~bilateral LE pain.... - pindi

[ArchivalUser]

A 60-year-old man is evaluated for a 1-month history of bilateral lower-extremity pain. He describes the pain as an ache in both calves and upper legs that worsens after exercise and at night, but he denies predictable occurrence while active. His medical history includes hypercholesterolemia, hypertension, and osteoarthritis for which he takes fluvastatin, atenolol, and aspirin. His family history is negative for coronary artery disease.

On physical examination, blood pressure is 140/85 mm Hg. Dorsalis pedis pulses and sensation to light touch bilaterally are normal. The remainder of the examination is unremarkable.

Laboratory Studies
Serum creatinine kinase

Normal
Serum total cholesterol

215 mg/dL (5.56 mmol/L)
Serum triglycerides

300 mg/dL (3.39 mmol/L)
Serum high-density lipoprotein cholesterol

35 mg/dL (0.91 mmol/L)
Serum low-density lipoprotein cholesterol

120 mg/dL (3.1 mmol/L)

Which of the following is the most appropriate next step in the management of this patient?

A Cholestyramine
B Fibric acid derivative
C Further lifestyle changes
D Pentoxifylline
E Substitution of another statin for fluvastatin

[ArchivalUser]

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[ArchivalUser]

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[ArchivalUser]

~ Correct Answer.......................................... E


This patient is likely experiencing myalgias from fluvastatin, but he may not have the same problem with another statin or when taking fluvastatin at a lower dose. If the patient's muscle symptoms were tolerable, he would not need to change his medication. Because his symptoms are bothersome, it is advisable to discontinue the fluvastatin and, after he becomes completely asymptomatic, try another statin.

Common dose-related muscle symptoms that can occur with the use of statins include in 1% to 5% of cases focal or diffuse myalgia and creatine kinase (CK) elevations that are less than 10 times the upper limit of normal levels. Myopathy, indicated by a serum CK level more than 10 times the upper limit of normal, occurs in 0.1% to 0.5% of patients treated with statins in clinical trials. Some medications increase the risk of statin-associated myopathy, including fibrates, cyclosporine, macrolide antibiotics, various antifungal drugs, and cytochrome P-450 inhibitors. The Medical Letter consultants recommend measuring CK levels before starting a statin and again on development of muscle pain. However, other expert panels do not recommend this approach. In general, the statin should be discontinued if the CK value is more than 3 to 10 times the upper limit of the normal range.

Cholestyramine is not recommended in this patient because it might increase his serum triglyceride level, which is already elevated. Although a fibric acid derivative would lower his triglyceride level, the more important objective is to lower his serum low-density lipoprotein cholesterol level to reduce his risk for coronary artery disease. Pentoxifylline may help treat symptoms of vascular disease, but this patient's symptoms are not likely caused by vascular disease. He does not have exercise-induced leg symptoms, and physical examination indicates normal peripheral pulses.