Cardiometabolic Chronicle

Addressing Statin Intolerance In Practice: Moving Beyond the Controversy

August 3, 2021
Tags: Featured Articles

Low-density lipoprotein cholesterol (LDL-C) has been shown to be atherogenic and likely have a causal relationship for the development of atherosclerotic cardiovascular disease (ASCVD).¹ Thus, reducing LDL-C levels is imperative in decreasing the impacts of ASCVD, as demonstrated in several studies.² Since their introduction more than 30 years ago, statins, along with lifestyle modifications, have been the treatment of choice in lowering cholesterol. They decrease cholesterol by inhibiting 3-hydroxy-3-methylglutaryl-coenzyme A (HMG-CoA), a rate-limiting step in cholesterol synthesis.³ Multiple large outcomes trials have demonstrated the efficacy of statins in not only lowering LDL-C but more importantly, reducing major adverse cardiovascular events both in the primary and secondary prevention of ASCVD.4 Given the strength of evidence and the cost-effectiveness, statins remain the first-line treatment of patients with elevated LDL-C, which was also highlighted in the updated 2018 AHA/ACC cholesterol guidelines.²

However, a large gap remains between guideline recommendations and use of statins in actual practice, with studies showing that a large number of eligible patients are not on statin therapy, or are not adherent to therapy.^5-9 This includes patients at high-risk for primary or secondary events, including patients with diabetes or cardiometabolic risk, and statin underutilization and non-adherence can increase ASCVD morbidity and mortality.⁸ Even when patients are initiated on statins, many discontinue statin therapy within the year of starting it.⁶ Real-world studies have shown that less than 40% of patients persist in taking statins for primary prevention at the 3-year post-initiation mark, while these number is only 45% for secondary prevention.⁸ One of the many reasons that lead to discontinuation of statin therapy can be statin intolerance, which is most frequently attributed to muscle-related adverse events.¹⁰ Often patients will discontinue statins without consulting their physician, which increases their cardiovascular risk.¹⁰

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