CASE
Mr L., a 57-year-old obese patient (BMI > 40) who had not been to a clinician in a decade, comes to see you after a health fair screening revealed dyslipidemia (LDL cholesterol, 188 mg/dL; HDL cholesterol, 32 mg/dL; total cholesterol, 240 mg/dL; triglycerides, 100 mg/dL). His blood pressure (BP) is 146/90 mm Hg, and his fasting glucose is 101 mg/dL. Labs drawn that day reveal an A1C of 5.9%, alanine aminotransferase (ALT) of 45 U/L, and aspartate aminotransferase (AST) of 62 U/L. In taking his history, you discover that Mr L. also has a notable family history of heart disease.
Mr L. agrees to take a low-dose statin, and you prescribe atorvastatin 10 mg and a thiazide diuretic. You advise the patient to contact you immediately if he develops significant myalgia, jaundice, dark urine, or symptoms of hyperglycemia such as excessive thirst or urination, and to schedule a follow-up visit in eight weeks.
Long recognized as the bedrock of hyperlipidemia therapy, statins achieved even greater prominence when the American College of Cardiology/American Heart Association (ACC/AHA) issued a new cholesterol guideline1 late last year. The ACC and AHA now recommend statins for a wider range of patients, often at a higher starting dose.
Based on the new recommendations, the use of statins is likely to rise.2 (A statin—rosuvastatin—is already the nation’s most widely prescribed medication.2) Thus, it is more important than ever for clinicians to know about the risks associated with statins and to be able to assess the benefits of therapy for individual patients.
A 2013 retrospective cohort study of more than 100,000 patients on statins found that 17% developed adverse effects (AEs). Therapy was withheld, at least temporarily, for 10% of study participants (60% of those experiencing AEs).3 At the same time, the authors of a large meta-analysis (135 randomized controlled trials [RCTs] and > 240,000 patients) reported that AEs associated with statins as a class were uncommon. The meta-analysis also found that the overall discontinuation rate for statin users—5.7%—was not significantly different from that of patients receiving placebo.4
Such discrepancies regarding particular risks, as well as the overall incidence of AEs and discontinuation rates, make the evidence difficult to sort out. We created this update with that in mind.
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