Statin intolerance still up for debate

Experts are divided about whether new lipid management guidelines should include information about statin intolerance.

Speaking at the annual CSANZ scientific meeting in Perth, Professor David Sullivan from the Lipid Clinic at Royal Prince Alfred Hospital in Sydney, revealed he is a statin intolerance sceptic.

He argued that including references to statin intolerance in proposed new guidance could risk medicalising the phenomenon.

“One of the worries about putting this into guidelines is that it immediately endorses it as a medical condition and I think we’ve got to be careful as to how far we go down that pathway,” he said.

Professor Sullivan said biased and alarmist media reports had patients increasingly concerned about statin use and an increased risk of muscle damage, diabetes, liver damage and neurological conditions like memory loss and dementia.

And even among doctors, muscle-related statin intolerance in particular remains a controversial topic. Some clinical researchers argue that intolerance is rare and mostly in a patient’s head while others contend it is a legitimate problem affecting as many as 20% of statin-treated patients.

While Professor Sullivan acknowledged that there does seem to be a time course relationship in a number of patients who report intolerance, which could give rise to some biological plausibility, he said there were many holes in the evidence.

“Compounding the issue is that the comparison between blind and observational studies has gathered force in a setting of alarmist reporting when it comes to the nocebo effect and it’s now occurring in a climate where alternative medications to treat these patients have become very expensive.”

But whether a patient refuses to take a statin because of the nocebo effect or because it’s a real disorder is largely irrelevant, as doctors must still deal with the fallout of that decision.

“It’s a big area and there is a lot of confusion but that doesn’t mean we ignore it,” said one delegate.

“I don’t think we’ve got a gold standard in this area,” said Professor Sullivan.

“We need to provide an approach that enables the patient to tolerate a useful dose of statin without putting that patient at undue risk … if patients stop therapy without a diligent effort to try to resume therapy, the opportunity lost is huge.”

Meanwhile other delegates pushed for guidelines to recommend that plasma levels become more routinely available to determine intolerance to the drugs.

“Patients are now being discharged from hospital on high dose statins but do you think we create this problem by not titrating the dose of statin out of hospital for the patient – are we giving them a statin intolerance by overdosing?” another delegate asked.

“If you want to make a case for plasma levels I think that would be precisely the case for most use,” Professor Sullivan said.

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