Treating Type 2 Diabetes: Looking Ahead - Episode 4
How to best prevent and manage statin-associated myalgias when managing cholesterol levels in patients with type 2 diabetes at risk for cardiovascular events.
Davida Kruger, NP: Can you speak about myalgias? Because a lot of times I have push back because a patient may or may not have had myalgias or they’re concerned about that.
Margo B. Minissian, PhD, ACNP: Yes. I’ve been working in a women’s heart center for 16 years, that’s where my clinical practice is, and we see a lot of statin-associated myalgias in our clinical practice. Many of the patients that I see probably wouldn’t have met the criteria for the randomized clinical control trial when the statin drugs were initially going through and as we all know women in particular tend to have much higher rates of adverse effects to medications. They also tend to be significantly less enrolled into these large clinical trials. These statin-associated myalgias are related mostly to drug-drug interactions and we have similar medications using the same CYP [cytochrome P450 enzymes; CYP3A4] pathway. For example, I was in Los Angeles, so we don’t talk about weather because our weather is always beautiful, but we definitely talk about traffic. I like to describe CYP pathways as freeway systems into your body. CYP3A4 pathway is sort of Los Angeles’s 101 or the 405 freeway. It’s a very large CYP pathway that many drugs and foods utilize to enter our body. Conversely, there are certain statins that may use this freeway to get into your body. And most other cardiac drugs, from Coumadin [warfarin] to calcium channel blockers and others, all use this CYP3A4 pathway. If I see someone that is on a lot of cardiac pills, oftentimes I will choose a statin that will take a side street, if you will. They may use a different…like the CYP450 [cytochrome P450], which is what rosuvastatin [Crestor] takes. It’s a different side street. And I can oftentimes avoid drug interactions that can lead to this muscle-associated adverse effects. That’s 1 good trick. We had a recent trial from the American Heart Association in 2019 that validated the whole nocebo effect. The fact that oftentimes it’s what’s in a pill, such as the dyes and the fillers and the other things, just any pill that you put into your mouth tends to have more adverse effects even if it’s the placebo, that has adverse effects than 1 that’s an injectable, for example, that avoids that first pass of metabolism. And oftentimes our patients are feeling muscle aches. We need to listen to them first and foremost, validating that you hear someone when describing a adverse effect will move mountains for you when you’re trying to get them on the right type of medication. And that’s what I would recommend–is taking a deeper look at those pills. And then utilize a lipid specialist. If you have a patient with diabetes who is at high risk and you’re having a hard time getting them on a statin, have somebody that you can refer to that’s got a lipid clinic, like myself and there are thousands and thousands of very interested, from primary care providers, endocrinologists, nurse practitioners alike that can help you with your patients.
Davida Kruger, NP: Your comment about rosuvastatin is interesting because we always say that that’s the 1 that has the least myalgia, but it’s because of the pathway it takes. That’s magnificent. Thank you for sharing.
Margo B. Minissian, PhD, ACNP: It’s very interesting. Yes, it also is a water-soluble drug as well. It’s likely also is playing into whether it’s hydrophilic or lipophilic. There are 7 different statins. They behave very differently, which is great. Unlike hypertension, where 1, they all behave very similarly. And if you’re having [an] adverse effect to 1, you can’t really do the other. Statins aren’t like that. I go through 5, if not 6 before I actually label somebody’s statin intolerant. You can also alternate day dosing. Rosuvastatin statin has a 30-hour half-life. You can utilize that drug on a Monday/Thursday dosing.
Davida Kruger, NP: I want to thank our audience for watching HCPLive® Peers and Perspectives. If you enjoyed the content, please subscribe for our new e-newsletter to receive upcoming Peers and Perspectives and other great content right in your inbox. I receive it and I really love it when I see it in there. Take some time to enjoy it. Thank you again for joining us.
Transcript edited for clarity.