if the workup suggests a neurologic, rheumatolic or metabolic aetiology, a referral to a specialist is indicated
if myopathy with multiple statin challenges then specialist advice should be sought
use of a statin holiday
a 6-week 'statin holiday' may be used to see if symptoms of myopathy resolve
some give these patient supplements of 600 mg daily of a bioavailable source of coenzyme Q10 and fish oil during this statin holiday (1)
if symptoms persist or if resolution is unclear at 6 weeks, extend the holiday for an additional 6 weeks, except in patients with recent unstable coronary disease:
for these patients, unless there is evidence of rhabdomyolysis, we believe that the benefits of continued statin therapy exceed the risks (1)
once the myopathy symptoms have abated or are controlled, a rechallenge of statin therapy is in order for those whose risk profile suggests greater benefit from statin therapy (note a statin rechallenge is not appropriate if there has been evidence of statin-induced rhabdomyolysis)
long acting fluvastatin or a statin with less cytochrome P 450 dependence, such as pravastatin, are often the first line if previous statin-induced myopathy
if myopathy has recurred with multiple statin rechallenges or whose lipid-lowering goal requires a more potent therapy, rosuvastatin in alternate-day or once- or twice-a-week schedules is efficacious and well tolerated in many patients
however, although such alternate-day therapies may produce excellent reductions in cholesterol levels, these regimens have not been proven to reduce cardiovascular end points
alternative therapies may require seeking specialist advice but include:
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