Statin holiday

For patients who cannot tolerate statin therapy, alternatives include a 'statin holiday' followed by a re-challenge with a different statin

Use of a statin holiday

• if there is 'statin intolerance' then one management option suggested is to prescribe a 6-week 'statin holiday' and see if symptoms resolve
  • the process of atherosclerotic plaque formation is one that occurs over months and years rather than weeks and therefore it is reasonable (in most cases) to suspend statin therapy for a 6 week period - the suspension of statin therapy is controversial if unstable coronary disease although Fernandez et al (1) suggest statin therapy can be halted for a maximum of 6 weeks in this situation
  • if statins are also for the management of high triglycerides then this makes the undertaking of a 'statin holiday' problematic because of the more immediate risk of pancreatitis associated with raised triglycerides - if there is any doubt about the suitability of the use of a 'statin holiday' then consult expert advice
    
    
• in patients whose evaluation suggests statin myopathy, a statin holiday indicates stopping all lipid-lowering therapy for 6 weeks and seeing if symptoms resolve
  • grip and hip strength increases can be assessed by dynamometry
    
    
• some give these patient supplements of 600 mg daily of a bioavailable source of coenzyme Q10 and fish oil during this statin holiday (1)
  • data supporting the use of these supplements are mixed but the risks are minimal
    
    
• if symptoms do not resolve after a 6-week course of the coenzyme Q10 and fish oil
  • it has been suggested (1) that 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
      
      
• if the initial evaluation is consistent with statin myopathy and the neuromuscular symptoms (myalgias and weakness) do not respond within a few months of statin withdrawal
  • specialist review is indicated to evaluate for an underlying muscular or neurologic disorder that has become symptomatic during statin therapy but whose existence is independent of the statin therapy
    • in some cases, the pre-existing disorder may become symptomatic because of the statin therapy and remain symptomatic despite discontinuation of the statin therapy
• if a 'statin holiday' has led to symptomatic resolution then alternative options for management include:
  • careful re-challenge with a different statin, use of same statin but at lower dose, intermittent use of a long acting statin such as rosuvastatin

Reference:

1. Fernandez G et al.Statin myopathy: a common dilemma not reflected in clinical trials. Cleve Clin J Med. 2011 Jun;78(6):393-403.
2. Sikka P et al. Statin intolerance: now a solved problem. J Postgrad Med. 2011 Oct-Dec;57(4):321-8.