Management of patients with statin intolerance

Abstract

In recent years statins have become an established option in lipid-lowering pharmacotherapy despite the fact that statin intolerance is fairly common. When muscle pains and/or an elevation of the creatine kinase appear, the dose must be lowered in patients with slight symptoms or stopped altogether if the symptoms are more severe. When the symptoms are alleviated and creatine kinase is normalized, re-exposition can be considered. If symptoms recur, treatment with another statin should be attempted - in these cases pravastatin or fluvastatin are recommended, although they are less effective in reducing LDL cholesterol. As a rule, at least 3 statins should be tested. In some patients an intake of atorvastatin or rosuvastatin twice weekly may be tolerated and effective. Alternative drugs for patients who cannot tolerate any of the statins are ezetimibe and/or bile acid sequestrants. If LDL cholesterol targets are not reached, PCSK9 inhibitors may be used. In high-risk patients with multiple cardio-vascular events and sub-optimal LDL cholesterol despite lipid-lowering drug therapy a lipoprotein apheresis should be started. In this context, we present the history of a patient, who also had high lipoprotein(a) levels, for whom lipoprotein apheresis therapy was indicated.

Keywords: Bile acid sequestrants; Ezetimibe; Lipoprotein apheresis; Myopathy; PCSK9 inhibitors; Statin intolerance; Statins.