# Statin induced muscle pain mostly isn't a thing ....



## Eddy Edson (Aug 30, 2022)

according to yet another large meta study.



			DEFINE_ME
		


_Background_​_Statin therapy is effective for the prevention of atherosclerotic cardiovascular disease and is widely prescribed, but there are persisting concerns that statin therapy might frequently cause muscle pain or weakness. We aimed to address these through an individual participant data meta-analysis of all recorded adverse muscle events in large, long-term, randomised, double-blind trials of statin therapy._
_Methods_​_Randomised trials of statin therapy were eligible if they aimed to recruit at least 1000 participants with a scheduled treatment duration of at least 2 years, and involved a double-blind comparison of statin versus placebo or of a more intensive versus a less intensive statin regimen. We analysed individual participant data from 19 double-blind trials of statin versus placebo (n=123 940) and four double-blind trials of a more intensive versus a less intensive statin regimen (n=30 724). Standard inverse-variance-weighted meta-analyses of the effects on muscle outcomes were conducted according to a prespecified protocol._
_Findings_​_Among 19 placebo-controlled trials (mean age 63 years [SD 8], with 34 533 [27·9%] women, 59 610 [48·1%] participants with previous vascular disease, and 22 925 [18·5%] participants with diabetes), during a weighted average median follow-up of 4·3 years, 16 835 (27·1%) allocated statin versus 16 446 (26·6%) allocated placebo reported muscle pain or weakness (rate ratio [RR] 1·03; 95% CI 1·01–1·06). During year 1, statin therapy produced a 7% relative increase in muscle pain or weakness (1·07; 1·04–1·10), corresponding to an absolute excess rate of 11 (6–16) events per 1000 person-years, which indicates that only one in 15 ([1·07–1·00]/1·07) of these muscle-related reports by participants allocated to statin therapy were actually due to the statin. After year 1, there was no significant excess in first reports of muscle pain or weakness (0·99; 0·96–1·02). For all years combined, more intensive statin regimens (ie, 40–80 mg atorvastatin or 20–40 mg rosuvastatin once per day) yielded a higher RR than less intensive or moderate-intensity regimens (1·08 [1·04–1·13] vs 1·03 [1·00–1·05]) compared with placebo, and a small excess was present (1·05 [0·99–1·12]) for more intensive regimens after year 1. There was no clear evidence that the RR differed for different statins, or in different clinical circumstances. Statin therapy yielded a small, clinically insignificant increase in median creatine kinase values of approximately 0·02 times the upper limit of normal._
_Interpretation_​_Statin therapy caused a small excess of mostly mild muscle pain. Most (>90%) of all reports of muscle symptoms by participants allocated statin therapy were not due to the statin. The small risks of muscle symptoms are much lower than the known cardiovascular benefits. There is a need to review the clinical management of muscle symptoms in patients taking a statin._


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## Felinia (Aug 30, 2022)

Nice to know how unique I am!!  Taken off statins after 18 months of trying, with the worst side effects seen by my GP.  Not just severe pain but many other even more unpleasant side effects.


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## Lucyr (Aug 30, 2022)

Was definitely a thing for me. Had to start driving/getting the bus to places I’d normally walk to as I wasn’t capable of walking the pain was that bad


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## silentsquirrel (Aug 30, 2022)

and me


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## Bloden (Aug 30, 2022)

I couldn't live with the pain, so I stopped taking them. They can do as many surveys / as much research as they like. The bottom line for me is: I developed pain when I was taking statins, I stopped taking them and the pain stopped too. Judging by comments on this forum, it happens. My mum had the same experience. I think there's one more statin I can try, so I'll give it a go if needs be.


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## Robin (Aug 30, 2022)

I had pains in my forearms and shins when I started taking statins just after I was diagnosed, and they stopped when I stopped taking them….BUT… I didn’t know at the time about transient neuropathy when your blood sugars start to fall, (and mine had been mega high for months) so I’m prepared to admit they were coincidental. I’ve recently started statins again, because my cholesterol had gone up a bit, and I haven’t got any aches and pains (except for normal ones after exercising at my age!) However, the jury is still out on the fact that my insulin needs suddenly increased, and I’ve just got early signs of a cataract. Again, maybe coincidence, maybe not, I shall never know.


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## grovesy (Aug 30, 2022)

If it was down to been older, as the media reporting today, how come 15 years of stopping them,I am not getting the pains I wad getting whilst on them!


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## Pattidevans (Aug 30, 2022)

Not to mention the decline in cognitive function that I and several other people I know had.  Back to normal once I ditched the darn things.


