceutica, Cattinara Hospital, Azienda Sanitaria Universitaria Integrata di Trieste, 34149 Trieste, Italy;
| | - Nicola Fiotti
- Clinica Medica, Cattinara Hospital, Department of Medical Surgical ad Health Science, University of Trieste, 34149 Trieste, Italy; (E.P.); (L.M.T.); (C.C.); (F.P.); (F.M.); (N.F.); (F.G.D.G.); (G.B.)
| | - Filippo Giorgio Di Girolamo
- Clinica Medica, Cattinara Hospital, Department of Medical Surgical ad Health Science, University of Trieste, 34149 Trieste, Italy; (E.P.); (L.M.T.); (C.C.); (F.P.); (F.M.); (N.F.); (F.G.D.G.); (G.B.)
- SC Assistenza Farmaceutica, Cattinara Hospital, Azienda Sanitaria Universitaria Integrata di Trieste, 34149 Trieste, Italy;
| | - Gianni Biolo
- Clinica Medica, Cattinara Hospital, Department of Medical Surgical ad Health Science, University of Trieste, 34149 Trieste, Italy; (E.P.); (L.M.T.); (C.C.); (F.P.); (F.M.); (N.F.); (F.G.D.G.); (G.B.)
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Warren T, McAllister R, Morgan A, Rai TS, McGilligan V, Ennis M, Page C, Kelly C, Peace A, Corfe BM, Mc Auley M, Watterson S. The Interdependency and Co-Regulation of the Vitamin D and Cholesterol Metabolism. Cells 2021; 10:2007. [PMID: 34440777 PMCID: PMC8392689 DOI: 10.3390/cells10082007] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/02/2021] [Revised: 07/27/2021] [Accepted: 07/28/2021] [Indexed: 12/30/2022] Open
Abstract
Vitamin D and cholesterol metabolism overlap significantly in the pathways that contribute to their biosynthesis. However, our understanding of their independent and co-regulation is limited. Cardiovascular disease is the leading cause of death globally and atherosclerosis, the pathology associated with elevated cholesterol, is the leading cause of cardiovascular disease. It is therefore important to understand vitamin D metabolism as a contributory factor. From the literature, we compile evidence of how these systems interact, relating the understanding of the molecular mechanisms involved to the results from observational studies. We also present the first systems biology pathway map of the joint cholesterol and vitamin D metabolisms made available using the Systems Biology Graphical Notation (SBGN) Markup Language (SBGNML). It is shown that the relationship between vitamin D supplementation, total cholesterol, and LDL-C status, and between latitude, vitamin D, and cholesterol status are consistent with our knowledge of molecular mechanisms. We also highlight the results that cannot be explained with our current knowledge of molecular mechanisms: (i) vitamin D supplementation mitigates the side-effects of statin therapy; (ii) statin therapy does not impact upon vitamin D status; and critically (iii) vitamin D supplementation does not improve cardiovascular outcomes, despite improving cardiovascular risk factors. For (iii), we present a hypothesis, based on observations in the literature, that describes how vitamin D regulates the balance between cellular and plasma cholesterol. Answering these questions will create significant opportunities for advancement in our understanding of cardiovascular health.
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Affiliation(s)
- Tara Warren
- Northern Ireland Centre for Stratified Medicine, C-TRIC, Altnagelvin Hospital Campus, School of Biomedical Sciences, Ulster University, Derry BT47 6SB, UK; (T.W.); (R.M.); (T.S.R.); (V.M.); (M.E.); (C.P.); (C.K.)
| | - Roisin McAllister
- Northern Ireland Centre for Stratified Medicine, C-TRIC, Altnagelvin Hospital Campus, School of Biomedical Sciences, Ulster University, Derry BT47 6SB, UK; (T.W.); (R.M.); (T.S.R.); (V.M.); (M.E.); (C.P.); (C.K.)
| | - Amy Morgan
- Department of Chemical Engineering, Faculty of Science & Engineering, University of Chester, Parkgate Road, Chester CH1 4BJ, UK; (A.M.); (M.M.A.)
| | - Taranjit Singh Rai
- Northern Ireland Centre for Stratified Medicine, C-TRIC, Altnagelvin Hospital Campus, School of Biomedical Sciences, Ulster University, Derry BT47 6SB, UK; (T.W.); (R.M.); (T.S.R.); (V.M.); (M.E.); (C.P.); (C.K.)
| | - Victoria McGilligan
- Northern Ireland Centre for Stratified Medicine, C-TRIC, Altnagelvin Hospital Campus, School of Biomedical Sciences, Ulster University, Derry BT47 6SB, UK; (T.W.); (R.M.); (T.S.R.); (V.M.); (M.E.); (C.P.); (C.K.)
| | - Matthew Ennis
- Northern Ireland Centre for Stratified Medicine, C-TRIC, Altnagelvin Hospital Campus, School of Biomedical Sciences, Ulster University, Derry BT47 6SB, UK; (T.W.); (R.M.); (T.S.R.); (V.M.); (M.E.); (C.P.); (C.K.)
| | - Christopher Page
- Northern Ireland Centre for Stratified Medicine, C-TRIC, Altnagelvin Hospital Campus, School of Biomedical Sciences, Ulster University, Derry BT47 6SB, UK; (T.W.); (R.M.); (T.S.R.); (V.M.); (M.E.); (C.P.); (C.K.)
| | - Catriona Kelly
- Northern Ireland Centre for Stratified Medicine, C-TRIC, Altnagelvin Hospital Campus, School of Biomedical Sciences, Ulster University, Derry BT47 6SB, UK; (T.W.); (R.M.); (T.S.R.); (V.M.); (M.E.); (C.P.); (C.K.)
| | - Aaron Peace
- Cardiology Unit, Western Health and Social Care Trust, Altnagelvin Regional Hospital, Derry BT47 6SB, UK;
| | - Bernard M. Corfe
- Human Nutrition Research Centre, Institute of Cellular Medicine, William Leech Building, Medical School, Newcastle University, Framlington Place, Newcastle upon Tyne NE2 4HH, UK;
| | - Mark Mc Auley
- Department of Chemical Engineering, Faculty of Science & Engineering, University of Chester, Parkgate Road, Chester CH1 4BJ, UK; (A.M.); (M.M.A.)
| | - Steven Watterson
- Northern Ireland Centre for Stratified Medicine, C-TRIC, Altnagelvin Hospital Campus, School of Biomedical Sciences, Ulster University, Derry BT47 6SB, UK; (T.W.); (R.M.); (T.S.R.); (V.M.); (M.E.); (C.P.); (C.K.)
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[Diagnostics and treatment of statin-associated muscle symptoms]. Internist (Berl) 2021; 62:827-840. [PMID: 34143250 DOI: 10.1007/s00108-021-01059-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/04/2021] [Indexed: 10/21/2022]
Abstract
Statins are among the most frequently prescribed drugs in Germany. Their benefits in lowering cardiovascular risk are beyond dispute. Nevertheless, many patients complain of side effects from statin therapy, including statin-associated muscle symptoms (SAMS) in particular. Despite their relative frequency, it is difficult to objectively diagnose them, as the time until appearance of first symptoms, the nature of the complaints and the severity of muscle problems vary widely. This narrative review summarizes the causes of SAMS as well as new possibilities regarding their diagnosis and therapy.
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Izzo M, Carrizzo A, Izzo C, Cappello E, Cecere D, Ciccarelli M, Iannece P, Damato A, Vecchione C, Pompeo F. Vitamin D: Not Just Bone Metabolism but a Key Player in Cardiovascular Diseases. Life (Basel) 2021; 11:life11050452. [PMID: 34070202 PMCID: PMC8158519 DOI: 10.3390/life11050452] [Citation(s) in RCA: 17] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/26/2021] [Revised: 05/03/2021] [Accepted: 05/13/2021] [Indexed: 12/12/2022] Open
Abstract
Vitamin D is the first item of drug expenditure for the treatment of osteoporosis. Its deficiency is a condition that affects not only older individuals but also young people. Recently, the scientific community has focused its attention on the possible role of vitamin D in the development of several chronic diseases such as cardiovascular and metabolic diseases. This review aims to highlight the possible role of vitamin D in cardiovascular and metabolic diseases. In particular, here we examine (1) the role of vitamin D in diabetes mellitus, metabolic syndrome, and obesity, and its influence on insulin secretion; (2) its role in atherosclerosis, in which chronic vitamin D deficiency, lower than 20 ng/mL (50 nmol/L), has emerged among the new risk factors; (3) the role of vitamin D in essential hypertension, in which low plasma levels of vitamin D have been associated with both an increase in the prevalence of hypertension and diastolic hypertension; (4) the role of vitamin D in peripheral arteriopathies and aneurysmal pathology, reporting that patients with peripheral artery diseases had lower vitamin D values than non-suffering PAD controls; (5) the genetic and epigenetic role of vitamin D, highlighting its transcriptional regulation capacity; and (6) the role of vitamin D in cardiac remodeling and disease. Despite the many observational studies and meta-analyses supporting the critical role of vitamin D in cardiovascular physiopathology, clinical trials designed to evaluate the specific role of vitamin D in cardiovascular disease are scarce. The characterization of the importance of vitamin D as a marker of pathology should represent a future research challenge.
