WHAT TO DO WITH STATIN INTOLERANT PATIENTS?

"Statins" is probably one of the more common cardiac drugs taken by patients for the primary and secondary prevention of CAD.Personally, Thy obviously make a lot of money for the big pharmas and continue to do so. The data for statins in the secondary prevention of CAD is very good. However the data for primary prevention is not so robust.
We must not forget that statins, like all drugs, does have side effects. In fact, the statin intolerance is now becoming more and more of a problem as more and more patients are prescribed the drug. The incidence of statin intolerance is probably about 5-10%.
What should we do with a patient who needs the statin but is intolerant.
My usual strategy is to change them to an alternative drug like cholesterol binding agents eg ezetimide. However the data on CAD prevention of these binding agents are not a good as statins.
A paper in the Sept 2013 issue of the American Heart Journal gives us another way. Dr Warner Mampunya and colleagues at the Cleveland Clinic studied 1605 patients refered to them for management of statin intolerance. One strategy ( tried in 1014patients ) was to gradually re-initiate an alternate statin, beginning gently at once weekly, then twice weekly, then thrice weekly, before using it daily. This did reduce LDL-C. The second strategy was to allow the patient to re-introduce another statin intermittently ( not daily ).
Only in 442 patients were they not able to re-introduce any other statins.
After a ean follow-up of bout 31months, they found that in the group who used the statins at their own discretion, intermittently, the LDL-C dropped by 27.7%, whereas in the group with the more gradual re-introduction of stains, the LDL-C fell by 21.3%.
After 31 months, there was a trend towards event reduction in the group who were taking statins intermittently, but it did not reach statistical significance ( P=0.08 ).
Interesting.
I learned a few things. One, we could re-introduce another statin to statin intolerant patient and we could succeed.Statins can be taken intermittently with good effect, though not as good as daily in the prescribed way.
Only in a minority of patients are they totally statins intolerant.