Statins — a group of cholesterol lowering drugs, belong to the group of the most widely prescribed medications, due to their ability to prevent cardiovascular disease and to extend life of cardiovascular patients by lowering the levels of LDL (the "bad") cholesterol in the bloodstream. These abilities make statin therapy one of the greatest therapeutic advances in modern medicine.
While statins are generally very well tolerated with a very low risk of serious side effects, statin intolerance may occur in some patients. Some statin side effects have been debunked, like the potential risk of causing diabetes mellitus, cancer, and memory loss that could jeopardize the continuation of statin therapy, but one side effect remains real and challenging issue. The most common symptoms of statin intolerance are mild muscle pain, weakness, or cramps, often called statin myopathies or myalgias, which can occur in up to 15% of treated patients. In most cases, these symptoms are mild and rarely associated with muscle inflammation (myositis). Importantly, the myopathy symptoms are completely reversible shortly after the statin is discontinued. Serious muscle damage (rhabdomyolysis) associated with statin treatment is extremely rare, occurring in 1 in 23 million individuals with prescriptions for atorvastatin.
These issues of statin intolerance, specifically statin myopathy, are comprehensively addressed in the Statin Intolerance app provided by American College of Cardiology.
This app guides clinicians through the steps of treating and managing a patient who reports muscle symptoms, and through the patients' symptom history in order to determine if they are truly statin intolerant.
These steps include three options visible on a home screen: Evaluate, Follow-Up and Compare.
Evaluate leads a clinician through the risk calculator, which tries to evaluate the patient's risk and possible intolerance to current statin's prescriptions, as well as interaction with other medications.
The evaluation includes the major considerations that should be taken into account, like the lab abnormalities, symptom type, severity and localization, patient's demographics (sex, age and race/ethnicity), current statin and interactions with other medications.
This risk evaluation calculator doesn't offer scores or any sort of qualitative risk assessment like low, medium, high, which would be more concise and more helpful during the evaluation process. Instead, Evaluate calculator is just a chart using a patient's history to tell which parts of it indicate statin myopathy. This is too broad interpretation, without any specific guidance or suggestion about what clinicians should do next. If Statin Intolerance app has a tendency to become a real management tool for dealing with statin intolerance symptoms, and not just a reference app, it should include more qualitative information, as well as better guidance and advice in its future updates.
The next option is Follow-Up, which simulates a follow-up visit, offering several options depending on lab results, or on the decision made at the last visit, e.g. if statin was stopped, or a low-dose has been reiniated. Unlike Evaluate option, Follow-Up section offers more practical advice regarding statin treatment and symptom clearance. What is missing though, are the recommendations on follow-up timing, as well as lab testing in the follow up visit.
Probably the best part of Statin Intolerance app is its Compare option. It gives detailed information on a range of statins like doses, half-life, lipophilicity, optimal frequency, metabolic pathway, and more. Clinician may also select other medications that could potentially interact with statins. If there's an interaction with another drug the patient is taking, another variant of statin could be chosen as a better option to avoid the interactions. You see the secondary medications as a useful list with warning advice regarding statin usage and doses listed beside each variant of statin. However, this option would be even better if it's been made with a pinch of interaction thrown in, or as a side-by-side drug comparison option. Also, shareable patient information on statin side-effects would be useful addition.
With a fair amount of practical and useful information about statin intolerance, this app is a great educational tool on how to perform the evaluation for statin myopathy and manage the patients with these symptoms. Information is given through three sections that guide users through the evaluation and follow-up process, but it could be improved with specifics on lab testing and follow-up intervals.
Another thing that could be improved is an app's design that could offer more interaction, especially in the Compare part.
As a general conclusion, Statin Intolerance is a good app, albeit a bit too complex to be used regularly as a decision support tool. It's designed to be used periodically and "casually" along with other lipid-related resources.
Benefit: Statin Intolerance app could be useful to all clinicians to assess, treat, and manage patients with possible statin intolerance, particularly patients with statin induced myopathy.