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Affiliation(s)
- Marcello Izzo
- Department of Mathematics for Technology, Medicine and Biosciences Research Center, University of Ferrara, 44121 Ferrara, Italy
- Specialist Medical Center-Via Cimitile, 80035 Nola, Italy
- Correspondence:
| | - Albino Carrizzo
- IRCCS Neuromed, 86077 Pozzilli, Italy; (A.C.); (E.C.); (D.C.); (A.D.); (C.V.); (F.P.)
- Department of Medicine, Surgery and Dentistry, University of Salerno, 84081 Baronissi, Italy; (C.I.); (M.C.); (P.I.)
| | - Carmine Izzo
- Department of Medicine, Surgery and Dentistry, University of Salerno, 84081 Baronissi, Italy; (C.I.); (M.C.); (P.I.)
| | - Enrico Cappello
- IRCCS Neuromed, 86077 Pozzilli, Italy; (A.C.); (E.C.); (D.C.); (A.D.); (C.V.); (F.P.)
| | - Domenico Cecere
- IRCCS Neuromed, 86077 Pozzilli, Italy; (A.C.); (E.C.); (D.C.); (A.D.); (C.V.); (F.P.)
| | - Michele Ciccarelli
- Department of Medicine, Surgery and Dentistry, University of Salerno, 84081 Baronissi, Italy; (C.I.); (M.C.); (P.I.)
| | - Patrizia Iannece
- Department of Medicine, Surgery and Dentistry, University of Salerno, 84081 Baronissi, Italy; (C.I.); (M.C.); (P.I.)
| | - Antonio Damato
- IRCCS Neuromed, 86077 Pozzilli, Italy; (A.C.); (E.C.); (D.C.); (A.D.); (C.V.); (F.P.)
| | - Carmine Vecchione
- IRCCS Neuromed, 86077 Pozzilli, Italy; (A.C.); (E.C.); (D.C.); (A.D.); (C.V.); (F.P.)
- Department of Medicine, Surgery and Dentistry, University of Salerno, 84081 Baronissi, Italy; (C.I.); (M.C.); (P.I.)
| | - Francesco Pompeo
- IRCCS Neuromed, 86077 Pozzilli, Italy; (A.C.); (E.C.); (D.C.); (A.D.); (C.V.); (F.P.)
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11
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Relationship between vitamin D receptor gene polymorphisms and vitamin D levels in children. JOURNAL OF SURGERY AND MEDICINE 2021. [DOI: 10.28982/josam.911212] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
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12
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The role of vitamin D in statin treated patients complaining of myalagia. COR ET VASA 2021. [DOI: 10.33678/cor.2020.021] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022]
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13
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Chogtu B, Ommurugan B, Thomson SR, Kalthur SG. Effect of Vitamin D Analogue on Rosuvastatin-Induced Myopathy in Wistar Rats. ScientificWorldJournal 2020; 2020:4704825. [PMID: 32292293 PMCID: PMC7150687 DOI: 10.1155/2020/4704825] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/12/2019] [Revised: 02/03/2020] [Accepted: 03/03/2020] [Indexed: 11/17/2022] Open
Abstract
OBJECTIVES Statin-induced myopathy is one of the major causes of poor adherence and discontinuation of this medication. There are contrary results regarding association of vitamin D insufficiency with statin-induced myopathy. This study was done to determine the effect of the vitamin D3 analogue alfacalcidol on Rosuvastatin-induced myopathy in rats. Methodology. Animals were divided into six groups with 6 rats in each group. Groups I and II acted as controls, Group III and Group IV were administered Rosuvastatin 120 mg/kg/day and 160 mg/kg/day, Groups V and VI were administered alfacalcidol 0.1 μg/kg/day in addition to Rosuvastatin 120 mg/kg/day and 160 mg/kg/day, respectively. All drugs were administered orally for 15 days. Plasma creatine kinase (CK) levels were estimated on day 10 and day 15. Animals were sacrificed and muscles were sent for histopathological examination. RESULTS On day 10, Groups V and VI showed a statistically significant increase in plasma CK levels as compared to the control (p < 0.001) and were significantly lower (p < 0.001) as compared to Groups III and IV, respectively. However, on day 15, plasma CK levels in Groups V and VI were comparable to those of control groups with a nonsignificant difference (p > 0.05). On comparing the histology, Groups V and VI showed a significant difference as compared to statin-only groups (Groups III and IV) as there were signs of regeneration, less splitting, and fragmentation of muscle fibres. CONCLUSION The present study shows that the vitamin D analogue alfacalcidol prevents statin-induced myopathy. The serum CK levels are comparable to the control group on day 15 of vitamin D administration.
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Affiliation(s)
- Bharti Chogtu
- Department of Pharmacology, Kasturba Medical College, Manipal, Manipal Academy of Higher Education, Manipal, Karnataka 576104, India
| | | | | | - Sneha G Kalthur
- Department of Anatomy, Kasturba Medical College, Manipal, Manipal Academy of Higher Education, Manipal, Karnataka 576104, India
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14
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Pergolizzi JV, Coluzzi F, Colucci RD, Olsson H, LeQuang JA, Al-Saadi J, Magnusson P. Statins and muscle pain. Expert Rev Clin Pharmacol 2020; 13:299-310. [PMID: 32089020 DOI: 10.1080/17512433.2020.1734451] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
Introduction: Statins remain among the most frequently prescribed drugs and constitute a cornerstone in the prevention of cardiovascular disease. However, muscle symptoms are often reported from patients on statins. Muscle symptoms are frequently reported as adverse events associated with statin therapy.Areas covered: In the present narrative review, statin-associated muscle pain is discussed. It elucidates potential mechanisms and possible targets for management.Expert opinion: In general, the evidence in support of muscle pain caused by statins is in some cases equivocal and not particularly strong. Reported symptoms are difficult to quantify. Rarely is it possible to establish a causal link between statins and muscle pain. In randomized controlled trials, statins are well tolerated, and muscle-pain related side-effects is similar to placebo. There are also nocebo effects of statins. Exchange of statin may be beneficial although all statins have been associated with muscle pain. In some patients reduction of dose is worth trying, especially in primary prevention Although the benefits of statins outweigh potential risks in the vast majority of cases, careful clinical judgment may be necessary in certain cases to manage potential side effects on an individual basis.
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Affiliation(s)
| | - Flaminia Coluzzi
- Department of Medical and Surgical Sciences and Biotechnologies, Unit of Anaesthesia, Intensive Care and Pain Medicine, Sapienza University of Rome, Rome, Italy
| | - Robert D Colucci
- NEMA Research, Inc., Naples, FL, USA.,Colucci & Associates, LLC, Newtown, Connecticut, USA
| | - Hanna Olsson
- Centre for Research and Development, Region Gävleborg/Uppsala University, Gävle, Sweden
| | | | - Jonathan Al-Saadi
- Centre for Research and Development, Region Gävleborg/Uppsala University, Gävle, Sweden
| | - Peter Magnusson
- Centre for Research and Development, Region Gävleborg/Uppsala University, Gävle, Sweden.,Cardiology Research Unit, Institution of Medicine, Karolinska Institutet, Stockholm, Sweden
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15
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Grunwald SA, Popp O, Haafke S, Jedraszczak N, Grieben U, Saar K, Patone G, Kress W, Steinhagen-Thiessen E, Dittmar G, Spuler S. Statin-induced myopathic changes in primary human muscle cells and reversal by a prostaglandin F2 alpha analogue. Sci Rep 2020; 10:2158. [PMID: 32034223 PMCID: PMC7005895 DOI: 10.1038/s41598-020-58668-2] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/03/2019] [Accepted: 01/17/2020] [Indexed: 12/18/2022] Open
Abstract
Statin-related muscle side effects are a constant healthcare problem since patient compliance is dependent on side effects. Statins reduce plasma cholesterol levels and can prevent secondary cardiovascular diseases. Although statin-induced muscle damage has been studied, preventive or curative therapies are yet to be reported. We exposed primary human muscle cell populations (n = 22) to a lipophilic (simvastatin) and a hydrophilic (rosuvastatin) statin and analyzed their expressome. Data and pathway analyses included GOrilla, Reactome and DAVID. We measured mevalonate intracellularly and analyzed eicosanoid profiles secreted by human muscle cells. Functional assays included proliferation and differentiation quantification. More than 1800 transcripts and 900 proteins were differentially expressed after exposure to statins. Simvastatin had a stronger effect on the expressome than rosuvastatin, but both statins influenced cholesterol biosynthesis, fatty acid metabolism, eicosanoid synthesis, proliferation, and differentiation of human muscle cells. Cultured human muscle cells secreted ω-3 and ω-6 derived eicosanoids and prostaglandins. The ω-6 derived metabolites were found at higher levels secreted from simvastatin-treated primary human muscle cells. Eicosanoids rescued muscle cell differentiation. Our data suggest a new aspect on the role of skeletal muscle in cholesterol metabolism. For clinical practice, the addition of omega-n fatty acids might be suitable to prevent or treat statin-myopathy.
