Practical management
We believe there are grounds for maintaining that statins are not the cause of muscle problems among the majority who report pain of this nature in clinical practice (11–15). Health personnel are recommended to allocate sufficient time with the individual patient to build a good relationship of trust (2, 8, 19). It is also important to explain to patients that statins are administered not merely to reduce a number, but that they actually cause regression of atherosclerosis and protect the individual from illness and death.
A thorough clinical history to show the relationship between intake of statins and symptoms, along with examination of alternative explanations for muscle symptoms, are of key importance
Patients' negative expectations regarding statin therapy should be managed, preferably in connection with prescription, by providing information about the beneficial preventive effect on cardiovascular disease, the low risk of adverse reactions and the good tolerability, which have now been documented in robust scientific studies (2, 8, 19). Many patients treated with statins are elderly, and there are several other possible reasons for their muscle problems. A thorough clinical history to show the relationship between intake of statins and symptoms, coupled with examination of alternative explanations for the muscle symptoms, such as musculoskeletal disorders or rheumatic disease, is therefore of key importance. (8, 14, 19). Breaks in drug therapy may help, and if the symptoms do not disappear within four weeks without statins, they very likely have another cause. A few very intolerant patients, often thin, elderly women, should be started on the lowest dose of atorvastatin or rosuvastatin, which because of their long half-life can be administered 2–3 times a week, with slow upward titration to the highest tolerable dose (2, 8). If this strategy is applied, our experience is that the great majority tolerate a statin.
Myopathy and rhabdomyolysis with a rise in creatine kinase occur very rarely. These conditions are reversible with few exceptions if the statin is discontinued for 4–6 weeks, and many will tolerate a statin from a different class if they are started on a low dose and gradually titrated up (6, 8). It is recommended that for this group the creatine kinase level should be monitored for the first few months after a change of medication. Investigating whether the patient uses interacting medicines is also recommended (2, 8). Some patients may have a high creatine kinase level without symptoms. This is often due to physical activity. In these cases it is important to tell the patient not to exercise in the week before a new blood test.
Ezetimibe inhibits the absorption of cholesterol from the bowel, is well tolerated and reduces the LDL cholesterol level achieved by statin therapy by a further 10–15 % (2). Combination therapy is therefore important and recommended (2) in attempts to attain the recommended LDL cholesterol levels.