A 62-year-old man comes to the office to follow up hypertension. He has a long history of hypertension treated with amlodipine and obstructive sleep apnea requiring continuous positive airway pressure at night. The patient does not use tobacco, alcohol, or illicit drugs and has no medication allergies.
Blood pressure is 134/90 mm Hg and pulse is 78/min. BMI is 33 kg/m². Physical examination is unremarkable.
Laboratory results are as follows:
Liver function tests are normal.
The patient is counseled on indications for lipid-lowering therapy with statin drugs. He is at greatest risk for which of the following adverse effects if he starts high-intensity atorvastatin therapy?

Question

A 62-year-old man comes to the office to follow up hypertension. He has a long history of hypertension treated with amlodipine and obstructive sleep apnea requiring continuous positive airway pressure at night. The patient does not use tobacco, alcohol, or illicit drugs and has no medication allergies.
Blood pressure is 134/90 mm Hg and pulse is 78/min. BMI is 33 kg/m². Physical examination is unremarkable.
Laboratory results are as follows:

Liver function tests are normal.
The patient is counseled on indications for lipid-lowering therapy with statin drugs. He is at greatest risk for which of the following adverse effects if he starts high-intensity atorvastatin therapy?

Quizplus · Accepted Answer

Hydroxymethylglutaryl-coenzyme A reductase inhibitors (statins) lower LDL and VLDL cholesterol and triglycerides and have been shown to prevent cardiovascular events, with most studies indicating a relative risk reduction of approximately 20%-30%. They are indicated for patients with established atherosclerotic disease and those age 40-75 with diabetes mellitus. Patients with LDL cholesterol >190 mg/dL (as in this patient) are at very high risk for coronary events and also should be treated with statins, as should those who have a calculated 10-year risk for atherosclerotic cardiovascular disease >7.5%. Recent studies have shown that high-intensity statin therapy may increase the risk of new-onset diabetes or worsen glycemic control in established diabetes. The risk is dose dependent and is greater in older patients and women. However, this excess risk of developing diabetes is markedly outweighed by the reduction in risk for cardiovascular events; therefore, the benefits of statin therapy outweigh the adverse effects on blood glucose. New-onset or worsening diabetes does not warrant discontinuation of statin therapy. (Choice A) Hepatic dysfunction due to statin use is uncommon (0.5%-3%) and usually resolves without sequelae if the medication is withheld. Acute liver failure and cirrhosis are extremely rare. (Choice B) Statins are associated with an increased risk for hemorrhagic stroke; however, the excess risk is very small (~0.05%-0.1% over 5 years). (Choice D) Patients with hypothyroidism may be more susceptible to statin-induced myopathy, and many experts advise checking a serum TSH level prior to initiation of therapy. However, statins do not cause hypothyroidism. (Choice E) Statins have a 2%-10% risk of inducing myalgia (the most common side effect) but only a 0.1% risk for rhabdomyolysis. Muscle symptoms are most likely in patients with pre-existing liver or renal disease or hypothyroidism. Patients with statin myopathy should discontinue the medication until symptoms improve and then be considered for a statin less likely to cause muscle toxicity (eg, pravastatin, rosuvastatin). Educational objective: Statins are associated with an increased risk of diabetes and worsening glycemic control in patients with established diabetes mellitus. However, this excess risk is significantly less than the reduction in risk for cardiovascular events. The benefits of statin therapy outweigh the adverse effects on blood glucose, and new-onset or worsening diabetes does not warrant discontinuation of statin therapy. __________ References: Risk of incident diabetes with intensive-dose compared with moderate-dose statin therapy: a meta-analysis. (http://www.ncbi.nlm.nih.gov/pubmed/21693744) Interpretation of the evidence for the efficacy and safety of statin therapy. (http://www.ncbi.nlm.nih.gov/pubmed/27616593) Statins and risk of incident diabetes: a collaborative meta-analysis of randomised statin trials. (http://www.ncbi.nlm.nih.gov/pubmed/20167359) Statin induced diabetes and its clinical implications. (http://www.ncbi.nlm.nih.gov/pubmed/25210397)

A 62-Year-Old Man Comes to the Office to Follow Up