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Affiliation(s)
- Stefanie Anke Grunwald
- Muscle Research Unit, Experimental and Clinical Research Center, a joint cooperation between the Charité Universitätsmedizin and the Max Delbrück Center for Molecular Medicine, Berlin, 13125, Germany.
- Charité Universitätsmedizin Berlin, Berlin, 13125, Germany.
| | - Oliver Popp
- Mass Spectrometry Core Facility, Max Delbrück Center for Molecular Medicine in the Helmholtz Society, Berlin, 13125, Germany
- Mass Spectrometry Facility, Berlin Institute of Health, Berlin, 13125, Germany
| | - Stefanie Haafke
- Muscle Research Unit, Experimental and Clinical Research Center, a joint cooperation between the Charité Universitätsmedizin and the Max Delbrück Center for Molecular Medicine, Berlin, 13125, Germany
- Charité Universitätsmedizin Berlin, Berlin, 13125, Germany
| | - Nicole Jedraszczak
- Muscle Research Unit, Experimental and Clinical Research Center, a joint cooperation between the Charité Universitätsmedizin and the Max Delbrück Center for Molecular Medicine, Berlin, 13125, Germany
- Charité Universitätsmedizin Berlin, Berlin, 13125, Germany
| | - Ulrike Grieben
- Muscle Research Unit, Experimental and Clinical Research Center, a joint cooperation between the Charité Universitätsmedizin and the Max Delbrück Center for Molecular Medicine, Berlin, 13125, Germany
- Charité Universitätsmedizin Berlin, Berlin, 13125, Germany
| | - Kathrin Saar
- Genetics and Genomics of Cardiovascular Diseases, Max Delbrück Center for Molecular Medicine in the Helmholtz Society, Berlin, 13125, Germany
| | - Giannino Patone
- Genetics and Genomics of Cardiovascular Diseases, Max Delbrück Center for Molecular Medicine in the Helmholtz Society, Berlin, 13125, Germany
| | - Wolfram Kress
- Institute for Human Genetics, Julius-Maximilians-University of Würzburg, Würzburg, 97074, Germany
| | | | - Gunnar Dittmar
- Mass Spectrometry Core Facility, Max Delbrück Center for Molecular Medicine in the Helmholtz Society, Berlin, 13125, Germany
- Mass Spectrometry Facility, Berlin Institute of Health, Berlin, 13125, Germany
| | - Simone Spuler
- Muscle Research Unit, Experimental and Clinical Research Center, a joint cooperation between the Charité Universitätsmedizin and the Max Delbrück Center for Molecular Medicine, Berlin, 13125, Germany.
- Charité Universitätsmedizin Berlin, Berlin, 13125, Germany.
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16
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Turner RM, Pirmohamed M. Statin-Related Myotoxicity: A Comprehensive Review of Pharmacokinetic, Pharmacogenomic and Muscle Components. J Clin Med 2019; 9:jcm9010022. [PMID: 31861911 PMCID: PMC7019839 DOI: 10.3390/jcm9010022] [Citation(s) in RCA: 98] [Impact Index Per Article: 19.6] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/07/2019] [Revised: 12/17/2019] [Accepted: 12/18/2019] [Indexed: 02/06/2023] Open
Abstract
Statins are a cornerstone in the pharmacological prevention of cardiovascular disease. Although generally well tolerated, a small subset of patients experience statin-related myotoxicity (SRM). SRM is heterogeneous in presentation; phenotypes include the relatively more common myalgias, infrequent myopathies, and rare rhabdomyolysis. Very rarely, statins induce an anti-HMGCR positive immune-mediated necrotizing myopathy. Diagnosing SRM in clinical practice can be challenging, particularly for mild SRM that is frequently due to alternative aetiologies and the nocebo effect. Nevertheless, SRM can directly harm patients and lead to statin discontinuation/non-adherence, which increases the risk of cardiovascular events. Several factors increase systemic statin exposure and predispose to SRM, including advanced age, concomitant medications, and the nonsynonymous variant, rs4149056, in SLCO1B1, which encodes the hepatic sinusoidal transporter, OATP1B1. Increased exposure of skeletal muscle to statins increases the risk of mitochondrial dysfunction, calcium signalling disruption, reduced prenylation, atrogin-1 mediated atrophy and pro-apoptotic signalling. Rare variants in several metabolic myopathy genes including CACNA1S, CPT2, LPIN1, PYGM and RYR1 increase myopathy/rhabdomyolysis risk following statin exposure. The immune system is implicated in both conventional statin intolerance/myotoxicity via LILRB5 rs12975366, and a strong association exists between HLA-DRB1*11:01 and anti-HMGCR positive myopathy. Epigenetic factors (miR-499-5p, miR-145) have also been implicated in statin myotoxicity. SRM remains a challenge to the safe and effective use of statins, although consensus strategies to manage SRM have been proposed. Further research is required, including stringent phenotyping of mild SRM through N-of-1 trials coupled to systems pharmacology omics- approaches to identify novel risk factors and provide mechanistic insight.
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17
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Abstract
There is now overwhelming evidence to support lowering LDL-c (low-density lipoprotein cholesterol) to reduce cardiovascular morbidity and mortality. Statins are a class of drugs frequently prescribed to lower cholesterol. However, in spite of their wide-spread use, discontinuation and nonadherence remains a major gap in both the primary and secondary prevention of atherosclerotic cardiovascular disease. The major reason for statin discontinuation is because of the development of statin-associated muscle symptoms, but a range of other statin-induced side effects also exist. Although the mechanisms behind these side effects have not been fully elucidated, there is an urgent need to identify those at increased risk of developing side effects as well as provide alternative treatment strategies. In this article, we review the mechanisms and clinical importance of statin toxicity and focus on the evaluation and management of statin-associated muscle symptoms.
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Affiliation(s)
- Natalie C Ward
- From the School of Public Health, Curtin University, Perth, Western Australia, Australia (N.C.W.).,School of Medicine, University of Western Australia, Perth, Australia (N.C.W., G.F.W.)
| | - Gerald F Watts
- School of Medicine, University of Western Australia, Perth, Australia (N.C.W., G.F.W.).,Lipid Disorders Clinic, Department of Cardiology, Royal Perth Hospital, Western Australia, Australia (G.F.W.)
| | - Robert H Eckel
- Division of Endocrinology, Metabolism and Diabetes, Department of Medicine, University of Colorado School of Medicine, Anschutz Medical Campus, Aurora (R.H.E.)
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18
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Archontogeorgis K, Nena E, Papanas N, Steiropoulos P. The role of vitamin D in obstructive sleep apnoea syndrome. Breathe (Sheff) 2018; 14:206-215. [PMID: 30186518 PMCID: PMC6118887 DOI: 10.1183/20734735.000618] [Citation(s) in RCA: 30] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
Abstract
Obstructive sleep apnoea syndrome (OSAS) is a common disorder of multifactorial pathogenesis and is associated with obesity, diabetes and cardiovascular disease. Vitamin D is a fat-soluble vitamin with an important function in calcium absorption and homeostasis, which is also implicated in several nonskeletal conditions. The prevalence of vitamin D deficiency is increasing worldwide and is associated with similar metabolic disturbances to OSAS. Moreover, recent data suggest that in OSAS patients serum levels of vitamin D are lower compared with non-apnoeic subjects. However, the mechanisms linking vitamin D deficiency and OSAS are not completely understood and several hypotheses have been advanced. To date, a limited number of studies have assessed the association between lower serum concentrations of vitamin D and OSAS, and have reported inconsistent results. Similarly, contradictory results have been produced by studies which evaluated the effect of continuous positive airway pressure treatment on serum vitamin D levels. The aim of this review is to summarise current knowledge on the association between OSAS and vitamin D levels. Due to multiple confounding factors, vitamin D deficiency is common among sleep apnoea patients; thus, screening should be performed when clinically indicatedhttp://ow.ly/L3ow30krmol
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Affiliation(s)
- Kostas Archontogeorgis
- M.Sc. Program "Sleep Medicine", Medical School, Democritus University of Thrace, Alexandroupolis, Greece
| | - Evangelia Nena
- Laboratory of Hygiene and Environmental Protection, Medical School, Democritus University of Thrace, Alexandroupolis, Greece
| | - Nikolaos Papanas
- Second Dept of Internal Medicine, Medical School, Democritus University of Thrace, Alexandroupolis, Greece
| | - Paschalis Steiropoulos
- M.Sc. Program "Sleep Medicine", Medical School, Democritus University of Thrace, Alexandroupolis, Greece
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19
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[Indirect and mixed mechanisms of action in toxic myopathies]. ANNALES PHARMACEUTIQUES FRANÇAISES 2018; 76:273-285. [PMID: 29803327 DOI: 10.1016/j.pharma.2018.03.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/25/2017] [Revised: 03/03/2018] [Accepted: 03/05/2018] [Indexed: 11/24/2022]
Abstract
Toxic myopathies are a group of pathologies characterized by a structural and/or functional disturbance of muscles induced by an exogenous agent. The most frequent are those induced by drugs used in clinical practice. Illegal drugs, pesticides, solvents, metals and even physical and gaseous agents can cause this kind of disease and exert toxicity on muscle tissues. Some toxins from animals, plants or micro-organisms are potent myotoxic agents, which can lead to fatal complications. Respiratory arrest and rhabdomyolysis are often referred to as the ultimate complications of these pathologies. Several mechanisms of action can be triggered. Muscles may represent a direct target for exogenous agents by acting on the myocyte components or indirect target by inducing functional disorders. These disorders are triggered by neuromuscular interferences (organophosphates, antipsychotics, curares, etc.) and endocrine (glucocorticoids and ethyl alcohol), immune (d-penicillamine and statins) and hydroelectrolytic system dysfunctions (diuretics, laxatives and toluene). Direct and indirect effects can be induced by the same toxic agent, such as carbon monoxide, glucocorticoids, ethyl alcohol and some toxins from snake venoms.
