A 55-year-old Caucasian man with a prior computed tomography calcium score in the
75th percentile for age, sex, and race at age 39 years, and on long-term high-intensity
statin therapy presented with episodic myalgia. He reported 3 episodes within the
past year of sudden severe quadriceps pain that self-resolved within 2 days. His activities
included biking 10 hours per week, weight lifting 3 times per week, and a new activity,
boxing, for 2-3 hours per week. On 80 mg/day of atorvastatin for 10 years, 6 months
prior to presentation his dose was reduced to 40 mg/day due to muscle symptoms. After
another episode of quadriceps pain, the patient visited his primary physician where
labs showed an elevated creatine kinase (CK) level of 28,190 IU/L (Table 1). Atorvastatin was stopped and a systematic investigation into the etiology of his
CK elevation revealed that boxing was the culprit. After an extensive risk–benefit
discussion, treatment was initiated with 10 mg ezetemibe. His symptoms improved initially
but recurred when he resumed boxing. Ezetemibe was stopped and the patient's low-density
lipoprotein cholesterol began to increase (Table 1). After another risk–benefit discussion, he agreed to stop boxing and was started
on rosuvastatin 5 mg every other day, which he is currently tolerating well.
Table 1Patient's LDL-C, CK, and Cr Relationship to Statin Therapy
| Date | LDL-C (mg/dL) | CK (IU/L) | Cr (mg/DL) | Boxing | Statin Therapy at Time |
|---|---|---|---|---|---|
| 5/19/16 | 28,190 | 0.8 | Yes | Atorvastatin 40 | |
| 6/8/16 | 90 | 412 | 0.91 | No | None |
| 6/29/16 | 106 | 444 | 0.91 | No | None |
| 9/8/16 | 90 | 576 | 1.01 | No | Ezetemide 10 mg |
| 1/17/17 | 91 | 197 | 0.98 | No | Ezetemide 10 mg |
| 8/4/17 | 124 | 268 | 0.98 | No | None |
| 9/28/17 | 80 | 834 | 0.92 | Yes | Rosuvastatin 5 mg (every other day) |
| 10/23/17 | 331 | No | Rosuvastatin 5 mg (every other day) | ||
| 2/27/18 | 112 | 505 (1 h post aerobic exercise) | No | Rosuvastatin 5 mg (every other day) | |
| 3/17/18 | 365 (24-h post aerobic exercise) |
CK = creatine kinase; Cr = Creatinine; LDL = low-density lipoprotein cholesterol.
To read this article in full you will need to make a payment
Purchase one-time access:
Academic & Personal: 24 hour online accessCorporate R&D Professionals: 24 hour online accessOne-time access price info
- For academic or personal research use, select 'Academic and Personal'
- For corporate R&D use, select 'Corporate R&D Professionals'
Subscribe:
Subscribe to The American Journal of MedicineAlready a print subscriber? Claim online access
Already an online subscriber? Sign in
Register: Create an account
Institutional Access: Sign in to ScienceDirect
References
- 2013 ACC/AHA guideline on the treatment of blood cholesterol to reduce atherosclerotic cardiovascular risk in adults: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines.J Am Coll Cardiol. 2014; 63: 2889-2934
- Air Force/Texas Coronary Atherosclerosis Prevention Study (AFCAPS/TEXCAPS): additional perspectives on tolerability of long-term treatment with lovastatin.Am J Cardiol. 2001; 87: 1074-1079
- Effect of statins on skeletal muscle function.Circulation. 2013; 127: 96-103
- Serum creatine kinase levels and renal function measures in exertional muscle damage.Med Sci Sports Exerc. 2006; 38: 623-627
- Continued statin prescriptions after adverse reactions and patient outcomes: a cohort study.Ann Intern Med. 2017; 167: 221-227
Article info
Publication history
Published online: April 09, 2018
Footnotes
Funding: None.
Conflicts of Interest: None.
Authorship: All authors had role in writing manuscript.
Identification
Copyright
© 2018 Elsevier Inc. All rights reserved.
