Statin-related myalgia management algorithm

From Article: How Do You Treat Patients With Myalgia Who Take Statins?
Saadi A. Siddiqi, MD, and Paul D. Thompson, MD

Table 2. Statin-related myalgia management algorithm
I. Asymptomatic patients
A. Routine determination of CK levels is not required
except in high-risk patients
B. If CK is measured:
1. CK < 5x ULN: provide reassurance
2. CK > 5x but < 10x ULN: check periodic CK and
monitor for symptoms
3. CK > 10x ULN: probably stop statin
II. Symptomatic patients
A. Reevaluate risks and benefi ts of statin treatment
B. Tolerable symptoms
1. Follow recommendations per above CK guidelines
2. If symptom primarily is cramping, trial tonic water
(quinine) before sleep
3. Trial coenzyme Q10 supplements
C. Intolerable symptoms, stop statin
1. Patients with consequent acute renal failure or
CK > 10,000 U/L
a. When recovered, readdress benefi t-risk of
statin therapy
b. Consider use of alternative lipid-lowering agent
2. Others, once asymptomatic and CK returns to
baseline, can:
a. Try a lower dose of the same statin
b. Try another statin
c. Try lower statin dose plus/minus ezetimibe
d. Try another class of drug
e. Switch to statin-containing regimen tried in
statin-intolerant patients
i. Atorvastatin (10–40 mg) 3 times weekly
ii. Atorvastatin 10 mg twice weekly and
ezetimibe 10 mg/d
iii. Rosuvastatin (2.5–10 mg) 2 to 3 times weekly
f. Pulse therapy
g. Trial coenzyme Q10 supplements
h. Chinese red yeast rice 2 tablets every night
before sleep
i. LDL apheresis for qualifi ed patients
CK—creatine kinase; LDL—low-density lipoprotein; ULN—upper
limit of normal.