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20
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Nguyen KA, Li L, Lu D, Yazdanparast A, Wang L, Kreutz RP, Whipple EC, Schleyer TK. A comprehensive review and meta-analysis of risk factors for statin-induced myopathy. Eur J Clin Pharmacol 2018; 74:1099-1109. [PMID: 29785580 DOI: 10.1007/s00228-018-2482-9] [Citation(s) in RCA: 41] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/05/2018] [Accepted: 05/10/2018] [Indexed: 12/13/2022]
Abstract
PURPOSE To aid prescribers in assessing a patient's risk for statin-induced myopathy (SIM), we performed a comprehensive review of currently known risk factors and calculated aggregated odds ratios for each risk factor through a meta-analysis. METHODS This meta-analysis was done through four phases: (1) Identification of the relevant primary literature; (2) abstract screening using inclusion and exclusion criteria; (3) detailed review and data extraction; and (4) synthesis and statistical analysis. RESULTS Out of 44 papers analyzed from 836 papers searched from MEDLINE, 18 different potential risk factors were collected, divided into three categories: three demographics (11 papers), ten clinical factors (31 papers), and five pharmacogenetics/biomarkers (12 papers). Risk factors significant for myopathy and/or rhabdomyolysis included age, gender, diabetes, renal impairment, cardiovascular disease, certain interacting drugs, and mutations of the SLCO1B1 gene, which encodes a transporter protein in the liver. Several factors, such as gender, race, cardiovascular disease, and the GATM gene, which encodes a protein for creatine synthesis, appeared to be protective in terms of the outcomes of interest. CONCLUSIONS This comprehensive assessment of risk factors can help support clinicians in reducing the incidence of SIM in their patient population on statins.
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Affiliation(s)
- Khoa A Nguyen
- Center for Health Information and Communication, Department of Veterans Affairs (VA), Veterans Health Administration, Health Service Research and Development Service (CIN 13-416), Richard L. Roudebush VA Medical Center, D6004-02, 1481 West 10th Street, Indianapolis, IN, 46202, USA. .,Department of Pharmacy Practice, College of Pharmacy, Purdue University, Indianapolis, IN, USA.
| | - Lang Li
- Department of Biomedical Informatics, College of Medicine, The Ohio State University, Columbus, OH, USA
| | - Deshun Lu
- Division of Clinical Pharmacology, Department of Medicine, Indiana University School of Medicine, Indianapolis, IN, USA
| | - Aida Yazdanparast
- Center for Computational Biology and Bioinformatics, Indiana University School of Medicine, Indianapolis, IN, USA
| | - Lei Wang
- Department of Biomedical Informatics, College of Medicine, The Ohio State University, Columbus, OH, USA
| | - Rolf P Kreutz
- Department of Medicine, Krannert Institute of Cardiology, Indiana University School of Medicine, Indianapolis, IN, USA
| | - Elizabeth C Whipple
- Research and Translational Sciences, Indiana University School of Medicine, Indianapolis, IN, USA
| | - Titus K Schleyer
- Department of Medicine, Indiana University School of Medicine, Indianapolis, IN, USA.,Center for Biomedical Informatics, Regenstrief Institute, Indianapolis, IN, USA
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21
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Ward NC, Pang J, Ryan JDM, Watts GF. Nutraceuticals in the management of patients with statin-associated muscle symptoms, with a note on real-world experience. Clin Cardiol 2018; 41:159-165. [PMID: 29363784 DOI: 10.1002/clc.22862] [Citation(s) in RCA: 20] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/09/2017] [Revised: 11/16/2017] [Accepted: 11/21/2017] [Indexed: 12/21/2022] Open
Abstract
There is considerable evidence for the role of low-density lipoprotein cholesterol (LDL-C) in the development of atherosclerotic cardiovascular disease. Although statin therapy remains the most frequency prescribed medication to reduce LDL-C and lower risk of cardiovascular disease, a considerable number of patients develop muscle-related side affects. This review summarizes recent literature supporting the role of nutraceuticals as LDL-C-lowering therapy in statin-intolerant patients, with evidence from our own clinical practices.
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Affiliation(s)
- Natalie C Ward
- School of Medicine, Faculty of Health & Medical Sciences, University of Western Australia, Perth.,School of Biomedical Sciences and Curtin Health Innovation Research Institute, Perth, Australia
| | - Jing Pang
- School of Medicine, Faculty of Health & Medical Sciences, University of Western Australia, Perth.,Lipid Disorders Clinic, Department of Cardiology, Royal Perth Hospital, Perth, Australia
| | - Jacqueline D M Ryan
- School of Medicine, Faculty of Health & Medical Sciences, University of Western Australia, Perth.,Perth Lipid Clinic, Primary Care, Perth, Australia
| | - Gerald F Watts
- School of Medicine, Faculty of Health & Medical Sciences, University of Western Australia, Perth.,Lipid Disorders Clinic, Department of Cardiology, Royal Perth Hospital, Perth, Australia
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22
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Jacobson TA, Khan A, Maki KC, Brinton EA, Cohen JD. Provider recommendations for patient-reported muscle symptoms on statin therapy: Insights from the Understanding Statin Use in America and Gaps in Patient Education survey. J Clin Lipidol 2018; 12:78-88. [DOI: 10.1016/j.jacl.2017.09.006] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/05/2017] [Revised: 08/26/2017] [Accepted: 09/19/2017] [Indexed: 01/24/2023]
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23
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Houston M. Dyslipidemia. Integr Med (Encinitas) 2018. [DOI: 10.1016/b978-0-323-35868-2.00027-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
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24
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Elsaid O, Taylor B, Zaleski A, Panza G, Thompson PD. Rationale for investigating metformin as a protectant against statin-associated muscle symptoms. J Clin Lipidol 2017; 11:1145-1151. [DOI: 10.1016/j.jacl.2017.06.019] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/04/2017] [Revised: 06/23/2017] [Accepted: 06/29/2017] [Indexed: 11/30/2022]
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25
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Kang JH, Nguyen QN, Mutka J, Le QA. Authors’ Response. J Pharm Pract 2017; 30:386-387. [DOI: 10.1177/0897190017709810] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Affiliation(s)
- Jenny H. Kang
- Western University of Health Sciences, College of Pharmacy, Pomona, CA, USA
- Department of Pharmacy, Veterans Affairs Loma Linda Healthcare System, Loma Linda, CA, USA
| | - Quynh-Nhu Nguyen
- Department of Pharmacy, Veterans Affairs Loma Linda Healthcare System, Loma Linda, CA, USA
| | - Juleann Mutka
- Department of Pharmacy, Veterans Affairs Loma Linda Healthcare System, Loma Linda, CA, USA
| | - Quang A. Le
- Western University of Health Sciences, College of Pharmacy, Pomona, CA, USA
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26
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Significant association between statin-associated myalgia and vitamin D deficiency among treated HIV-infected patients. AIDS 2017; 31:681-688. [PMID: 28060020 DOI: 10.1097/qad.0000000000001397] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
BACKGROUND Several studies have shown a significant association between vitamin D deficiency and an increased risk of statin-related symptomatic myalgia in the general population, but there are no data among HIV-infected persons. METHODS A retrospective, cohort study was conducted to assess the incidence of symptomatic myalgia and elevation in serum creatine kinase level among HIV-positive adults on combination antiretroviral therapy and treated with atorvastatin or rosuvastatin for at least 12 months between 2011 and 2015 in our outpatient unit. RESULTS A total of 545 patients (mean age 53.4 years) were enrolled into the study. Atorvastatin was prescribed in 55.8% of patients and rosuvastatin in 44.2%. After a mean duration of statin therapy of 29 months, an isolated symptomatic myalgia was diagnosed in 42 patients (7.7%) and a myalgia associated with elevated creatine kinase level in 25 (4.6%). The mean concentration of 25-hydroxyvitamin D was significantly lower in patients with myalgia (19.4 ng/ml) and with creatine kinase elevation and myalgia (22.8 ng/ml) than in those without muscle toxicity (32.1 ng/ml; P = 0.017 and 0.024, respectively). In stratified multivariable-adjusted logistic regression models, there was a statistically significant association between vitamin D deficiency and occurrence of symptomatic myalgia (P = 0.009) or creatine kinase elevation and myalgia (P = 0.046). Other factors significantly associated with development of myalgia were duration of statin therapy more than 24 months, history of myalgia, and age older than 60 years. DISCUSSION In our observational study, vitamin D deficiency was significantly associated with a statin-induced myalgia among HIV-infected patients on combination antiretroviral therapy, in conformity with data of the general population.
