Association Between Vitamin D and Statin-Related Myopathy: A Meta-analysis

Treatment response variations to a single large bolus of enteral cholecalciferol in vitamin D deficient critically Ill children: Metabolomic insights for precision nutrition

Vitamin D deficiency (VDD) is prevalent globally and in pediatric intensive care units, where it represents a modifiable risk factor that may impact patient recovery during hospitalization. Herein, we performed a retrospective analysis of serum samples from a phase-II randomized placebo-controlled trial involving a single large bolus of 10,000 IU/kg vitamin D3 ingested by critically ill children with VDD (25-OH-D < 50 nmol/L). Targeted and untargeted methods were used to comprehensively measure 6 vitamin D metabolites, 239 lipids, 68 polar metabolites, and 4 electrolytes using a multi-step data workflow for compound authentication. Complementary statistical methods classified circulating metabolites/lipids associated with vitamin D repletion following high-dose vitamin D3 intake (n = 20) versus placebo (n = 11) comprising an optional standard of care maintenance dose (< 1000 IU/day). There was a striking increase in median serum concentrations of 25-OH-D3 (4.7-fold), 3-epi-25-OH-D3 (24-fold) and their C3-epimer ratio (6.7-fold) in treated patients on day 3, whereas serum vitamin D3 peaked on day 1 (128-fold) unlike placebo. Treatment response differences were attributed to D3 bioavailability and C3-epimerase activity without evidence of hypercalcemia. For the first time, we report the detection of circulating 3-epi-D3 that was strongly correlated with vitamin D3 uptake (r = 0.898). Metabolomic studies revealed that vitamin D sufficiency (serum 25-OH-D >75 nmol/L) coincided with lower circulating levels of 3-methylhistidine, cystine, S-methylcysteine, uric acid, and two lysophosphatidylcholines 7 days after treatment. Rapid correction of VDD was associated with indicators of lower oxidative stress, inflammation, and muscle protein turn-over that may contribute clinical benefits in high-risk critically ill children.

Vitamin D Deficiency-Induced Proximal Myopathy in a Pediatric Patient During COVID-19 Lockdown: A Case Report

Vitamin D deficiency is a significant public health concern that affects bone health and muscle function in children, especially in developing countries. The COVID-19 pandemic has intensified this issue because lockdowns have reduced sunlight exposure. We report a rare case of a 13-year-old Indian boy who developed severe proximal myopathy induced by vitamin D deficiency during the pandemic. The patient presented with generalized body aches, progressive lower limb weakness, difficulty walking, waddling gait, and a positive Gower's sign. Laboratory tests revealed severe hypovitaminosis D (25[OH]D level, 3.8 ng/ml), hypocalcemia, hypophosphatemia, elevated parathyroid hormone, and elevated alkaline phosphatase levels. Electromyography and nerve conduction study results were normal. The patient was diagnosed with vitamin D deficiency-induced proximal myopathy and osteomalacia, likely due to reduced sunlight exposure, inadequate dietary intake, and obesity. The treatment involved high-dose vitamin D supplementation, oral calcium, lifestyle modifications, and a structured physiotherapy program focusing on resistance training and functional mobility exercises. Despite biochemical normalization after 2 months, significant symptomatic improvement was achieved only after intensifying physiotherapy. By 7 months, the patient had fully recovered muscle strength, achieved normal gait, and maintained normal follow-up laboratory values. This case emphasizes the importance of considering vitamin D deficiency in children with muscle weakness during periods of limited sunlight exposure, and highlights the need for a multidisciplinary approach for effective management and full functional recovery.

Progressive Muscle Weakness: Identifying Necrotizing Autoimmune Myopathy as a Rare Culprit

Statin-induced necrotizing autoimmune myopathy (SINAM) is a rare but critical complication of statin therapy that leads to progressive muscle weakness. The complicated mechanisms underlying it make both diagnosis and treatment difficult. It is essential to recognize the condition early, especially in people who have had muscle problems treated with statins in the past. A 73-year-old woman arrived at the emergency department due to increasingly severe symmetrical muscle weakness accompanied by markedly elevated liver enzymes, creatine kinase (CK), and cardiac troponins. Although an acute cardiac event was ruled out, further tests indicated progressive myositis, necessitating hospitalization. A muscle biopsy subsequently confirmed myopathy with complement deposition, and anti-3-hydroxy-3-methylglutaryl-coenzyme A reductase (anti-HMGCR) antibodies were detected. With treatment that included corticosteroids, intravenous immunoglobulin, and rehabilitation, the patient showed remarkable improvement. This case undeniably highlights the critical importance of early detection of SINAM and intervention and emphasizes the absolute need for further research into causes and treatment strategies.

