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New Patient Visit Reveals Surprises

A 64-year-old male presents to your clinic for a new patient visit. Though he does not complain of myalgia, you check his creatine kinase levels. It is revealed that his level is nearly 1.5 times the normal range.

The patient underwent a triple coronary bypass about one year prior. He also received a diagnosis of diabetes mellitus the same point in time.

The patient is unsure what if any, statin he was prescribed following these diagnoses as he has moved since then and he did not have any of his previous health records. He does note that he is not allergic to any medications that he is aware of.

Which statin would you recommend for this patient and why?

What other elements would you add to his treatment plan and why?

  • from Doctor Unite 2 weeks
    Add low dose Crestor and zetia follow cpk
  • from Doctor Unite 2 weeks 3 days
    i would use water soluble statin, moderate dose. But needs to get CK after a few days and after a week and then 2 weeks after that. If it goes up, then no statin after that. Then use PCSK9. add CoQ10, also at least 6 glasses of water every day at least. exercise has to be graduated slowly up. High fiber diet. Also make sure pt is on asa.
    stop smoking immediately is the pt is a smoker, stop alcohol if the pt drinks
  • 2 weeks 4 days
    Pravachol, but if it is not effective enough, at that level of CK and no symptoms, I would have a low threshold to using Crestor while watching for further elevations or symptoms. Obviously it is worth rechecking the CK to ensure it wasn't just a transient phenomenon and probably an echo to look for cardiomyopathy which may chronically elevate CK levels.
  • from Doctor Unite 2 weeks 4 days
    Pravastatin, most water soluble. Other choice would be Crestor second most water soluble. Both less likely to cause muscle symptoms. Zetia would be a good non-statin choice. Could always add CoQ10
  • from Doctor Unite 2 weeks 4 days
    Based on the information provided, the patient may benefit from taking Nexletol with another cholesterol lowering medication such as Zetia. Nexlizet would be the other option along with diet modification. Studies have shown that Nexletol reduced HbA1c which could help with his diabetes.
  • from Doctor Unite 2 weeks 4 days
    First of all, you must find out his meds. Call his pharmacy. I would consider Crestor with CoQ 10 and repeat CPK.
  • from Doctor Unite 2 weeks 4 days
    Additional history should include what medications were started for his diabetes and to see role , if any, of these into patient reported lab abnormalities and symptoms reported.
  • from Doctor Unite 2 weeks 4 days
    I am not sure the mild CK is of significance. A thorough history is needed along with other medications used. He does have other serious comorbidities so a strong statin is needed. I would start Crestor with coenzyme Q10. I would also recommend adequate hydration.
  • from Doctor Unite 2 weeks 5 days
    First, determine if the elevated CPK is of clinical significance; if it could relate to recent exercise, renal issues, hypothyroidism or other medications he might be taking.
    Since the patient has fairly recently had CABG and is diabetic, he will almost always require high-dose statin therapy. A water-soluble statin-pravastatin, fluvastatin or rosuvastatin might be safest, but the efficacy is much better with rosuvastatin. I would start rosuvastatin at 10mg and workup, watching the CPK and serial lipid levels. CoQ10 supplements may or not be helpful. Consider a PCSK-9 inhibitor if his LDL cannot be taken close to goal <70mg/dl.
  • from Doctor Unite 2 weeks 5 days
    I would feel comfortable starting any statin an monitoring closely
  • from Doctor Unite 2 weeks 5 days
    CK elevation is minimal at this time whether pt is on statin or not. I will continue statin ..likely pravachol which is relatively better tolerated. Follow pt clinically and may check CPK 4-6 weeks down to follow up unless pt is symptomatic
  • from Doctor Unite 2 weeks 5 days
    Patient needs to verify whether he is on any statin. If he is already on a statin, I will hold the statin and recheck CK in 4 weeks to see if it is coming down. If it is coming down and if it is no longer elevated, I will try a different statin and monitor CK in 6 weeks post initiation of the new statin. If he is not on a statin, I will start him on a low dose statin along with Co-Q and check lipid, liver function and CK in 4-6 weeks. If there is any hint of CK elevation associated with his use of statin, I will stop his statin and switch him to a PCSKP inhibitor instead.
  • from Doctor Unite 2 weeks 5 days
