A 76-year-old woman is brought to the office by her daughter due to generalized weakness, muscle aches, and loss of appetite for the past 2-3 weeks. The patient has a history of hypertension and hypercholesterolemia. Current medications include amlodipine and rosuvastatin which was started 6 weeks ago. The patient is an ex-smoker with a 40-pack-year history.
Temperature is 35.6 C (96 F), blood pressure is 140/100 mm Hg, and pulse is 62/min. Examination shows normal first and second heart sounds. The lungs are clear to auscultation. There is no jugular venous distension. The abdomen is soft and nontender. Muscle strength is 4/5 in both upper and lower extremities, with diffuse muscle tenderness but no joint swelling.
Laboratory results are as follows:
Rosuvastatin is held.
Which of the following is the most appropriate next step in management?

Question

A 76-year-old woman is brought to the office by her daughter due to generalized weakness, muscle aches, and loss of appetite for the past 2-3 weeks.  The patient has a history of hypertension and hypercholesterolemia.  Current medications include amlodipine and rosuvastatin which was started 6 weeks ago.  The patient is an ex-smoker with a 40-pack-year history.
Temperature is 35.6 C (96 F), blood pressure is 140/100 mm Hg, and pulse is 62/min.  Examination shows normal first and second heart sounds.  The lungs are clear to auscultation.  There is no jugular venous distension.  The abdomen is soft and nontender.  Muscle strength is 4/5 in both upper and lower extremities, with diffuse muscle tenderness but no joint swelling.
Laboratory results are as follows:
 Rosuvastatin is held.
Which of the following is the most appropriate next step in management?

Quizplus · Accepted Answer

11ec193a_97a1_e5c5_853d_1b7a833a732e_MD0002_00 This patient has features suggesting hypothyroidism, including weakness, normocytic anemia, borderline low body temperature, and diastolic hypertension. Many patients with hypothyroidism also have musculoskeletal symptoms such as myalgias, joint pain, and stiffness. Symmetrical, progressive myopathy can be seen, often with a mild creatinine kinase (CK) elevation (usually <10 times the upper limit of normal). In addition, statins can cause myopathy ranging from very mild muscle pain without CK elevation to myonecrosis or severe rhabdomyolysis. Factors influencing the risk include choice of drug (lower risk with pravastatin and rosuvastatin), dose, and concurrent medications (eg, fibrates). Hypothyroidism can precipitate statin myopathy, and conversely statins can aggravate hypothyroid myopathy. Therefore, many experts suggest screening for hypothyroidism prior to initiating statin therapy, and patients with new muscular symptoms after starting statins should have assay of thyroid function. (Choice A) Polymyositis can resemble hypothyroid myopathy with proximal muscle weakness and elevated CK levels. Antinuclear antibody titers and characteristic findings on electromyography can support the diagnosis. However, polymyositis is much less common than hypothyroid myopathy, and patients typically have only mild, if any, muscle pain. (Choice B) Statin therapy is associated with reduced concentrations of coenzyme Q10 in muscle cells. However, supplementation with coenzyme Q10 has not been shown to prevent or treat statin myopathy. (Choice C) Polymyalgia rheumatica presents with proximal myalgias associated with elevated inflammatory markers (eg, erythrocyte sedimentation rate, C-reactive protein). However, muscle weakness and CK elevation are not usually seen. (Choice E) Prolonged vitamin D deficiency can lead to secondary hyperparathyroidism and osteomalacia. Symptoms can include bone pain and muscle weakness. However, patients with this degree of deficiency often also have hypophosphatemia and elevated bone turnover markers (eg, alkaline phosphatase). Educational objective: Hypothyroidism can cause myopathy with pain, weakness, and elevated creatine kinase. Statins can worsen hypothyroid myopathy, and hypothyroidism can exacerbate statin myopathy. __________ References: Hypothyroidism as a risk factor for statin intolerance. (http://www.ncbi.nlm.nih.gov/pubmed/25110221)

A 76-Year-Old Woman Is Brought to the Office by Her