Gettysburg Medical News
 The Clinical View
 by P.E. Hoffsten, MD
 24 May 2006

CHOLESTEROL MEDICINES AND MUSCLE ACHES

            Adults over age 50 frequently have complaints of diffuse muscle aches and arthritic problems.  Our 18-year-old high school students can play a whole football game with bumps and bruises galore then bounce of bed the next day just ripping ready to go.  But as we age, vigorous physical activity has a way of taking its toll.  I played city league basketball until I was about 50.  I had to give it up at that point because our Sunday games were followed by three days of not being able to walk straight. By age 55, I gave up competitive racket ball for the same reason.  Now in my 60’s, a day of unusual physical activity is followed by two days of moany, groanies and it seems like the worst time is two days after I do something unusual.  The point to make here is that muscle aches are a very, very common symptom.  Most of the time, we attribute the muscle aches to our age and unusual physical activity.

            But then comes our wonderful news media with TV, newspapers, and magazines telling us that the statin family of cholesterol drugs cause muscle aches.  This leads to a story such as the following.

            A patient came to the clinic and was found to have a high blood cholesterol.  He had heard that high blood cholesterol is bad.  After discussion, he got started on a statin family medication to get the cholesterol down.  He started the medication and mentioned up to friends and family that he had a new cholesterol medication.  Then “well meaning???” family and friends told him that those cholesterol medications cause muscle aches.  The gentleman taking the cholesterol pill had had muscle aches long before he started the pill but had always attributed the muscle aching simply to his age and unusual activity.  Now that he was taking the pill and somebody had brought it to his attention, the muscle aches seemed worse.  So the patient made a return appointment saying that the pill he was given for his cholesterol was causing muscle aches.  A standard rule known by healthcare professionals is that when a patient comes in and complains about a side effect from a medication, they have already stopped that medication.  Once the idea that the medication is causing a side effect has led the patient to stopping the medication, it is most generally a futile effort trying to convince the patient that the pill is really not the cause of their muscle aches.  So the best thing that a healthcare professional can do is agree with the patient, stop the statin pill and see if the muscle aches go away.  Based on the patient’s belief system, sure enough, the muscle aches went away.  The fact that statin drugs are unusually expensive doesn’t help the problem at all.

            At this point, the gentleman said he was going try diet, exercise and work harder to get his cholesterol down and would check it again in a couple of months.  When he came back the cholesterol hadn’t budged one iota.  The truth is that short of a very significant weight loss, diet and exercise really don’t lower cholesterol.  Oatmeal doesn’t lower cholesterol either and garlic has no effect at all.  So now he wanted to know what he was going to do to get his cholesterol down.

            The above story is relatively common.  Sometimes at this point, a patient will acknowledge that the muscle aches that they had really weren’t that much better off of the statin drug.  Perhaps they should try it again and this is usually the best choice they can make.  But if they are still convinced that the statin drug caused their muscle aches, patients want to know what else they might try.  I point out that the statin drugs are the most effective anti-cholesterolemic medications with the fewest side effects.  They are clearly our best anti-cholesterolemic medications and then I say, “Since we can’t use the statin drugs with you, we will have to go to the second best medication”.  The patient might then choose to use one of the cholesterol binding resins that taste like drinking a glassful of sandy juice.  These resins are effective but really not that much fun to use.  Or we might try a fibrate drug which can lower the triglyceride levels and raise the good cholesterol; but this family has a relatively modest effect on the bad (LDL) cholesterol or we could try fish oil which does lower triglycerides and raise the good cholesterol slightly.  But fish oil has modest if any effect on bad cholesterol.  The percentage of patients developing side effects secondary to the fibrate family of drugs is slightly higher than the percentage that have problems with statin drugs.  Thus, these medications really are “second best”. Patient’s responses as to what to do about high cholesterol at this point are highly variable.  Certain individuals will want to use “the best drug” after all, while others will chose a fibrate or a cholesterol binding resin or the fish oil or nothing at all.

            What is the objective evidence that statin drugs cause muscle aches?

            When this family of drugs was first introduced, it was noticed that very rare individuals would indeed get a diffuse muscle abnormalities characterized by diffuse aching, weakness and very abnormal blood tests.  It turns out after years of experience with this family of drugs, that the incidence of this serious side effect is about 1 in 2,000.  About 5 in 100 individuals will have normal blood tests but will have muscle aches that are different than their usual state.  In those patients that continue to use the medication, the muscle aches eventually go away.

But when a warning gets put on a package insert with the drug or on the sheet that the pharmacist passes out when the drug is picked up, it seems to be interpreted that everyone that takes the drug will have muscle aches.  That is no place close to the truth.  Ninety five percent of the time there is really no difference in whatever muscle aching the person had with or without the drug.  I mentioned previously that the statin family of drugs is the most effective product we have for preventing heart attacks and strokes.  As was mentioned in last week’s column, there is now evidence that getting the bad cholesterol below 70 mg% results in actual dissolving of the cholesterol plaque in a person’s arteries.  The risk/benefit ratio for this family of medications is highly in favor of the benefit side.  The healthcare professionals at your local clinics are aware of these considerations.  They are aware of the suspicions that patients have about this family of medications and can help identify those patients who really have statin related complications and those that spend too much time reading magazines, newspapers and watching TV or spend too much time listening to “well meaning???” family and friends who try to terrorize them.