    Obtain prior records to see if he is on a statin (he should be with history of CAD). No need to further check the creatinine kinase if no symptoms (also 1.5 x is not significant). Any statin with CV benefit would be appropriate.
  • from Doctor Unite 2 weeks 5 days
    Unclear whether patient has elevated ck baseline or from med -so recheck and workup the CK abnormality if not on statin .make sure he doesn’t exercise prior to lab . if on statin no need to stop but need to follow Ck -if Ck escalating then switch to crestor low dosage with zetia, or switch to repatha or praluent.
  • from Doctor Unite 2 weeks 5 days
    The vignette does not indicate the patient is currently on a statin. With there being an abnormal lab, it’s the duty of the primary care provider to determine the etiology of the elevated CPK, including repeating the test to make sure it is ongoing. Considering the history of vascular disease and diabetes, evidence-based therapy for secondary prevention should be followed. That would indicate a moderate to high intensity statin. If the CPK continues to be elevated at a low level and a non-serious etiology is identified or idiopathic I would start at a low dose of Crestor, check the CPK after one month then titrate if tolerated and patient not experiencing side effects. If the Crestor is not tolerated or increases CPK levels, I would probably have the discussion with the patient to try at least one more Stan considering the evidence, probably Livalo, and if not tolerated and then go to some thing like Repatha since it does have outcomes data
  • from Doctor Unite 2 weeks 5 days
    There is no need to check the CPK in the asymptomtic patients on Statin as it raises the same dilemmna as this vignette , But now once we have an elevated level we need to find the cause of it and needs the historical interrogation and the physical exam to see what could be responsible for it , There is no need to stop the statin that he is on at this point in time , CPK need to be repeated , Renal Function needs to be checked , By virtute of having a CABG needs to be on high potency statin and LDL needs to be less than 70 or it should be lowered to 30-40 % less than the LDL when the CAD event was diagnosed , As per the IMPROVE IT trial addition of Ezetemibe is extremely desirable for the maximal LDL reduction in the secondary prevention of CAD , Statins are Hydrophilic and Lipophilic and generally Hydrophilic statins like Rosuvastatin , Pravastatin and Fluvastatin cause less myalgias ! This pt should not be deprived of the Statins at this stage on mere elevation of CPKs if at all Statin associated Myositis becomes an issue then PCSK-9 inhibitors should be prescribed !
  • from Doctor Unite 2 weeks 6 days
    I recommend pravastatin due to leas incidence of myalgia
  • from Doctor Unite 2 weeks 6 days
    According to the Daniel David study Pravastatin may be preferred.
  • from Doctor Unite 2 weeks 6 days
    Eugene Gillman MD
    I would change his medical regimen to either pravastain or fluvastatin as they cause less myositis than simvastatin. I would be certain that the patient was on CoQ10. If his symptoms of myalgia/myositis persisted I would change him to nexletol which is not a statin an is good to lower bad cholesterol without complicating myositis.
  • from Doctor Unite 2 weeks 6 days
    CK elevation is mild; would add rosuvastatin or atorvastatin and recheck CPK; advise to stop statin if develops myalgias; check old records first.
  • from Doctor Unite 2 weeks 6 days
    Having had a CABG puts him at high risk of recurrent stenosis. He needs high intensity statin treatment. The minimal asymptomatic CK elevation is of no consequence. Start the statin. The potent statins are rosuvastatin and atorvastatin. Use one of them and titrate to max dose. The preferred DM meds for this man are Met, a SGLT2 inhibitor, and GLP1 agonists. All parameters should be optimally treated. Recheck the CK later and monitor for symptoms. If worse comes to worse you can use Nexletol, a PCSK9 inhibitor, or ezetemibe.
  • from Doctor Unite 2 weeks 6 days
    Hold statin, repeat enzymes and if stable start Livalo. If 4mg dose does not get to goal add Zetia
  • from Doctor Unite 2 weeks 6 days
    I would hold current statin for 2-3 weeks and repeat lipid panel, CPK, check aldolase, CMP
    If CPK level is wnl on the repeated blood work - switch to different statin (rosuvastatin or Livalo ). If patient is not able to tolerate any statin, I would try bempedoic acid-zeta 180-10mg combination with LDL goal < 70. Ideally, if patient would be able to tolerate low dose of the statin, keep at least low dose of the statin plus bempedoic acid or bempedoic acid/zetia combo. Monitor CPK and CMP on the regular basis
