1/ Your 56-year-old patient with DM2, HTN, HLD, and a prior MI, comes to clinic reporting he stopped his statin a few weeks ago. “The muscle cramps were killing me, doc,” he tells you.
Let's take a deep dive into statin intolerance 💊🩺🫀
#tweetorial #statinintolerance
2/ We’ll cover these 4 Learning Objectives:
🔺List the indications for statin therapy as 1º prevention.
🔺Define statin intolerance (SI).
🔺Understand the prevalence of SI and its impact on mortality.
🔺Develop an approach to statin intolerance.
3/ I feel comfortable listing the indications for statin therapy.
4/ Statin therapy as 1º prevention:
➡️ Statins are widely prescribed to mitigate CV risk.
➡️ Common indications for statin therapy include diabetes & very elevated LDL.
➡️ ACC/AHA recommends using CV risk estimators for less clear-cut cases.
5/ A question ❓❓❓
What exactly is statin intolerance?
6/ Why does it matter?
Well, stopping statins leads to increased mortality and worse CV outcomes!
🔺 14% greater risk of all-cause mortality over 5-years!
➡️ bit.ly/AnnalsStatins
➡️ bit.ly/JAMAStatin
7/ This is a BIG problem, because it’s actually pretty common....
Take a guess at how common...?
8/
Well, different studies tell different stories, from 2-3% to 50%.
This 2022 @ehj_ed meta-analysis reported 9.1% of patients w/ adverse MSK effects that prevented them from using statins or limited guideline-recommended doses.
bit.ly/EHJStatinIntol…
9/ Sidebar: whether the MSK side-effects of statins are “real” or psychosomatic is a fascinating question, but may be a moot point if patients are stopping their statin regardless.
Nonetheless, here’s one of my favorite studies of statins vs. placebo.
bit.ly/StatinVsPlacebo
10/ Here’s a framework you might use when tackling statin intolerance...
For a deeper dive into the contemporary management of HLD, check out this terrific review article by @RichardAFerraro & colleagues!
bit.ly/HLDmanagement
11/ And do these changes to dosing patterns work?
Yes! In fact, prior work in the @AmericanHeartJ suggests that up to 72% of patients can tolerate a statin when transitioned to intermittent dosing while still achieving great LDL ⬇️
bit.ly/StatinRe-trial
12/ If a shared decision to re-trial a lower dose statin is unsuccessful, you would next reach for ezetimibe or a PCSK-9 inhibitor.
After that, you may consider bempedoic acid.
bit.ly/CLEAROUTCOMES
13/ For a deep dive into the CLEAR Outcomes Trial, check out last month’s @CardioNerdsJC from May 31st.
14/ Today we learned:
🔺Indications for statin therapy as 1º prevention.
🔺Definition of statin intolerance (SI).
🔺The prevalence of SI and its impact on mortality.
🔺A framework to statin intolerance.
15/ I feel comfortable describing listing the indications for statin therapy and defining statin intolerance.
16/ I learned something in this Tweetorial that might change my clinical practice.
17/ To learn more, check out @CardioNerds Prevention Series Episodes 38, 39, 42 and the #DecipherTheGuidelines Q&A series!
And a BIG thanks to my friends/mentors @RichardAFerraro, @DrAlaaDiab, @dinubalanescu & @AmitGoyalMD for peer-reviewing🫀🤓 + the whole @CardioNerds fam! 🙏
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