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27
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Riche KD, Arnall J, Rieser K, East HE, Riche DM. Impact of vitamin D status on statin-induced myopathy. JOURNAL OF CLINICAL AND TRANSLATIONAL ENDOCRINOLOGY 2016; 6:56-59. [PMID: 29067242 PMCID: PMC5644425 DOI: 10.1016/j.jcte.2016.11.002] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 06/01/2016] [Revised: 11/15/2016] [Accepted: 11/15/2016] [Indexed: 11/16/2022]
Abstract
INTRODUCTION There is a multitude of evidence supporting the benefit of statin use in cardiovascular disease; however, statin-induced myopathy is a major reason for statin discontinuation and non-adherence. Vitamin D deficiency has been independently associated with muscle weakness and severe myopathy, and may be a confounder for statin-induced myopathies. Since there is no consensus on a treatment course of action for statin-induced myopathy, investigation into potential confounders to elucidate the dynamics of statin-induced myopathy is warranted. METHODS A retrospective chart review was conducted on 105 patients in a cardiometabolic clinic with a vitamin D drawn from December 2006 to April 2008. Patients exposed to statins were divided into two groups: (1) patients with low vitamin D (<32 ng/mL) [n = 52] and (2) patients with a sufficient vitamin D level (⩾32 ng/mL) [n = 32]. Data were compared via t-tests or Fisher's Exact, as appropriate. RESULTS There were 41 statin-specific myopathies amongst the 24 statin-intolerant patients. Low vitamin D was significantly associated with statin-induced myopathy (p = 0.048). Following prescription vitamin D supplementation, statin tolerance rates were significantly higher in patients with a baseline vitamin D ⩽20 ng/mL than those with a baseline vitamin D >20 ng/mL (90% vs 33%; p = 0.036). CONCLUSION Vitamin D status may be considered a modifiable risk factor for muscle-related adverse effects of statins, and supplementation of vitamin D (particularly when ⩽20 ng/mL) may improve statin tolerance.
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Affiliation(s)
- Krista D Riche
- The University of Mississippi, School of Pharmacy, Jackson, MS, United States.,St. Dominic Hospital, Jackson, MS, United States
| | - Justin Arnall
- Wake Forest University, Winston-Salem, NC, United States
| | - Kristin Rieser
- The University of Mississippi, School of Pharmacy, Jackson, MS, United States
| | - Honey E East
- Premier Medical Group, Jackson, MS, United States
| | - Daniel M Riche
- The University of Mississippi, School of Pharmacy, Jackson, MS, United States.,The University of Mississippi School of Medicine, Jackson, MS, United States
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Pereda CA, Nishishinya MB. Is There Really a Relationship Between Serum Vitamin D (25OHD) Levels and the Musculoskeletal Pain Associated With Statin Intake? A Systematic Review. ACTA ACUST UNITED AC 2016. [DOI: 10.1016/j.reumae.2016.03.001] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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Kang JH, Nguyen QN, Mutka J, Le QA. Rechallenging Statin Therapy in Veterans With Statin-Induced Myopathy Post Vitamin D Replenishment. J Pharm Pract 2016; 30:521-527. [PMID: 27798247 DOI: 10.1177/0897190016674407] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/14/2023]
Abstract
BACKGROUND Statins are the primary class of medications used to lower cholesterol and reduce risks for coronary heart disease. However, statin muscular adverse effects are one of the main reasons for statin nonadherence and a barrier to cardiovascular risk reduction. OBJECTIVES The primary objective of our study was to examine the effect of replenishing vitamin D on statin-induced myopathy in veteran patients who failed to maintain statin therapy in a pharmacist-run ambulatory care setting. Secondary objectives were to examine changes in patients' vitamin D levels, fasting lipid profiles, and achievement of lipid goals after reinitiation of statin therapy. METHODS This was a retrospective cohort study of veteran patients conducted at a pharmacist-managed cholesterol-optimization clinic. Patients with low-serum vitamin D, history of statin-induced myopathy, and who received vitamin D replenishment prior to rechallenging statin therapy between December 1, 2008, and April 1, 2015, were identified. The primary outcome was the percentage of patients who maintained their statin therapy at 12 months after statin reinitiation. RESULTS Twenty-seven patients met the study criteria. All patients were able to maintain their statin therapy without myalgia after vitamin D supplementation. Eleven patients (40.7%) tolerated their previously failed statins. The most frequently restarted statins were atorvastatin, pravastatin, and rosuvastatin. A 22% to 30% increase in the number of patients who achieved cholesterol goals based on the national lipid guidelines was observed at 12-month follow-up. CONCLUSION Replenishing low vitamin D in patients with statin-induced myopathy appears to be an effective strategy in improving medication adherence and subsequently preventing cardiovascular and mortality events.
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Affiliation(s)
- Jenny H Kang
- 1 Department of Pharmacy Practice and Administration, College of Pharmacy, Western University of Health Sciences, Pomona, CA, USA.,2 Department of Pharmacy, Veterans Affairs Loma Linda Healthcare System, Loma Linda, CA, USA
| | - Quynh-Nhu Nguyen
- 2 Department of Pharmacy, Veterans Affairs Loma Linda Healthcare System, Loma Linda, CA, USA
| | - Juleann Mutka
- 2 Department of Pharmacy, Veterans Affairs Loma Linda Healthcare System, Loma Linda, CA, USA
| | - Quang A Le
- 1 Department of Pharmacy Practice and Administration, College of Pharmacy, Western University of Health Sciences, Pomona, CA, USA.,2 Department of Pharmacy, Veterans Affairs Loma Linda Healthcare System, Loma Linda, CA, USA
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Gluba-Brzozka A, Franczyk B, Toth PP, Rysz J, Banach M. Molecular mechanisms of statin intolerance. Arch Med Sci 2016; 12:645-58. [PMID: 27279860 PMCID: PMC4889699 DOI: 10.5114/aoms.2016.59938] [Citation(s) in RCA: 47] [Impact Index Per Article: 5.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/21/2016] [Accepted: 03/29/2016] [Indexed: 01/13/2023] Open
Abstract
Statins reduce cardiovascular morbidity and mortality in primary and secondary prevention. Despite their efficacy, many persons are unable to tolerate statins due to adverse events such as hepatotoxicity and myalgia/myopathy. In the case of most patients, it seems that mild-to-moderate abnormalities in liver and muscle enzymes are not serious adverse effects and do not outweigh the benefits of coronary heart disease risk reduction. The risk for mortality or permanent organ damage ascribed to statin use is very small and limited to cases of myopathy and rhabdomyolysis. Statin-induced muscle-related adverse events comprise a highly heterogeneous clinical disorder with numerous, complex etiologies and a variety of genetic backgrounds. Every patient who presents with statin-related side effects cannot undergo the type of exhaustive molecular characterization that would include all of these mechanisms. Frequently the only solution is to either discontinue statin therapy/reduce the dose or attempt intermittent dosing strategies at a low dose.
