American College of Physicians: Internal Medicine — Doctors for Adults ®

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Benefits of statins may outweigh the risks for many patients

From the September ACP Observer, copyright © 2007 by the American College of Physicians.

By Deborah Gesensway

TORONTO—When a patient complains of muscle aches and pains after starting to take statins for high cholesterol, many physicians suspect statin intolerance. But that isn't always the case, particularly during monotherapy, said an expert on dislipidemia.

Muscle complaints are exceedingly common, said Lisa Tannock, MD, assistant professor of internal medicine and endocrinology at the University of Kentucky. They may even be pre-existing or coincidental. But the cardiovascular benefits most patients receive from taking these cholesterol-lowering drugs far outweigh the common side effects, she said. And adverse events are very uncommon.

As she told attendees at a session on "Treatment of Lipid Disorders" at the Endocrine Society's annual meeting in June, studies have determined a need to treat only 27 patients with a statin in order to prevent one myocardial infarction, revascularization, stroke, cardiovascular death or other mortality. That compares with treating 3,400 people to observe serious creatine kinase elevation or 7,428 people to find rhabdomyolysis.

"Once a patient has been told by their primary care doctor that they are statin intolerant, it doesn't matter what I tell them. They will not go on a statin," said Dr. Tannock. "We need to really educate the primary care doctors that minor rises in liver function tests, minor muscle aches and pains are not necessarily signs of statin intolerance."

Her strategy with a patient who is wary about starting statins because of potential side effects is to have them keep a symptom diary.

"I show them the data that hypercholesteremia is strongly associated with CVD," she said. In addition, she generally starts such patients on a low dose. In a pinch, niacin can be an alternative. Zetia is an alternative, but as monotherapy is not ideal, she said.

She also counsels aggressive treatment for young patients with very high cholesterol and a strong family history. For example, a 23-year-old healthy female college student with a total cholesterol of 458 mg/dl, LDL of 378 mg/dl and HDL of 69 mg/dl would be a candidate for aggressive treatment.

"We now know that atherosclerotic plaques are building up over decades," Dr. Tannock said. "Her risks are huge, but not in the next 10 years. The protection that premenopausal women have against CVD, moreover, is not nearly as great as people assume. "It's only about 5% less in women than in men," she said. She said she would start the college student on medium to high dose of a potent statin and counsel her about the need to stay on birth control and to plan for pregnancy.

"Many people say they would not treat her because of her age and because she might become pregnant, but I say, how many of you know 23-year-olds on [isotretinoin] for their acne, and that is much more teratogenic than statins," Dr. Tannock said. "She may not get pregnant for 10 years, and meanwhile I've lowered her lipids. The risk of this type of lipid panel is too great."

Dr. Tannock also stressed the importance of thinking about different causes of the disease. Sometimes, she said, dyslipidemia can be caused by thyroid dysfunction, endocrinopathies such as Cushing's syndrome or renal disease.

She presented a case of a 43-year-old man with a strong family history of CVD who came to her with a total cholesterol of 322 mg/dl, LDL of 248 mg/dl, and HDL of 52 mg/dl. After discovering he had hypothyroidism, she treated him with thyroxine, which alone dramatically lowered his cholesterol.

"It is important to do a physical exam, because that's how I found the enlarged thyroid," she said. "It demonstrates a case in which [statin] therapy may not have been appropriate."

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