After 2 years of treatment with atorvastatin 80 mg daily free of muscle symptoms, the patient developed progressive muscle pains in both lower legs. He stopped the statin 2 weeks prior to his clinic visit but the muscle pain and weakness did not noticeably improve. He now wants to know if he can be switched to red yeast Chinese rice. On examination, he has mild difficulty getting out of a chair and also has weakness after doing 3 squats. He remembers he felt fine doing squats at the gym about 6 months ago.
Which of the following is the best answer?
Show Answer
The correct answer is: b. He should stay off the statin until he is evaluated for possible causes of his muscle problems. A useful approach is to look for exogenous causes, systemic causes, and primary muscle disorders.
The history is consistent with statin-associated muscle symptoms, but muscle symptoms on a statin can be mimicked by a variety of other conditions, including polymyalgia rheumatica in older adults. Because his muscle symptoms had not shown any improvement within 2 weeks and the muscle weakness persisted after discontinuing the atorvastatin 80 mg, he was evaluated for systemic causes of myopathy. His CK was normal but his sedimentation rate was over 100 mm/hr and he was treated for his polymyalgia rheumatica. In general, statin-related muscle symptoms begin resolving within 1-2 weeks after statin discontinuation and muscle symptoms have completely resolved within 2 months. Failure of muscle symptoms to resolve within this time frame suggests another cause for the muscle symptoms.
Switching to another statin without determining the underlying etiology for the muscle symptoms denies the patient the opportunity to have a correct diagnosis. If his symptoms had instead resolved within two weeks, the cholesterol guidelines suggest he should be re-challenged with a lower dose of the same statin or switched to a comparable lower dose of another statin. The statin dose should then be increased as tolerated.
CoQ10 would not be useful in this case of polymyalgia rheumatica. The data supporting the use of CoQ10 for statin-associated muscle symptoms is inconsistent.
African Americans have higher CK levels on average than nonAfrican Americans. However, CK elevation above baseline can still be useful for monitoring statin-associated muscle symptoms.
Finally, a Chinese formulation containing red yeast rice was shown to reduce ASCVD events more than placebo in a randomized trial performed in China. There are no ASCVD outcomes data from U.S. RCTs trials available for red yeast Chinese rice.
References
Eckel RH. Approach to Patient Who is Intolerant of Statin Therapy J Clin Endocrinol Metab 95: 2015–2022, 2010).
Mancini GB, Baker S, Bergeron J, Fitchett D, Frohlich J, Genest J, Gupta M, Hegele RA, Ng D, Pope J. Diagnosis, prevention, and management of statin adverse effects and intolerance: proceedings of a Canadian Working Group Consensus Conference. Can J Cardiol. 2011 27(5):635-62.
Shamim S, Al Badarin FJ, DiNicolantonio JJ, Lavie CJ, O'Keefe JH. Red yeast rice for dyslipidemia. Mo Med. 2013 Jul-Aug; 110(4):349-54.
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