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Affiliation(s)
- Anna Gluba-Brzozka
- Department of Nephrology, Hypertension and Family Medicine, WAM University Hospital, Lodz, Poland
- Healthy Aging Research Center, Medical University of Lodz, Lodz, Poland
| | - Beata Franczyk
- Department of Nephrology, Hypertension and Family Medicine, Medical University of Lodz, Lodz, Poland
| | - Peter P. Toth
- CGH Medical Center, Sterling, Illinois, and Ciccarone Center for the Prevention of Cardiovascular Disease, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Jacek Rysz
- Healthy Aging Research Center, Medical University of Lodz, Lodz, Poland
- Department of Nephrology, Hypertension and Family Medicine, Medical University of Lodz, Lodz, Poland
| | - Maciej Banach
- Healthy Aging Research Center, Medical University of Lodz, Lodz, Poland
- Department of Hypertension, Medical University of Lodz, Lodz, Poland
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Fernandes V, Santos MJ, Pérez A. Statin-related myotoxicity. ACTA ACUST UNITED AC 2016; 63:239-49. [DOI: 10.1016/j.endonu.2016.01.001] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/11/2015] [Revised: 12/01/2015] [Accepted: 01/11/2016] [Indexed: 10/22/2022]
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Pereda CA, Nishishinya MB. Is there really a relationship between serum vitamin D (25OHD) levels and the musculoskeletal pain associated with statin intake? A systematic review. ACTA ACUST UNITED AC 2016; 12:331-335. [PMID: 27133556 DOI: 10.1016/j.reuma.2016.03.009] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/23/2015] [Revised: 03/05/2016] [Accepted: 03/10/2016] [Indexed: 11/26/2022]
Abstract
INTRODUCTION Musculoskeletal pain associated to statin use, is the most common adverse event, leading to cessation of treatment. Several studies proposed Vitamin D deficiency to increase the risk of pain associated to statin intake. OBJECTIVES To evaluate whether vitamin D status is linked to musculoskeletal pain associated to statin use. METHODS We performed a systematic review based on electronic searches through MEDLINE, Cochrane Central and EMBASE to identify studies that 1) included patients on statin therapy 2) with vitamin D serum levels assessment, 3) in relation to musculoskeletal pain. RESULTS The electronic search identified 127 potentially eligible studies, of which three were included and analysed in the present study. The heterogeneity of studies did not allow metanalysis. A systematic review and two cohort studies not included in the previous systematic review, revealed a statistically significant association of vitamin D deficit in patients with musculoskeletal pain on statin therapy. CONCLUSION The displayed evidence suggests a significant association between 25OHD serum levels<30ng/ml and the presence of musculoskeletal pain in patients on statin therapy.
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Whayne TF. Statin Intolerance From a Clinician’s Perspective. Angiology 2016; 67:205-7. [DOI: 10.1177/0003319715587416] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Affiliation(s)
- Thomas F. Whayne
- Division of Cardiovascular Medicine, Gill Heart Institute, University of Kentucky, Lexington, KY, USA
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Vrablik M, Zlatohlavek L, Stulc T, Adamkova V, Prusikova M, Schwarzova L, Hubacek JA, Ceska R. Statin-associated myopathy: from genetic predisposition to clinical management. Physiol Res 2016; 63:S327-34. [PMID: 25428737 DOI: 10.33549/physiolres.932865] [Citation(s) in RCA: 36] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/14/2023] Open
Abstract
Statin-associated myopathy (SAM) represents a broad spectrum of disorders from insignificant myalgia to fatal rhabdomyolysis. Its frequency ranges from 1-5 % in clinical trials to 15-20 % in everyday clinical practice. To a large extent, these variations can be explained by the definition used. Thus, we propose a scoring system to classify statin-induced myopathy according to clinical and biochemical criteria as 1) possible, 2) probable or 3) definite. The etiology of this disorder remains poorly understood. Most probably, an underlying genetic cause is necessary for overt SAM to develop. Variants in a few gene groups that encode proteins involved in: i) statin metabolism and distribution (e.g. membrane transporters and enzymes; OATP1B1, ABCA1, MRP, CYP3A4), ii) coenzyme Q10 production (e.g. COQ10A and B), iii) energy metabolism of muscle tissue (e.g. PYGM, GAA, CPT2) and several others have been proposed as candidates which can predispose to SAM. Pharmacological properties of individual statin molecules (e.g. lipophilicity, excretion pathways) and patients´ characteristics influence the likelihood of SAM development. This review summarizes current data as well as our own results.
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Affiliation(s)
- M Vrablik
- Third Department of Internal Medicine, First Faculty of Medicine, Charles University, Prague, Czech Republic.
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Abstract
Several guidelines and expert recommendations have been published recently regarding the prevention and treatment of atherosclerotic cardiovascular disease (ASCVD) risk. The American College of Cardiology/American Heart Association (ACC/AHA) guidelines recommend a drastic paradigm change in the treatment of cholesterol where treatment, based on level of cardiovascular risk, is based around using a fixed statin intensity therapy. This approach is endorsed by the American Diabetes Association. However, recommendations by the National Lipid Association (NLA) consist of the traditional approach of titrating therapy to achieve patient-specific lipoprotein targets. Despite the differences in overall approaches, the use of statin therapy as the cornerstone of treatment to reduce risk of cardiovascular events in at risk patients is a strong common theme. Clinicians should be aware of these differences, as they represent controversies with the overall treatment of ASCVD risk. Additional controversies related to the treatment of patients with ASCVD risk pertain to the role of nonstatin drugs and approaches to managing side effects. These topics are reviewed within this article and discuss implications for patient care.
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Affiliation(s)
- Elizabeth Phillips
- Department of Pharmacy Practice, Wegmans School of Pharmacy, St. John Fisher College, Rochester, NY, USA Department of Medicine, Section of Clinical Pharmacology, SUNY-Upstate Medical University, Aurora, CO, USA
| | - Joseph J Saseen
- Department of Clinical Pharmacy, Skaggs School of Pharmacy & Pharmaceutical Sciences, University of Colorado Anschutz Medical Campus, Aurora, CO, USA Department of Family Medicine, School of Medicine, University of Colorado, Aurora, CO, USA
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Argov Z. Statins and the neuromuscular system: a neurologist's perspective. Eur J Neurol 2015; 22:31-6. [PMID: 25495398 DOI: 10.1111/ene.12604] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/29/2014] [Accepted: 10/07/2014] [Indexed: 02/02/2023]
Abstract
Statins intolerance is mainly due to their side effects on the neuromuscular system (primarily muscle). It has become an important issue because of the major cardiovascular risk reduction of this class of drugs. However, the facts related to these side effects are sometimes under-recognized or controversial. A literature review of the recent developments in the field is given. The clinical definition of statin myopathy and its presentation are not suitable for the myology field. Management and prevention are not validated. More genetic risk factors need to be established. Neurologists should become more involved in statin intolerance evaluation and management.
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Affiliation(s)
- Z Argov
- Hebrew University- Hadassah School of Medicine, Ein Kerem, Jerusalem, Israel
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Abstract
PURPOSE OF REVIEW This article highlights the recent findings regarding statin-associated muscle side effects, including mechanisms and treatment as well as the need for more comprehensive clinical trials in statin myalgia. RECENT FINDINGS Statin myalgia is difficult to diagnose and treat, as major clinical trials have not routinely assessed muscle side-effects, there are few clinically relevant biomarkers and assessment tools for the symptoms, many apparent statin-related muscle symptoms may be nonspecific and related to other drugs or health conditions, and prevalence estimates vary widely. Data thus suggest that only 30-50% of patients with self-reported statin myalgia actually experience muscle pain on statins during blinded, placebo-controlled trials. In addition, evidence to date involving mechanisms underlying statin myalgia and its range of symptoms and presentations supports the hypothesis that there are multiple, interactive and potentially additive mechanisms underlying statin-associated muscle side-effects. SUMMARY There are likely multiple and interactive mechanisms underlying statin myalgia, and recent studies have produced equivocal data regarding prevalence of statin-associated muscle side-effects, contributing factors and effectiveness of common interventions. Therefore, more clinical trials on statin myalgia are critical to the field, as are systematic resources for quantifying, predicting and reporting statin-associated muscle side-effects.
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Affiliation(s)
- Beth A Taylor
- aDivision of Cardiology, Henry Low Heart Center, Hartford Hospital, Hartford bDepartment of Health Sciences, University of Hartford, West Hartford cUniversity of Connecticut School of Medicine, Farmington, Connecticut, USA
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Khayznikov M, Hemachrandra K, Pandit R, Kumar A, Wang P, Glueck CJ. Statin Intolerance Because of Myalgia, Myositis, Myopathy, or Myonecrosis Can in Most Cases be Safely Resolved by Vitamin D Supplementation. NORTH AMERICAN JOURNAL OF MEDICAL SCIENCES 2015; 7:86-93. [PMID: 25838999 PMCID: PMC4382771 DOI: 10.4103/1947-2714.153919] [Citation(s) in RCA: 74] [Impact Index Per Article: 8.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
Background: Low serum vitamin D can cause myalgia, myositis, myopathy, and myonecrosis. Statin-induced myalgia is a major and common cause of statin intolerance. Low serum vitamin D and statins, additively or synergistically, cause myalgia, myositis, myopathy, and/or myonecrosis. Statin-induced myalgia in vitamin D deficient patients can often be resolved by vitamin D supplementation, normalizing serum vitamin D levels. Aims: In 74 men and 72 women (age 59 ± 14 years) intolerant to ≥2 statins because of myalgia, myositis, myopathy, or myonecrosis and found to have low (<32 ng/mL) serum vitamin D, we prospectively assessed whether vitamin D supplementation (vitamin D2: 50,000-100,000 units/week) to normalize serum vitamin D would allow successful rechallenge therapy with statins. Materials and Methods: Follow-up evaluation on vitamin D supplementation was done on 134 patients at 6 months (median 5.3), 103 patients at 12 months (median 12.2), and 82 patients at 24 months (median 24). Results: Median entry serum vitamin D (22 ng/mL, 23 ng/mL, and 23 ng/mL) rose at 6 months, 12 months, and 24 months follow-up to 53 ng/mL, 53 ng/mL, and 55 ng/mL, respectively, (P < .0001 for all) on vitamin D therapy (50,000-100,000 units/week). On vitamin D supplementation, serum vitamin D normalized at 6 months, 12 months, and 24 months follow-up in 90%, 86%, and 91% of the patients, respectively. On rechallenge with statins while on vitamin D supplementation, median low-density lipoprotein cholesterol (LDLC) fell from the study entry (167 mg/dL, 164 mg/dL, and 158 mg/dL) to 90 mg/dL, 91 mg/dL, and 84 mg/dL, respectively, (P < .0001 for all). On follow-up at median 6 months, 12 months, and 24 months on statins and vitamin D, 88%, 91%, and 95% of the previously statin-intolerant patients, respectively, were free of myalgia, myositis, myopathy, and/or myonecrosis. Conclusions: Statin intolerance because of myalgia, myositis, myopathy, or myonecrosis associated with low serum vitamin D can be safely resolved by vitamin D supplementation (50,000-100,000 units /week) in most cases (88-95%).
