Announcer:
Welcome to CME on ReachMD. This episode is part of our MinuteCE curriculum.

Prior to beginning the activity, please be sure to review the faculty and commercial support disclosure statements as well as the learning objectives. 

Dr. Gluckman: 
Welcome to CME on ReachMD. I'm Dr. Ty Gluckman.

Dr. Wadhera:
And I'm Dr. Rishi Wadhera.

Dr. Gluckman:
In this episode, we're going to talk about safety concerns with statin therapy. And I suspect for all of you listening, it's not lost on you, either from patients or your own sentiments that there's concern about the potential risks related to statin therapy. I think it's important to ground ourselves in the recognition that over decades, there is substantial accumulated evidence showing a net favorable clinical benefit associated with statin therapy, both in primary and secondary prevention. Now, not only do statins lower LDL cholesterol, but this translates into a reduction in the rate of adverse cardiovascular events, there has been shown to be some modest regression of atherosclerosis as well. And there are risks that do occur, a modest increased risk of new onset diabetes, the potential for muscle-related side effects or symptoms. It's also important to realize that there are a lot of misnomers or misimpressions of what statin therapy may be associated with as well.

There are a range of so-called statin- associated side effects, and most notably, or most commonly, these involve muscle-related symptoms. But one should recognize that there is always the potential for statins, not unlike other medications in causing other effects. And so being attentive to patients’ potential side effects that are occurring that especially occur temporarily with initiation of therapy is important. It is also important to realize that statin-related side effects can occur potentially at any time, so even though someone's been on therapy for a long period of time, don't dismiss the potential of there being a side effect, that it can occur months or sometimes even years later overall.

As you're beginning to dig into statin-associated side effects, and in particular, statin-associated muscle symptoms, there are a number of approaches that can be taken to systematically evaluate individuals with muscle symptoms, tease out the likelihood that those muscle symptoms are related to statin therapy or not, what types of history information should be assessed for that patient, laboratory testing. And in short, this often involves temporary cessation of therapy for a time-limited period to be able to gauge whether or not there is any temporality or relationship to exposure to the drug. And certainly, if those symptoms go away with cessation of the drug, it reinforces an increased likelihood that their statin may be causing muscle-related symptoms.

It's also important to very much realize that not all statins are the same. So an individual who has muscle symptoms with one statin doesn't mean that they won't have those symptoms with another statin or be free of those symptoms. And so you should not be dismissive of statin therapy in general, if an individual experiences muscle-related side effects and exploring an alternate statin. In general, when someone's on a fat-soluble statin, such as atorvastatin, simvastatin, lovastatin, switching to a water-soluble statin, such as rosuvastatin or pravastatin, may be a reasonable option.

In addition, where we may begin with a high-intensity statin for those at highest risk, if you're going to have to choose to add on another statin on the back end of someone having tolerability issues, it may make more sense to start at a lower dose or lower intensity and build up just to ensure that patients are able to tolerate the regimen.

Now, there are other questions that get asked, namely about diabetes, and it is important to realize that there is a small increased risk of developing new onset diabetes. However, the overwhelming majority of patients who develop diabetes on statin therapy had a clustering of metabolic risk factors, and unfortunately, were well on their way to developing diabetes, and as a result of having diabetes, do benefit from statin therapy and reducing cardiovascular risk.

A question that comes up a lot to me from patients, is about the potential for cognitive dysfunction, and there's been a wealth of data that's been explored across all different statins, really failing to observe that there is an association with cognitive dysfunction or new onset dementia, quite the opposite, there's actually been data showing that it can reduce the risk of dementia, particularly in terms of vascular dementia or multi-infarct dementia in this patient population.

There's also no signal of an increased susceptibility to cancer. So patients who are receiving statin therapy we have not observed this across different statin regimens over many, many years of exposure.

And so Rishi, I may turn to you and say, making sure that we're communicating well to our patients and they're being provided information is an ongoing process; it doesn't just happen at the first visit. How does the rurality of some patients potentially create challenges? And certainly, how do you go about overcoming those challenges in ensuring people have the right information?

Dr. Wadhera: 
Yeah, I think such great points, Ty. I think it's important to remember that patients are inundated with information about health and therapies from many different diverse sources. Now that's not just scientific papers or lay media outlets, it’s TikTok, Twitter, Instagram. And because of this, some of the facts that come out from those mediums are grounded in evidence, and some of the information that patients are gathering are really just misinformation. And there are pockets or parts of the country where misinformation is more common when it comes to therapies like statins or healthcare in general. And so I think no matter what the sources are and whether they're grounded, whether the information that patients are obtaining are grounded in evidence or not, it's important that we take their concerns seriously and talk to them about data and evidence, particularly in regards to statin therapy and the benefits and risks. And I think this is where counseling strategies are really, really important. Shared decision-making about the benefits and risks of therapies is really critical and important.

Dr. Gluckman:
Rishi, I think you brought up some really great points, and I think it reinforces the notion that shared decision-making is not just a one and done, but it requires ongoing discussion with patients as they're going to get new information over time as well.

Well, this has been a great discussion. Unfortunately, our time is up. I want to thank you all for listening.

Announcer:
You have been listening to CME on ReachMD. This activity is jointly provided by the University of Kentucky and Partners for Advancing Clinical Education and is part of our MinuteCE curriculum.

To receive your free CME credit, or to download this activity, go to ReachMD.com/CME. Thank you for listening.