Advances in the Management of Hypercholesterolemia - Episode 8
Howard Weintraub, MD: There isn’t a week that goes by that I don’t see a patient who is coming in who has been determined to be statin intolerant. I have to tell you that maybe half the time—consistent with the PCSK9 studies that were done with evolocumab and alirocumab in people who were “presumed to be statin intolerant”—many of these people are nowhere near statin intolerant. Tell me how you define statin intolerance. I find that in a very busy primary care office, if a patient is concerned and has maybe a few too many looks on Google, they may have a rotator cuff injury that has been present 10 years before they knew what a statin was. Now their shoulder starts to hurt again, and they’ve made the decision that this is obviously going to be the statin. The doctor or the staff of any kind, being overwhelmed, more or less say, “I’ll do whatever I can to not annoy Mrs Smith or Mr Smith.” There’s nothing gender-wise here. They will acquiesce, and the problem with that comes once the patient has been told that it’s the statin that’s causing it. Then the loop has been closed, and they are officially deemed statin intolerant. How do you address that?
Alan S. Brown, MD, FACC, FAHA, FNLA: That’s a good question. I think there’s a scientific answer and there’s a practical answer.
Howard Weintraub, MD: I’ll take both of them.
Alan S. Brown, MD, FACC, FAHA, FNLA: The NLA [National Lipid Association] went to great pains to write a beautiful document on statin intolerance and even developed a scoring system to determine whether the patient’s symptoms are consistent with statin intolerance. From a scientific standpoint, if it’s in the proximal muscles, goes away when you stop the drug, etc—there’s some science that many patients, when you rechallenge them, tend to be able to tolerate something that they previously couldn’t.
That’s all interesting from a scientific standpoint, but when you’re in the office, most patients couldn’t care less about that science. If they believe they’re having an adverse effect from the drug, there’s nothing you’re going to say to persuade them to go back on it. The most important thing when you start treatment in a patient is to set expectations and say, “Look, some patients will develop some muscle aches or mild weakness, usually about a month after you start the drug. The good news is, we can almost always find 1 of the statins that people can tolerate. We may have to try a couple of different ones, but we can always come up with 1, so be prepared if you have a symptom to expect that we may try another.” I find that even in people who have had adverse effects from 2 statins, which is usually when the primary care physicians throw up their hands and refer. Of course, NLA documents suggested that you had to have intolerance to 3 statins to be truly statin intolerant. So it’s science that’s not practical. Set that expectation by saying, “Look, this happens to a lot of people. We’re going to try multiple things.” Most of the time, you can find something that works, even if you have to go to the every-2- or 3-day approach that we talked about earlier or go to a lower dose with ezetimibe. There are some patients who, no matter what you give them, have adverse effects. We know that 15% of people have adverse effects on placebo. Either way, it’s irrelevant, because if the patient perceives they’re having an adverse effect, all the science in the world isn’t going to change their mind. You work with them, and you do just what you’ve so eloquently described. You listen to them. You give them options and have them participate in the decision of where you’re going to go next, whether it’s a different class of drug like a PSCK9 inhibitor or bempedoic acid, trying additional statins, or even some nonpharmacological interventions like plant stanols.
Transcript Edited for Clarity