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Affiliation(s)
- Maksim Khayznikov
- Department of Internal Medicine, The Cholesterol, Metabolism and Thrombosis Center, Jewish Hospital of Cincinnati, Cincinnati, Ohio, USA
| | - Kallish Hemachrandra
- Department of Internal Medicine, The Cholesterol, Metabolism and Thrombosis Center, Jewish Hospital of Cincinnati, Cincinnati, Ohio, USA
| | - Ramesh Pandit
- Department of Internal Medicine, The Cholesterol, Metabolism and Thrombosis Center, Jewish Hospital of Cincinnati, Cincinnati, Ohio, USA
| | - Ashwin Kumar
- Department of Internal Medicine, The Cholesterol, Metabolism and Thrombosis Center, Jewish Hospital of Cincinnati, Cincinnati, Ohio, USA
| | - Ping Wang
- Department of Internal Medicine, The Cholesterol, Metabolism and Thrombosis Center, Jewish Hospital of Cincinnati, Cincinnati, Ohio, USA
| | - Charles J Glueck
- Department of Internal Medicine, The Cholesterol, Metabolism and Thrombosis Center, Jewish Hospital of Cincinnati, Cincinnati, Ohio, USA
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Babu S, Li Y. Statin induced necrotizing autoimmune myopathy. J Neurol Sci 2015; 351:13-17. [DOI: 10.1016/j.jns.2015.02.042] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/05/2014] [Revised: 02/07/2015] [Accepted: 02/24/2015] [Indexed: 12/20/2022]
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Deichmann RE, Lavie CJ, Asher T, DiNicolantonio JJ, O'Keefe JH, Thompson PD. The Interaction Between Statins and Exercise: Mechanisms and Strategies to Counter the Musculoskeletal Side Effects of This Combination Therapy. Ochsner J 2015; 15:429-437. [PMID: 26730228 PMCID: PMC4679305] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/05/2023] Open
Abstract
BACKGROUND Broad indications for the use of statin medications are resulting in more patients using these therapies. Simultaneously, healthcare professionals are strongly advocating recommendations to increase exercise training (ET) as a means of decreasing cardiovascular disease (CVD) risk and improving other parameters of fitness. METHODS We review the literature to explore mechanisms that may increase the risk of statin/ET interactions, examine the benefits and risks of combining ET and statin use, and offer strategies to minimize the hazards of this combination therapy. RESULTS The combined use of statins and ET can result in health gains and decreased CVD risk; however, multiple factors may increase the risk of adverse events. Some of the events that have been reported with the combination of statins and ET include decreased athletic performance, muscle injury, myalgia, joint problems, decreased muscle strength, and fatigue. The type of statin, the dose, drug interactions, genetic variants, coenzyme Q10 deficiency, vitamin D deficiency, and underlying muscle diseases are among the factors that may predispose patients to intolerance of this combined therapy. CONCLUSION Effective strategies exist to help patients who may be intolerant of combined statin therapy and ET so they may benefit from this proven therapy. Careful attention to identifying high-risk groups and strategies to prevent or treat side effects that may occur should be employed.
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Affiliation(s)
- Richard E. Deichmann
- Department of Internal Medicine, Ochsner Clinic Foundation, New Orleans, LA
- The University of Queensland School of Medicine, Ochsner Clinical School, New Orleans, LA
| | - Carl J. Lavie
- The University of Queensland School of Medicine, Ochsner Clinical School, New Orleans, LA
- Department of Cardiovascular Diseases, John Ochsner Heart & Vascular Institute, Ochsner Clinic Foundation, New Orleans, LA
| | - Timothy Asher
- The University of Queensland School of Medicine, Ochsner Clinical School, New Orleans, LA
| | - James J. DiNicolantonio
- Department of Cardiology, Mid America Heart Institute, Saint Luke's Health System, Kansas City, MO
| | - James H. O'Keefe
- Department of Cardiology, Mid America Heart Institute, Saint Luke's Health System, Kansas City, MO
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Rosenson RS, Baker SK, Jacobson TA, Kopecky SL, Parker BA, The National Lipid Association's Muscle Safety Expert Panel. An assessment by the Statin Muscle Safety Task Force: 2014 update. J Clin Lipidol 2014; 8:S58-71. [PMID: 24793443 DOI: 10.1016/j.jacl.2014.03.004] [Citation(s) in RCA: 306] [Impact Index Per Article: 30.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/03/2014] [Accepted: 03/11/2014] [Indexed: 01/14/2023]
Abstract
The National Lipid Association's Muscle Safety Expert Panel was charged with the duty of examining the definitions for statin-associated muscle adverse events, development of a clinical index to assess myalgia, and the use of diagnostic neuromuscular studies to investigate muscle adverse events. We provide guidance as to when a patient should be considered for referral to neuromuscular specialists and indications for the performance of a skeletal muscle biopsy. Based on this review of evidence, we developed an algorithm for the evaluation and treatment of patients who may be intolerant to statins as the result of adverse muscle events. The panel was composed of clinical cardiologists, clinical lipidologists, an exercise physiologist, and a neuromuscular specialist.
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Affiliation(s)
- Robert S Rosenson
- Mount Sinai Heart, Icahn School of Medicine at Mount Sinai, 1425 Madison Avenue, New York, NY 10029, USA.
| | | | | | | | - Beth A Parker
- Department of Cardiology, Henry Low Heart Center, Hartford Hospital, Hartford, CT, USA
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Analysis of vitamin D levels in patients with and without statin-associated myalgia - a systematic review and meta-analysis of 7 studies with 2420 patients. Int J Cardiol 2014; 178:111-6. [PMID: 25464233 DOI: 10.1016/j.ijcard.2014.10.118] [Citation(s) in RCA: 124] [Impact Index Per Article: 12.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/11/2014] [Accepted: 10/21/2014] [Indexed: 11/21/2022]
Abstract
INTRODUCTION Vitamin D (vit D) deficiency may be associated with an increased risk of statin-related symptomatic myalgia in statin-treated patients. The aim of this meta-analysis was to substantiate the role of serum vitamin D levels in statin-associated myalgia. METHODS The search included PUBMED, Cochrane Library, Scopus, and EMBASE from January 1, 1987 to April 1, 2014 to identify studies that investigated the impact of vit D levels in statin-treated subjects with and without myalgia. Two independent reviewers extracted data on study characteristics, methods and outcomes. Quantitative data synthesis was performed using a fixed-effect model. RESULTS The electronic search yielded 437 articles; of those 20 were scrutinized as full texts and 13 studies were considered unsuitable. The final analysis included 7 studies with 2420 statin-treated patients divided into subgroups of patients with (n=666 [27.5%]) or without (n=1754) myalgia. Plasma vit D concentrations in the symptomatic and asymptomatic subgroups were 28.4±13.80ng/mL and 34.86±11.63ng/mL, respectively. The combination of data from individual observational studies showed that vit D plasma concentrations were significantly lower in patients with statin-associated myalgia compared with patients not manifesting this side effect (weighted mean difference -9.41ng/mL; 95% confidence interval: -10.17 to -8.64; p<0.00001). CONCLUSIONS This meta-analysis provides evidence that low vit D levels are associated with myalgia in patients on statin therapy. Randomized controlled trials are necessary to establish whether vitamin D supplementation reduces the risk for statin-associated myalgia.
