That Myalgia of Yours Is Not From Statin Intolerance

Statin-Associated muscle symptoms and vitamin D supplementation

PURPOSE OF REVIEW

Statin medications play a pivotal role in the primary and secondary prevention and management of cardiovascular disease due to their potent lipid-lowering and anti-inflammatory effects. Nevertheless, the clinical application of statins is often hampered by statin-associated muscle symptoms (SAMS), which deter patient adherence and treatment efficacy considerably. SAMS currently affects 10-20% of statin users, thus understanding potential mitigation strategies is crucial. This review focuses on the role of vitamin D in mitigating SAMS, given the growing interest in vitamin D deficiency as a potentially modifiable risk factor.

RECENT FINDINGS

Despite observational suggestions linking vitamin D deficiency to heightened SAMS risk, recent studies have yielded conflicting results on the role of vitamin D supplementation in preventing SAMS. Some studies report an improvement in statin tolerance following vitamin D repletion. However, recent large-scale clinical trials, particularly the Vitamin D and Omega-3 trial (VITAL) report no significant benefit of vitamin D supplementation in preventing SAMS or reducing statin discontinuation rates, regardless of baseline vitamin D levels.

SUMMARY

Observational data provides evidence for the use of vitamin D supplementation in SAMS management, however conflicting evidence in recent clinical trials do not support its routine use for preventing or treating SAMS. To explore alternative strategies in improving statin tolerance and adherence, this discourse aims to elucidate the current understanding the complex mechanisms underlying SAMS, the influence of serum vitamin D levels, and the implications for clinical management.

Is there a role for earlier use of combination therapy?

As the global population ages and cardiovascular risk factors rise, we can expect a continued increase in atherosclerotic disease. Low-density lipoprotein cholesterol (LDL-C) reduction is a cornerstone of cardiovascular risk reduction with strong, causal evidence indicating that the greatest benefit is derived from early and large decreases in LDL-C. Despite the adoption of statins as the backbone of lipid-therapy regimens, numerous studies and registry analyses reveal our collective inability to achieve LDL-C goals in high-risk patients. Combination therapy with ezetimibe has been shown to result in statistically significant decreases in LDL-C level, atheroma volume, and cardiovascular adverse event rates. A major barrier to implementing an upfront combination therapy approach is the perceived side effects from therapeutic agents although multiple studies show that a therapeutic patient-physician relationship could overcome this issue. Novel agents such as PCSK-9 inhibitors, bempedoic acid, and inclisiran have the potential to achieve similar outcomes although additional research is needed regarding the cost effectiveness of these approaches. Despite these hurdles, there is a role for the newer agents early in the disease course of high-risk patients such as those with markedly elevated LDL-C >190 mg/dL and FH. The implementation of upfront combination therapy, especially in high-risk patients, will decrease clinical inertia while allowing for earlier consideration of newer, effective agents to decrease cardiovascular burden.

Effect of rosuvastatin 20 mg versus rosuvastatin 5 mg plus ezetimibe on statin side-effects in elderly patients with atherosclerotic cardiovascular disease: Rationale and design of a randomized, controlled SaveSAMS trial

BACKGROUND

Current guidelines recommend that patients with established atherosclerotic cardiovascular disease (ASCVD) use high-intensity statin therapy to lower low-density lipoprotein (LDL)-cholesterol levels by at least 50%, irrespective of age. However, in real-world practice, there is reluctance to maintain statin use in response to side-effects, particularly statin-associated muscle symptoms (SAMS). Moreover, no randomized trial has been conducted on the safety of statin therapy in elderly patients.

TRIAL DESIGN

This investigator-initiated, multicenter, randomized clinical trial aimed to investigate the incidence of SAMS and its effect on LDL-cholesterol levels in elderly patients with established ASCVD. Eligible patients were aged 70 years or older with established ASCVD. Consecutive patients who met the inclusion criteria were randomized in a 1:1 fashion to receive either intensive statin monotherapy (rosuvastatin 20 mg) or combination therapy (rosuvastatin/ezetimibe, 5/10 mg). The primary endpoint of the study is SAMS at 6 months with regard to treatment strategy. Positive SAMS results are defined as patients with a proposed statin myalgia index score of 7 or higher. The key secondary end-points are target LDL-cholesterol achievement (LDL < 70 mg/dL), incidence of myopathy, rhabdomyolysis, frequency of drug discontinuation, and creatinine kinase, aspartate transaminase, alanine transaminase, total cholesterol, LDL-cholesterol, high-density lipoprotein-cholesterol, triglyceride, and highly sensitive C-reactive protein levels at 6 months.

CONCLUSIONS

The SaveSAMS study is a multicenter, randomized trial that will compare the incidence of SAMS in patients with established ASCVD who are 70 years or older on intensive statin monotherapy to that combination therapy.

Dyslipidemia in Diabetes: When and How to Treat?

Elevated triglyceride and reduced high-density lipoprotein cholesterol (HDL-C) are common in type 2 diabetes, but increased atherogenic particles and dysfunctional HDL are demonstrable in both types 1 and 2 diabetes, contributing to a two-fold increase in atherosclerotic cardiovascular disease (ASCVD). ASCVD risk accelerates with diabetes duration and severity, aging, risk factors, and risk enhancers. Using statins or other LDL-C-lowering agents if needed in adults with intermediate or greater degrees of risk is recommended. Although hypertriglyceridemia enhances risk, most guidelines do not recommend fibrates or omega 3 fatty acid for risk reduction except for icosapent ethyl in patients with ASCVD.

New insights into the role of bempedoic acid and ezetimibe in the treatment of hypercholesterolemia

PURPOSE OF REVIEW

A number of new cholesterol-lowering drugs have been recently developed and approved, enriching the pharmacological armamentarium beyond and above statins. Ezetimibe, available since two decades, and bempedoic acid, a new drug inhibiting the same biosynthetic pathway targeted by statins but at an early step, represent valuable tools for the treatment of hypercholesterolemia, particularly in specific groups of patients.

RECENT FINDINGS

Bempedoic acid, either alone or in combination with ezetimibe, appears to reduce significantly LDL-C levels, an effect that has been observed also in patients with statin intolerance. A Mendelian randomization study has anticipated a protective cardiovascular effect of bempedoic acid; a randomized clinical trial is currently assessing whether the pharmacological control of hypercholesterolemia with bempedoic acid translates into a clinical benefit. Bempedoic acid, as well as ezetimibe, does not appear to induce adverse events in muscles; moreover, whereas statins are associated with a modest, although significant, increased risk of new-onset diabetes, bempedoic acid does not, at least based on the available evidence.

SUMMARY

On the basis of available data, and while awaiting the results of the outcome trial, bempedoic acid appears to represent a valuable approach for the treatment of hypercholesterolemia, either alone or in combination in ezetimibe.