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Myopathy Mini CasesCASE 1.Jessica is a 33 yo female with DM. Based on her CVD risk factors, she is indicated for a moderate to high intensity statin. You discuss starting atorvastatin 20 mg once daily with her. She asks what side effects she may experience. How should you counsel her?Atorvastatin (Lipitor) safe for the most partSome people have stomach upset, gas, heartburn, or diarrhea with their statin. Take it with supper if you have these symptoms and tell your prescriber if these side effects are severe or don’t go awayA more serious but not common side effect is muscles sorenessCan be a sign of muscle injury.Often in large muscles such as thigh or calfTypically symmetrical Important to tell your prescriber if you have muscle pain, soreness, or weaknessVERY important to tell them if you have severe muscle pain or dark urine Multiple alleviating strategies!!!People with DM are at a much higher risk of heart attach and stroke, and the use of cholesterol medications like atorvastatin have been shown to significantly reduce these risksCASE 2.Wilma is a 63 yo female with DM who was started on atorvastatin 80 mg 4 weeks ago. She calls the office reporting that she is experiencing leg pains and difficulty climbing the stairs at her apartment. She states “both my calves hurt and feel weak like they cannot support me.” The medical resident asks your advice on how to address this possible statin induced myopathy.Consider checking CKHold statin for 2-4 weeksCheck renal and hepatic functionEvaluate other possible causesOnce symptoms resolve, options includeRestart with same statin at same or lower doseIf symptoms return – d/c statin and start different statin at lower dose once symptoms resolveStart a low or target dose of a different statin, increase as toleratedIf not tolerated, try extended dosing frequency (EOD or 2x/week)If low CV risk, consider lifestyle interventions. If high-risk, consider adding ezetimibe. CASE 3.Henry is a 66 yo male male who has been taking simvastatin 80 mg for the past 5 years. He is a current alcoholic who drinks 3-5 beers per day and up to 12 per day on the weekends. On a Monday he calls the clinic reporting severe leg pains and weakness “can hardly walk, my legs feel so unstable and hurt”. He also mentions that his urine this morning was “the color of brown ale”. Current medications-stimvastatin 80 mg once daily-HCTZ 25 mg once daily-gemfibrozil 600 mg twice daily-niacin ER 1,000 mg nightly -Prestalia 14/10 mg once daily (perindopril/amlodipine)What muscle related issue might this patient have? rhabdomyolysis What signs/symptoms are consistent with your suspicion? severe muscle crams/weakness; dark urineComplete a drug interaction report. What interactions did you find?Gemfibrozil – simvastatin: contraindicatedAmlodipine – simvastatin: max dose of simva 20 mgNiacin – simvastatin: increase risk of rhabdomyolysis with niacin doses > 1 g/day What risk factors does he have for developing a myopathy?Multiple drug-drug interactions Multiple drugs that can cause myopathyAlcoholic – acute on chronic (Monday after the weekend)Simvastatin 80 mgPossible hepatic damage from chronic ETOHHow would you manage this patient?Initial response to patient on phone: Staff with physician. Patient needs to be referred to hospital for rhabdo work upLabs you would order: CK, Scr, possibly ALT/ASTMedications you would change: stop simvastatin, gemfibrozil, and niacinLong-term ASCVD management plan: if rhabdo confirmed, would likely not restart a statinCASE 4.Kate, a medical resident comes to you about her patient Cathy who is having mild muscle pain that she suspects is from rosuvastatin, which was started 2 weeks ago. Cathy has had terrible muscle pains with simvastatin, atorvastatin, and pravastatin in the past, but her ASCVD risk is 26% and she is indicated for high intensity statin therapy. The medical resident knows she heard that statins can sometimes be doses with “extended regimens” but is unsure which statins this applies to and what doses have been studied. What would you recommend to her?Rosuvastatin5 mg 2-3x/week – LDL lowering of 30%5-10 mg/week – LDL lowering of 10%Atorvastatin 20 mg EOD – LDL lowering ~ 40%Could consider adding Ezetimibe (IMPROVE-IT)Kate recently completed her cardiology rotation and saw many patients on CoQ10 as a measure to reduce muscle symptoms. She asks you if this she should start Cathy on this supplement. What resource would provide a summary of evidence for the use of CoQ10?Natural Medicines Comprehensive DatabaseBriefly summarize the efficacy and safety of CoQ10 for prevention of statin related muscle symptoms as well as the recommended dosing instructions. Efficacy studies have found conflicting resultsPlacebo-controlled crossover rechallenge of CoQ10 600 mg daily did not affect pain, muscle strength, or aerobic performance vs placeboLikely safe when dosed appropriatelyConsider 100 mg once daily or 200 mg divided two or three times daily (to minimize gastrointestinal side effects) ................
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