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Auer J, Sinzinger H, Franklin B, Berent R. Muscle- and skeletal-related side-effects of statins: tip of the iceberg? Eur J Prev Cardiol 2014; 23:88-110. [DOI: 10.1177/2047487314550804] [Citation(s) in RCA: 40] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/02/2014] [Accepted: 08/18/2014] [Indexed: 11/15/2022]
Affiliation(s)
- Johann Auer
- Department of Cardiology and Intensive Care, General Hospital Braunau, Braunau, Austria
| | - Helmut Sinzinger
- Department of Nuclear Medicine, Medical University, Vienna, Austria
| | - Barry Franklin
- Cardiac Rehabilitation and Exercise Laboratories, William Beaumont Hospital Royal Oak, MI, USA
| | - Robert Berent
- Center of Cardiac Rehabilitation, Bad Ischl, Austria
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Moßhammer D, Schaeffeler E, Schwab M, Mörike K. Mechanisms and assessment of statin-related muscular adverse effects. Br J Clin Pharmacol 2014; 78:454-66. [PMID: 25069381 PMCID: PMC4243897 DOI: 10.1111/bcp.12360] [Citation(s) in RCA: 64] [Impact Index Per Article: 6.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/05/2013] [Accepted: 02/14/2014] [Indexed: 12/11/2022] Open
Abstract
Statin-associated muscular adverse effects cover a wide range of symptoms, including asymptomatic increase of creatine kinase serum activity and life-threatening rhabdomyolysis. Different underlying pathomechanisms have been proposed. However, a unifying concept of the pathogenesis of statin-related muscular adverse effects has not emerged so far. In this review, we attempt to categorize these mechanisms along three levels. Firstly, among pharmacokinetic factors, it has been shown for some statins that inhibition of cytochrome P450-mediated hepatic biotransformation and hepatic uptake by transporter proteins contribute to an increase of systemic statin concentrations. Secondly, at the myocyte membrane level, cell membrane uptake transporters affect intracellular statin concentrations. Thirdly, at the intracellular level, inhibition of the 3-hydroxy-3-methylglutaryl coenzyme A (HMG-CoA) reductase results in decreased intracellular concentrations of downstream metabolites (e.g. selenoproteins, ubiquinone, cholesterol) and alteration of gene expression (e.g. ryanodine receptor 3, glycine amidinotransferase). We also review current recommendations for prescribers.
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Affiliation(s)
- Dirk Moßhammer
- Division of General Practice, University Hospital TübingenTübingen, D-72074, Germany
| | - Elke Schaeffeler
- Dr. Margarete Fischer-Bosch Institute of Clinical PharmacologyStuttgart, D-70376, Germany
- University TübingenTübingen, Germany
| | - Matthias Schwab
- Department of Clinical Pharmacology, University Hospital TübingenTübingen, D-72076, Germany
- Dr. Margarete Fischer-Bosch Institute of Clinical PharmacologyStuttgart, D-70376, Germany
- University TübingenTübingen, Germany
| | - Klaus Mörike
- Department of Clinical Pharmacology, University Hospital TübingenTübingen, D-72076, Germany
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Murlasits Z, Radák Z. The Effects of Statin Medications on Aerobic Exercise Capacity and Training Adaptations. Sports Med 2014; 44:1519-30. [DOI: 10.1007/s40279-014-0224-4] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/22/2023]
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Wilkinson MJ, Laffin LJ, Davidson MH. Overcoming toxicity and side-effects of lipid-lowering therapies. Best Pract Res Clin Endocrinol Metab 2014; 28:439-52. [PMID: 24840269 DOI: 10.1016/j.beem.2014.01.006] [Citation(s) in RCA: 32] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
Abstract
Lowering serum lipid levels is part of the foundation of treating and preventing clinically significant cardiovascular disease. Recently, the American Heart Association/American College of Cardiology released cholesterol guidelines which advocate for high efficacy statins rather than LDL-c goals for five patient subgroups at high risk for cardiovascular disease. Therefore, it is critical that clinicians have an approach for managing side-effects of statin therapy. Statins are associated with myopathy, transaminase elevations, and an increased risk of incident diabetes mellitus among some patients; connections between statins and other processes, such as renal and neurologic function, have also been studied with mixed results. Statin-related adverse effects might be minimized by careful assessment of patient risk factors. Strategies to continue statin therapy despite adverse effects include switching to another statin at a lower dose and titrating up, giving intermittent doses of statins, and adding non-statin agents. Non-statin lipid-lowering drugs have their own unique limitations. Management strategies and algorithms for statin-associated toxicities are available to help guide clinicians. Clinical practice should emphasize tailoring therapy to address each individual's cholesterol goals and risk of developing adverse effects on lipid-lowering drugs.
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Affiliation(s)
| | - Luke J Laffin
- University of Chicago, Department of Medicine, Chicago, IL, USA.
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Abstract
The term statin intolerance refers to an inability to use statins because of muscle symptoms or elevated creatine kinase, and the major diagnostic challenge is to unambiguously link these to statin use. Roughly 5% to 10% of statin users develop statin intolerance, and because statin use is expected to increase--especially after recent updated guidelines have expanded the statin benefit groups--adverse effects from statins will become a growing issue. Unfortunately, the pathophysiology--and even the terminology--of statin-related muscle injury lacks clarity. Several risk factors have been identified, including advanced age, family history of myopathy and statin dose; many cases manifest only after patients are administered an interacting medication (e.g., azole antifungals, cimetidine, clarithromycin, erythromycin and cyclosporine). The diagnosis of myopathy remains challenging, especially because some patients can have normal serum creatine kinase levels despite demonstrable weakness and muscle biopsy-proven statin-induced myopathy. A statin withdrawal and rechallenge helps patients distinguish whether their myalgia symptoms are because of statins, but, in at least 1 clinical trial, even 5% of placebo-treated patients developed myalgias during a controlled withdrawal and rechallenge. No consensus exists for management of patients with statin intolerance. Many patients can eventually tolerate a statin but often at suboptimal doses. A subset of patients do well with nondaily regimens such as every other day or once weekly dosing. Some patients cannot tolerate statins at all, requiring nonstatin lipid-lowering medications--the benefit of which remains unclear with regard to preventing atherosclerotic events. Ultimately, statin intolerance undermines the drug adherence that is critical for achieving the benefits of lifelong lipid-lowering therapy. In conclusion, statin myopathy is a common challenge in lipid management, and further work is needed to establish a standard diagnostic criterion as well as treatment algorithms.
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Affiliation(s)
- Zahid Ahmad
- Division of Nutrition and Metabolic Diseases, Department of Internal Medicine, Center for Human Nutrition, University of Texas Southwestern Medical Center, Dallas, Texas.
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Norata GD, Tibolla G, Catapano AL. Statins and skeletal muscles toxicity: from clinical trials to everyday practice. Pharmacol Res 2014; 88:107-13. [PMID: 24835295 DOI: 10.1016/j.phrs.2014.04.012] [Citation(s) in RCA: 34] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/06/2013] [Revised: 04/23/2014] [Accepted: 04/27/2014] [Indexed: 12/26/2022]
Abstract
The mechanism(s) underlying the occurrence of statin-induced myopathy are ill defined, but the results of observational studies and clinical trials provide compelling evidence that skeletal muscle toxicity is a frequent, dose-dependent, adverse event associated with all statins. It has been suggested that reduced availability of metabolites produced by the mevalonate pathway rather than intracellular cholesterol lowering per se might be the primary trigger of toxicity, however other alternative explanations have gained credibility in recent years. Aim of this review is: (i) to describe the molecular mechanisms associated to statin induced myopathy including defects in isoprenoids synthesis followed by altered prenylation of small GTPase, such as Ras and Rab proteins; (ii) to present the emerging aspects on pharmacogenetics, including CYP3A4, OATP1B1 and glycine amidinotransferase (GATM) polymorphisms impacting either statin bioavailability or creatine synthesis; (iii) to summarize the available epidemiological evidences; and (iii) to discuss the concepts that would be of interest to the clinicians for the daily management of patients with statin induced myopathy. The interplay between drug-environment and drug-drug interaction in the context of different genetic settings contribute to statins and skeletal muscles toxicity. Until specific assays/algorithms able to combine genetic scores with drug-drug-environment interaction to identify patients at risk of myopathies will become available, clinicians should continue to monitor carefully patients on polytherapy which include statins and be ready to reconsider dose, statin or switching to alternative treatments. The beneficial effects of adding agents to provide the muscle with the metabolites, such as CoQ10, affected by statin treatment will also be addressed.
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Affiliation(s)
- Giuseppe Danilo Norata
- Department of Pharmacological and Biomolecular Sciences, University of Milan, Italy; Center for the Study of Atherosclerosis, Società Italiana Studio Aterosclerosi, Bassini Hospital, Cinisello Balsamo, Italy
| | - Gianpaolo Tibolla
- Department of Pharmacological and Biomolecular Sciences, University of Milan, Italy; I.R.C.C.S. Multimedica, Milan, Italy
| | - Alberico Luigi Catapano
- Department of Pharmacological and Biomolecular Sciences, University of Milan, Italy; I.R.C.C.S. Multimedica, Milan, Italy.
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