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Continuing Professional Development
Some investigators have tested the
use of coenzyme Q10 supplementation
(between 100--200 mg daily) in patients
experiencing statin myopathy who
continued with their statin. Pain and
myalgia scores improved in the coenzyme
Q10 groups in some trials, but not all.3
Marcoff, et al. in their systematic review
concluded that there is little evidence
to routinely recommend coenzyme Q10,
but some patients may respond and it
therefore it may be worthwhile using
in those who do not respond to other
measures.40 Some have recommended
the use of 600 mg daily of coenzyme
Q107 -- an ongoing clinical trial is assessing
the efficacy of coenzyme Q10 in reducing
muscle pain in previously statin intolerant
patients who are concurrently receiving
simvastatin 20 mg daily.41
As discussed the vast majority of patients
have resolution of their symptoms
relating to statin-induced myopathy
within three months of withdrawal
from the medication. However, there
may be a subgroup of patients whose
symptoms fail to improve and muscle
weakness progresses. Biopsy specimens
taken in some of these patients have
shown necrotising myopathy with
inflammatory changes and small case
studies have demonstrated the benefit
of using immunosuppressive therapy
(e.g. prednisolone, methotrexate).5
Patients who develop rhabdomyolysis
usually recover completely within days
• Consider reducing prednisolone to
25 mg daily and review blood glucose
• Consider ceasing amlodipine and
review blood pressure, constipation,
and use of laxatives.
• Consider once monthly risedronate
with vitamin D and calcium.
• Consider ceasing budesonide.
• Consider ceasing clotrimazole cream.
• Advised GP that there is no convincing
evidence that chronic use of stimulant
laxatives causes structural and/or
functional damage to the colon and
induce a 'lazy bowel'.42,43
Outcomes at 12 months
• Prednisolone dose was reduced to
25 mg (and eventually 15 mg daily)
without increase in muscle pains or
worsening mobility. Methotrexate had
been commenced 10 mg per week with
improvement in muscle symptoms.
• Amlodipine was ceased and blood
pressure remained acceptable (no
change in laxative use), but diltiazem
was eventually commenced without
any worsening of constipation.
• Risedronate, calcium, vitamin D not
commenced (patient refused).
• Budesonide was ceased without any
change in use of salbutamol (patient
continued to smoke).
• Clotrimazole cream was ceased.
1. Baigent C, Keech A, Kearney PM, et al. Efficacy and safety of
cholesterol-lowering treatment: prospective meta-analysis of
data from 90,056 participants in 14 randomised trials of statins.
2. Thompson PD, Clarkson P, Karas RH. Statin-associated
myopathy. Jama 2003;289:1681--90.
3. Joy TR, Hegele RA. Narrative Review: Statin-Related Myopathy.
Ann Intern Med 2009;150:858--U63.
4. Scott D, Blizzard L, Fell J, Jones G. Statin therapy, muscle
function and falls risk in community-dwelling older adults.
5. Mastaglia FL. Iatrogenic myopathies. Curr Opin Neurol
6. Bruckert E, Hayem G, Dejager S, Yau C, Begaud B. Mild to
moderate muscular symptoms with high-dosage statin
therapy in hyperlipidemic patients -- The PRIMO study.
Cardiovasc Drug Ther 2005;19:403--14.
7. Fernandez G, Spatz ES, Jablecki C, Phillips PS. Statin myopathy:
a common dilemma not reflected in clinical trials. Cleve Clin J
8. Armitage J. The safety of statins in clinical practice. Lancet
9. MIMS Australia. Product Information (Zocor). In. Sep 2013 ed;
Accessed Sep 2, 2013.
10. Furberg CD, Pitt B. Withdrawal of cerivastatin from the world
market. Curr Control Trials Cardiovasc Med 2001;2:205--7.
11. Davidson MH. Controversy surrounding the safety of
cerivastatin. Expert Opin Drug Saf 2002;1:207--12.
12. Sinzinger H, O'Grady J. Professional athletes suffering
from familial hypercholesterolaemia rarely tolerate statin
treatment because of muscular problems. Br J Clin Pharmacol
13. Ahmad A, Bhella HS, Umar M, et al. Low Serum 25(Oh) Vitamin
D Levels (< 32ng/Ml) Are Associated with Reversible Myositis-
Myalgia in Statin-Treated Patients. J Invest Med 2010;58:657.
14. Lee P, Greenfield JR, Campbell LV. Vitamin D insufficiency - a
novel mechanism of statin-induced myalgia? Clin Endocrinol
15. Link E, Parish S, Armitage J, et al. SLCO1B1 variants and
statin-induced myopathy--a genomewide study. N Engl J Med
16. Romaine SP, Bailey KM, Hall AS, Balmforth AJ. The influence
of SLCO1B1 (OATP1B1) gene polymorphisms on response to
statin therapy. Pharmacogenomics J 2010;10:1--11.
17. Notarangelo MF, Marziliano N, Demola MA, et al. Genetic
predisposition to atorvastatin-induced myopathy: a case
report. J Clin Pharm Ther 2012;37:604--6.
Table 4. Risk factors for statin-related myopathy (adapted from3,7,8)
• Advanced age
• Small body frame and frailty
• Multisystem disease (especially liver, kidney)
• Grapefruit juice consumption (> 1 L/day)
• Major surgery/perioperative period
• Excessive physical activity
• Family history of statin myopathy
• History of creatine kinase elevation
• Prior history of statin myopathy
• Unexplained cramps
• Vitamin B12 deficiency
• Vitamin D deficiency
• High dose statin therapy
• Red yeast rice (contains lovastatin)‡
• Medications used concurrently
-- Fibrates (gemfibrozil 15X > risk
-- Azole antifungals;
-- Macrolide antibiotics;
-- HIV protease inhibitors;
*Those medications which inhibit with CYPP450 or organic anion transporter peptides may increase some statin
levels. Refer to other resources for more information for specific drug-drug interaction information.
†= myopathy can be caused by colchicine alone.27 ‡ The fungus Monascus purpureus is myotoxic and grows on rice/
corn silage and has a purple/red colour which is commonly found in Asian foods as colourant or ingredient, such as
pickled tofu, red rice vinegar, Peking duck, Chinese barbecued pork.27
'As discussed the vast
majority of patients
have resolution of
relating to statin-
within three months
of withdrawal from
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