management of statin induced myopathy

Last edited 08/2020 and last reviewed 01/2023

  • undertake diagnostic workup as described
  • 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:
      • ezetimibe
      • bile sequestrants
      • fibrates
      • nicotinic acid
      • PCSK9 inhibitors