Thread by @CFAndersenMD

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! 🙏