Lipids, lipid-modified drug target genes, and the risk of male infertility: a Mendelian randomization study

Background

Previous observational studies have reported a possible association between circulating lipids and lipid-lowering drugs and male infertility (MIF), as well as the mediating role of circulating vitamin D. Then, due to issues such as bias, reverse causality, and residual confounding, inferring causal relationships from these studies may be challenging. Therefore, this study aims to explore the effects of circulating lipids and lipid-lowering drugs on MIF through Mendelian randomization (MR) analysis and evaluate the mediating role of vitamin D.

Method

Genetic variations related to lipid traits and the lipid-lowering effect of lipid modification targets are extracted from the Global Alliance for Lipid Genetics Genome-Wide Association Study. The summary statistics for MIF are from the FinnGen 9th edition. Using quantitative expression feature loci data from relevant organizations to obtain genetic variations related to gene expression level, further to explore the relationship between these target gene expression levels and MIF risk. Two-step MR analysis is used to explore the mediating role of vitamin D. Multiple sensitivity analysis methods (co-localization analysis, Egger intercept test, Cochrane's Q test, pleiotropy residuals and outliers (MR-PRESSO), and the leave-one-out method) are used to demonstrate the reliability of our results.

Result

In our study, we observed that lipid modification of four lipid-lowering drug targets was associated with MIF risk, the LDLR activator (equivalent to a 1-SD decrease in LDL-C) (OR=1.94, 95% CI 1.14-3.28, FDR=0.040), LPL activator (equivalent to a 1-SD decrease in TG) (OR=1.86, 95% CI 1.25-2.76, FDR=0.022), and CETP inhibitor (equivalent to a 1-SD increase in HDL-C) (OR=1.28, 95% CI 1.07-1.53, FDR=0.035) were associated with a higher risk of MIF. The HMGCR inhibitor (equivalent to a 1-SD decrease in LDL-C) was associated with a lower risk of MIF (OR=0.38, 95% CI 0.17-0.83, FDR=0.39). Lipid-modifying effects of three targets were partially mediated by serum vitamin D levels. Mediation was 0.035 (LDLR activator), 0.012 (LPL activator), and 0.030 (CETP inhibitor), with mediation ratios of 5.34% (LDLR activator), 1.94% (LPL activator), and 12.2% (CETP inhibitor), respectively. In addition, there was no evidence that lipid properties and lipid modification effects of six other lipid-lowering drug targets were associated with MIF risk. Multiple sensitivity analysis methods revealed insignificant evidence of bias arising from pleiotropy or genetic confounding.

Conclusion

This study did not support lipid traits (LDL-C, HDL-C, TG, Apo-A1, and Apo-B) as pathogenic risk factors for MIF. It emphasized that LPL, LDLR, CETP, and HMGCR were promising drug targets for improving male fertility.

Decoding the Intricacies of Statin-Associated Muscle Symptoms

PURPOSE OF REVIEW

Hyperlipidemia is the major cardiovascular morbidity and mortality risk factor. Statins are the first-line treatment for hyperlipidemia. Statin-associated muscle symptoms (SAMS) are the main reason for the discontinuation of statins among patients. The purpose of this review is to guide clinicians to recognize the difference between self-limited and autoimmune statin myopathy in addition to the factors that potentiate them. Finally, treatment strategies will be discussed. This review mostly focuses on new data in the past 3 years.

RECENT FINDINGS

Recent findings suggest that SAMS is a complex and multifactorial condition that involves mitochondrial dysfunction, oxidative stress, and immune-mediated mechanisms. Effective management of SAMS requires a thorough evaluation of the patient's symptoms, risk factors, and medication history, as well as consideration of alternative treatment options. While statins are effective in reducing the risk of cardiovascular events, their use is associated with a range of adverse effects, including SAMS.

Statin Intolerance: a Review and Update

OBJECTIVE

To review evidence of existing literature on the management of statin intolerance.

METHODS

We searched for literature pertaining to statin intolerance and treatments in PubMed. We reviewed articles published between 2005 and 2022.

RESULTS

Statin-associated myalgia is the most common adverse effect of statin therapy and the most common reason for statin discontinuation. Risk factors for statin intolerance include unexplained muscle pain with other lipid-lowering therapy, unexplained cramps, history of elevated creatinine kinase levels, family history of muscle symptoms, and family history of muscle symptoms with lipid therapy. Vitamin D repletion and coenzyme Q supplementation may help alleviate the musculoskeletal effects of statins. Trials of different types of statins and different dosing regimens are recommended to improve tolerability. The use of statins in individuals who perform regular exercise requires closer attention to muscular symptoms and creatinine kinase levels, but it does not preclude the use of statins.

