Tuesday, October 13, 2009

Lowering your cholesterol or attacking your muscles? The complications of Statin drugs

Lowering your cholesterol or attacking your muscles? The complications of Statin drugs. Inspired by a past classmate

Important definitions
Creatine Kinase- A protein in muscles. Often used as a marker in blood test indicating muscle break down.
Myopathy – A pathology of a muscle
Myalgia – Muscle aches and pains without elevation of creatine kinase
Myositis –Includes muscle discomfort involving the elevation of creatine kinase
Rhabdomyolysis – Muscle complaint that involves CK elevation greater then 10x the normal limit.

I am not a pharmacist and never claim to know a lot about medication. However, I am always looking for information and research on medications which may cause a patient’s symptoms. Occasionally a diagnosis may not be a diagnosis but merely a side effect from medication. It’s important for all health care practitioners to be able to spot the difference.

Statins are a group of medications which were introduced in the late 1980’s. Statins are designed to help lower cholesterol levels, reduce cardiovascular events and in the long term mortality.  However, every medication has its side effects and complications. The following article “Neuromuscular Complications of Statins” attempts to explain, discuss and outline some of the complications starting to evolve with this group of medication. 

The main complication starting to be shown with Statins are myopathies (Definition above). The cause of a “Statin-associated myopathy” is not fully known.  Right now most of the explanations are merely “theory” and not “fact”. It is believed that Statins lower important chemical components that cells use for stability and growth. Another theory is Statins lower a molecule called ubiquionones or coenzyme Q10. This particular molecule is used by certain cells as an energy source to help stabilize their outer shell. Thus, lower levels equal less stability and a cell which is more prone to develop pathology. However, why only muscle cells are affected is not known. The strongest research for this theory is in the treatment. There have been two studies which have shown by supplementing this particular molecule symptoms improved significantly [2,3].

The only real symptom of a Statin-associated myopathy is diffuse muscle pain with associated weakness. Diagnosis may lie in correlating symptoms with the onset of Statin treatment. It has been shown to be on average 6.3 months duration until Statin usage may create a myopathy. Furthermore, the answer may be found in certain testing procedures such as measuring CK levels, EMG studies and muscle biopsy. Finding elevated CK levels can give indication that muscle tissue is being broken down. Approximately 65% of patients with symptoms have increased CK levels. However, it’s important to not be mistaken in the athletic patient. CK levels can also be elevated in athletes who train and compete. Studies have also used muscle biopsy to indicate pathology in muscle tissue. However, this procedure is fairly invasive and may be hard to come by depending on your network or location. In addition, EMG studies have been shown to be inconclusive in research with each study producing different results.

As you can see making such a diagnosis is a difficult task. First of all, the symptoms overlap a numerous number of other clinical conditions. Secondly, only a diligent history taking and knowledgeable practitioner could correlate the medication with such symptoms.  Lastly, testing procedures are invasive and scarce. Furthermore, symptoms last for approximately 2.3 months (0.25 -14 range) after Statin use has been ceased. This is not a treatment you can afford to have your patient attempt to stop based merely on a hunch.

Often the only treatment which we can provide for such a complication is attempting to prevent it. Furthermore, having the knowledge to spot such a diagnosis is often treatment enough. If not diagnosed these patients could go a long time with conflicting symptoms. Eventually they may be misdiagnosed, given further medication, exposed to numerous test and worse cause scenario mortality.  Consider the following for patients to discuss with their family doctor or local pharmacist:

1. Conventional methods should be pursued first with those who have high cholesterol. Diet, nutritional advice and exercise are sometimes enough.
2. Often the lowest dose of a Statin can produce therapeutic LDL levels in these patients. The risk-benefit ratio should be discussed with their physician to find the right dose and Statin.
3. Being knowledgeable on other medications which may affect Statin usage is a must. Often it may not be the Statin but another drug the patient is taking which is causing the symptoms. Case studies have even been written on grapefruit consumption affecting Statins to cause these symptoms. Pretty scary considering Grapefruit juice is often deemed useful in helping cholesterol levels [4].
4. Collaborate with a doctor on establishing baseline values. It’s important to not just monitor CK levels but to set a baseline in which to compare new findings with.
5. Be aware of risk factors which increase the likelihood of such a condition [5].
6. Educate your current patient who is on Statins or starting Statin treatment on this condition. This may allow you to spot the problem early.
7. Supplementing with CoQ10 may help prevent symptoms from developing or reducing them after they have already developed.
In summary, I cannot stress enough how this is not a diagnosis to take likely. This is something which should be communicated with others who are PROFESSIONALS ON MEDICATION. Dosage and Statin recommendations should be discussed with a family physician or pharmacist. However, the knowledge of this condition can help us perhaps save a life. Dr. Wayne Button, BSc, DC

Ahn SC (2008). Neuromuscular complications of statins. Physical medicine and rehabilitation clinics of North America, 19 (1) PMID: 18194749

Koumis T, Nathan JP, Rosenberg JM, & Cicero LA (2004). Strategies for the prevention and treatment of statin-induced myopathy: is there a role for ubiquinone supplementation? American journal of health-system pharmacy : AJHP : official journal of the American Society of Health-System Pharmacists, 61 (5), 515-9 PMID: 15018231

Langsjoen PH, Langsjoen JO, Langsjoen AM, & Lucas LA (2005). Treatment of statin adverse effects with supplemental Coenzyme Q10 and statin drug discontinuation. BioFactors (Oxford, England), 25 (1-4), 147-52 PMID: 16873939

Ando, H., Tsuruoka, S., Yanagihara, H., Sugimoto, K., Miyata, M., Yamazoe, Y., Takamura, T., Kaneko, S., & Fujimura, A. (2005). Effects of grapefruit juice on the pharmacokinetics of pitavastatin and atorvastatin British Journal of Clinical Pharmacology, 60 (5), 494-497 DOI: 10.1111/j.1365-2125.2005.02462.x

Bellosta, S. (2004). Safety of Statins: Focus on Clinical Pharmacokinetics and Drug Interactions Circulation, 109 (23_suppl_1) DOI: 10.1161/01.CIR.0000131519.15067.1f


  1. The first step to getting your cholesterol under control is to have it tested. Once you know what your numbers are and mean, you can measure the success or failure of any cholesterol management program you follow.

  2. I eat very little, you need to check my cholesterol level in my body?.
    Personally I always thought it was not necessary, but I do not suffer from such problems

    Sara Rides

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