  • from Doctor Unite 2 weeks 6 days
    Crestor and change the statin he's currently on if he is on one.
  • from Doctor Unite 2 weeks 6 days
    I would use Livalo less myalgia and add nexlitol or nexlizet if not at goal
  • from Doctor Unite 2 weeks 6 days
    Is there a presumption that the statin caused the elevated CK? Consider confounding conditions...hypothyroid, vigorous exercise (1 hr cardio), long distance walking, recent muscle trauma (fell from bike), shivering from winter cold, recent seizure, rigors from fever/chills, multiple injections (EMG done), other meds (fibrates, colchicine, hydroxychloroquine). If none of these exist and concerned about rhabdo from statin, recommend pitavastatin or pravastatin at higher dose. If LDL goal not achieved, atorvastatin or rosuvastatin.
  • from Doctor Unite 2 weeks 6 days
    Recheck cpk isoenzymes. Consider low dose statin creator 5 and depend on level Rapatha
  • from Doctor Unite 2 weeks 6 days
    By history, he is needing statin for secondary prevention. His CK elevation is mild and is asymptomatic. Since he is diabetic, would like to know his renal function. Would chose Atorvastatin since no renal adjustment is needed. Would gradually increase to reach LDL < 70 . If myalgia develops before goal is reached ,will need PCSK9. Would recommend Coenzyme Q10 (CoQ10) supplementation has been shown to help reduce myalgia as well as transaminase and CK elevation caused by statins. https://www.ahajournals.org/doi/10.1161/JAHA.118.009835
    https://heart.bmj.com/content/97/Suppl_3/A126.3
  • from Doctor Unite 2 weeks 6 days
    I'm generally concerned about liver insufficiency not renal insufficiency when prescribing the statin I would probably prescribe generic atorvastatin but make darn sure that we obtain old records so we're not duplicating drug classes we're creating polypharmacy.atorvastatin to deliver high value care but I wouldn't do that until we get his old records see what medications he's on so there's not polypharmacy and not a duplication of medications.
    Q
  • from Doctor Unite 2 weeks 6 days
    Bitzur R, Cohen H, Kamari Y, Harats D. Intolerance to statins: mechanisms and management. Diabetes Care. 2013;36 Suppl 2(Suppl 2):S325-S330. doi:10.2337/dcS13-2038
    See Figure 1 Algorithm.
  • from Doctor Unite 2 weeks 6 days
    Fluvastatin or Pravastatin. if symptoms persist rosuvastatin (Crestor)
  • 2 weeks 6 days
    clearly needs a statin CK level is nonspecific would try lipitor 40 or crestor 20 QD can recheck CK and look for symptoms myalgia. If still not at target or cannot tolerate statin try PCSK9 .Aim LDL < 70 lower is better
  • from Doctor Unite 2 weeks 6 days
    I would add Crestor 20 and PCSKI if LDL is more than 70 and make sure he is on Beta blocker and ACE/ARB
  • 2 weeks 6 days
    add low dose of a statin like atorvastatin with repeat ck 4 wks
  • from Doctor Unite 2 weeks 6 days
    If the patient wants and is willing, either atorvastatin or rosuvastatin would be ideal at high intensity doses such as 20mg of Crestor. The patient would need to be told rhabdo recurrence can happen
  • from Doctor Unite 2 weeks 6 days
    A link to help with this question is
    https://www.ahajournals.org/doi/full/10.1161/CIRCOUTCOMES.111.000039
  • from Doctor Unite 2 weeks 6 days
    Crestor 5mg. Given the rhabdomyolysis I would suggest prescribing a statin with a low risk of rhabdo and at a lower dose to further reduce the risk of rhabdo again. Although this dose is not high intensity which would be ideal given his cardiovascular disease, it reduces his risk in the setting of rhabdo due to statins. I do not believe other cholesterol lowering medications would help
  • from Doctor Unite 2 weeks 6 days
    Livalo
  • from Doctor Unite 2 weeks 6 days
    Crestor 20 mg
  • from Doctor Unite 2 weeks 6 days
    I would add Crestor
  • from Doctor Unite 2 weeks 6 days
    Look for other drugs sued along with statin, such as fibrate, niacin. If patient is stable and relatively asymptomatic, up to 3X UNL is probably safe, there is not a need to change.
  • from Doctor Unite 2 weeks 6 days
    Crestor with goal LDL<70
  • from Doctor Unite 2 weeks 6 days
    Adding ezetimibe might also help reducing ldl while adding cv benefits without risks of increasing ck levels. Definitely knowing his history is mandatory and trending his ck levels might help considering if he can stay on any statin and what dose he can tolerate
  • from Doctor Unite 2 weeks 6 days
    Crestor but also evaluate for other possible causes (renal,exercise, etc) for the club elevation.
  • 2 weeks 6 days
    If his LDL did not fall below 70 I would add PK9
  • 2 weeks 6 days
    Crestor 20
  • 2 weeks 6 days
    Crestor