Clinical Management of SAMS

Abstract

The clinical management of statin-associated muscle symptoms or SAMS depends on the severity of symptoms and the patient’s willingness to continue statin therapy. Symptom severity is based on both the patient’s perception of his/her symptoms and whether or not there is evidence of muscle injury as assessed by creatine kinase (CK) levels. It is critical that patients without evidence of muscle injury be reassured that their symptoms will resolve with statin cessation. We generally stop the statin to observe the patient’s response. The patient can then be started on ezetimibe to see if symptoms return, which suggests a generalized drug aversion, or on low doses of the same or another statin. Low-dose statin therapy can include twice weekly treatment with long-acting statins such as atorvastatin, rosuvastatin, or pitavastatin. Proprotein convertase subtilisin kexin-9 or PCSK-9 inhibitors are indicated for treatment of patients with established atherosclerotic disease or inherited hypercholesterolemia who have not achieved their desired low-density lipoprotein cholesterol (LDL-C) level despite maximally tolerated statin and ezetimibe therapy. PCSK-9 inhibitors are now the preferred agents for managing statin-intolerant patients because of their tolerability and their remarkable reductions in LDL-C. Patients unable to obtain these agents can be managed as best possible with statins and ezetimibe plus niacin and bile acid sequestrants. The goal in patients with SAMS is to produce the lowest reduction in LDL-C possible using statin doses as well as other medications that do not produce intolerable symptoms.