CONCLUSION

Management of the adverse effects of statin therapy and improving statin tolerability is key to achieving optimum cardiovascular benefits. Identifying statin-associated adverse effects and managing appropriately can reduce unnecessary statin discontinuation and subsequently provide longer cardiovascular protection.

Side effects of statins: from pathophysiology and epidemiology to diagnostic and therapeutic implications

Treatment with statins, inhibitors of 3-hydroxy-3-methylglutaryl-coenzyme A reductase, has proven beneficial preventive effects on cardiovascular events. However, discontinuation due to intolerance and non-adherence remain two of the major gaps in both primary and secondary prevention. This leads many patients with high-risk of atherosclerotic cardiovascular disease (ASCVD) to be inadequately treated or not to achieve target lipid level goals, and as consequence they undergo an increased risk of cardiovascular events. The aim of this review is thus to give an overview of the reasons for discontinuation and on the possible mechanisms behind them. Although statins, as a class, are generally safe, they are associated with an increased risk of diabetes mellitus and hepatic transaminase elevations. Incidence of cataracts or cognitive dysfunction and others presented in the literature (e.g. proteinuria and haematuria) have been never confirmed to have a causal link. Conversely, debated remains the effect on myalgia. Muscle side effects are the most commonly reported, although myalgia is still believed by some to be the result of a nocebo/drucebo effect. Concerning mechanisms behind muscular side effects, no clear conclusions have been reached. Thus, if on one side it is important to identify individuals either at higher risk to develop a side effect, or with confirmed risk factors and conditions of statin intolerance, on the other side alternative strategies should be identified to avoid an increased ASCVD risk.

Statins Neuromuscular Adverse Effects

Statins are drugs widely prescribed in high-risk patients for cerebrovascular or cardiovascular diseases and are, usually, safe and well tolerated. However, these drugs sometimes may cause neuromuscular side effects that represent about two-third of all adverse events. Muscle-related adverse events include cramps, myalgia, weakness, immune-mediated necrotizing myopathy and, more rarely, rhabdomyolysis. Moreover, they may lead to peripheral neuropathy and induce or unmask a preexisting neuromuscular junction dysfunction. A clinical follow up of patients assuming statins could reveal early side effects that may cause neuromuscular damage and suggest how to better modulate their use. In fact, statin dechallenge or cessation, or the alternative use of other lipid-lowering agents, can avoid adverse events. This review summarizes the current knowledge on statin-associated neuromuscular adverse effects, diagnosis, and management. It is conceivable that the incidence of neuromuscular complications will increase because, nowadays, use of statins is even more diffused than in the past. On this purpose, it is expected that pharmacogenomic and environmental studies will help to timely predict neuromuscular complications due to statin exposure, leading to a more personalized therapeutic approach.

Association Between Vitamin D Supplementation and Statin-Associated Muscle Symptoms: A Systematic Review

INTRODUCTION

Although low vitamin D levels are associated with statin-associated muscle symptoms (SAMS), it remains unclear if vitamin D supplementation leads to symptom improvement.

AIM

We performed a systematic review to evaluate the association of vitamin D supplementation with resolution of SAMS.

METHODS

We searched Medline (PubMed), Embase and Cochrane Library till 12 December 2021. Full length articles that reported on the association between vitamin D supplementation in adult patients with SAMS were included.

RESULTS

We identified 8 interventional studies comprising 669 participants. Majority of the participants were of Caucasian ethnicity and the mean age of participants ranged from 59.5 to 64.8 years old. The studies recruited patients with initial mean pre-treatment vitamin D levels ranging from 17.8 to 22.0ng/mL. Follow up duration ranged from 2 to 24 months and mean post-treatment vitamin D levels ranged from 34.3 to 56.0ng/mL. We found that vitamin D supplementation was associated with improved statin tolerance in 509 out of 606 (83.9%) patients across the 7 studies which reported patient numbers after supplementation (95% CI = 0.81-0.87, I2 = 72% n = 7). None of the studies were randomized controlled trials (RCTs) and hence placebo effect of vitamin D could not be ruled out. Nocebo effect of statin was also not assessed by any of the studies.

CONCLUSION

Vitamin D supplementation in patients with mild-moderate vitamin D insufficiency was associated with improvement of SAMS. However, quantitative efficacy analysis was not possible and this observed association is likely confounded by nocebo and placebo effects. RCTs are required to conclusively assess the utility of vitamin D supplementation in improving SAMS.