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Statin Intolerance Assessment — EECC MCQ

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ModerateHypertension & Preventive CardiologyStatin Intolerance AssessmentEECC

A 68-year-old man with HFrEF and established ASCVD has an LDL-C of 2.8 mmol/L on atorvastatin 40 mg. He reports muscle aches that he attributes to the statin. Before diagnosing statin intolerance, what should be done?

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Correct answer: A — Assess for common mimics (vitamin D deficiency, hypothyroidism, excessive exercise, drug interactions), measure CK, and consider a rechallenge with the same or different statin at a lower dose — true statin intolerance (inability to tolerate ≥2 statins at any dose) affects only 5-10% of patients

Statin-associated muscle symptoms (SAMS) are reported by 10-30% of patients but true statin intolerance (inability to tolerate ≥2 statins at any dose after adequate rechallenge) affects only 5-10%. The SAMSON trial demonstrated a large nocebo effect (symptoms occurred equally on statin and placebo in 90% of 'intolerant' patients). Assessment before diagnosing intolerance: (1) exclude mimics: hypothyroidism, vitamin D deficiency (<25 nmol/L — very common and causes myalgia), excessive exercise, drug interactions (CYP3A4 inhibitors with simvastatin/atorvastatin); (2) measure CK (>10x ULN = rhabdomyolysis; 4-10x = significant myopathy); (3) rechallenge with same statin after 2-4 week washout; (4) try alternative statin (rosuvastatin or pravastatin — different metabolic pathway); (5) try intermittent dosing (rosuvastatin alternate days). If truly intolerant: ezetimibe, bempedoic acid, PCSK9 inhibitor, or inclisiran.

Reference: ESC/EAS Dyslipidaemia Guidelines; SAMSON Trial