Myalgias are common in patients with statins; however, the cause and effect relationship is unclear. We recommend trying other statins or lowering the dose. Consider a 10- to 14-day vacation from statins and see if the myaligia symptoms abate as a diagnostic maneuver. The evidence is inconclusive at this time for treating myalgia with Vitamin D and coenzyme Q. If patients are intolerant to a statin, clinicians are encouraged to have the patient try the other statins in reduced doses before ruling out all statins. If patients are unable to take a statin, then bile-acid sequestrants, niacin, fibric acid derivatives or fibrates, and ezetimibe are available. In the Lipid Research Clinics Coronary Primary Prevention Trial (LRC-CPPT), cholestyramine 24 grams/day showed a 10% reduction in risk of fatal and non-fatal MI. Adherence in this study varied, but a linear relationship was seen with reduction in CHD risk corresponding to cholestyramine dose and reduction in LDL-cholesterol (Lipid Research Clinics Program, 1984 [A]). In the Coronary Drug Project, niacin 3 grams/day reduced mortality 11% over placebo. There are also studies with angiographic endpoints that showed benefits of bile-acid sequestrants alone and in combination with niacin (Coronary Drug Project Research Group, The, 1975 [A]). The VA-HIT trial, utilizing gemfibrozil 600 mg twice daily, showed a 22% reduction in the combined incidence of CHD death and non-fatal MI. The ENHANCE study evaluated simvastin with and without ezetimibe on carotid intima-media thickness in familia hyperlipidemic patients and did not find a significant difference after 24 months in this surrogate endpoint, though the LDL was significantly lower with combination therapy (Kastelein, 2005 [A]). The SEAS study, while not showing a difference in aortic stenosis progression with combination therapy, did show a significant reduction in the secondary endpoint of non-fatal ischemic events in the simvastin/ezetimibe-treated group compared to placebo after 52 months (Rossebo, 2008 [A]). |