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## nonethewiser (Aug 30, 2022)

Heard this all over radio news yesterday, hopefully it will persuade those who most need them to take them.

Only took statin for 3 months, didn't have any side effects & didn't expect to as most folk don't, as evident by this research statins must be one of the most researched drugs around in modern times & considered safe.


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## Felinia (Aug 30, 2022)

Pattidevans said:


> Not to mention the decline in cognitive function that I and several other people I know had.  Back to normal once I ditched the darn things.


Within 2 days of starting them, my friend was found wandering round the next village in a confused state with no idea how she got there.  It took me 9 months to get back to normal after I stopped them, but the side effects had been building up for 18 months, getting worse all the time.  I was tried on 3 different ones, each as bad as the other.


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## Drummer (Aug 30, 2022)

It was 18 months before the last painful muscle subsided, but the damage to my memory was significant. 
I have a photo with 'Mother is the one on the right' on the dresser.


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## Eddy Edson (Aug 31, 2022)

nonethewiser said:


> Heard this all over radio news yesterday, hopefully it will persuade those who most need them to take them.
> 
> Only took statin for 3 months, didn't have any side effects & didn't expect to as most folk don't, as evident by this research statins must be one of the most researched drugs around in modern times & considered safe.


Hopefully will also help to persuade GP's to be less statin-hesitant. Studies show big under-prescribing versus guidelines, partly due to largely  unwarranted concern re side effects. 

You can see how that can happen: GP's will see a significant number of patients on statins with muscle pains which go away when the statin is dropped. 

There's no way for the GP to know that this is actually  nocebo effect, as it usually is - ie that the patients would get the same muscle pain from a placebo if they thought it was a statin.

So the GP gets gun-shy about statins & underprescribes versus guideline dosages & also through his/her words reinforces the nocebo effect. 

Sets up a crappy cycle between message board & media anecdotes and GP surgery ...


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## everydayupsanddowns (Sep 1, 2022)

We understand so little about how nocebo and placebo effects work unfortunately. 

Placebo improvements in symptoms are real and have been measured in studies if i remember right. Plus they are scalable - people get more improvement if the therapy is more ‘medically’ (eg bigger dose, or injection vs tablet).

Nocebo pain is just as real and unpleasant as any other I’d imagine.

I’m not sure how much work has been done on how to reduce nocebo effects?


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## Pattidevans (Sep 1, 2022)

The human body is an amazing machine and it produces cholesterol for a purpose, we know so little about interfering with chemicals and I feel we should not "blanket" prescribe any drugs whatsoever.  The cognitive function interference is well documented, after all cholesterol is a building block for every cell in the body, in particular brain cells.  So I regret @Eddy Edson I must disagree with you that these drugs should be distributed like sweeties.


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## Drummer (Sep 1, 2022)

Every year I am encouraged to go back on the tablets, and to try different ones. 
I just tell them about the photo on the dresser with the note on the back to tell me which one is my mother. They go a bit quiet then.
I can tell them about the screaming muscles and aching joints until I get hoarse from anxiety, thanks to studies which show it was all in my mind.


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## nonethewiser (Sep 1, 2022)

Eddy Edson said:


> Hopefully will also help to persuade GP's to be less statin-hesitant. Studies show big under-prescribing versus guidelines, partly due to largely  unwarranted concern re side effects.
> 
> You can see how that can happen: GP's will see a significant number of patients on statins with muscle pains which go away when the statin is dropped.
> 
> ...



Totally agree Eddie, this research is welcome in that respect.


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## VICTOR HILL (Sep 1, 2022)

WELL  NOW WE NO      over the  last 20years or more   over 3 main    DOCTORS        I Have tried and failed convince  me to take them no no no    
insulin   is absorbed      by muscle    action  , i have known    people to take   all complain of    aches and pain   all be linked to    THE     S    WORD  
PS    and in todays news     LYPMPHONY      all types       the person     suggested    to see the     DOCTOR   LAST YEAR
I TRIED  IN  GREAT PAIN   3  DAYS    UNABLE  to do this     because    of   COVID      so off to  A E   43  DAYS IN AND OUT HOSPITAL  2 major   opps        8 sessions of     KEMO     all clear    APRIL    now  owe      2 million   plus  TO OUR  GREAT    NHS    Many thank s  to staff    Nurses Docs    cleaners    tea    lunch       vic


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## Bruce Stephens (Sep 1, 2022)

everydayupsanddowns said:


> Placebo improvements in symptoms are real and have been measured in studies if i remember right. Plus they are scalable - people get more improvement if the therapy is more ‘medically’ (eg bigger dose, or injection vs tablet).
> 
> Nocebo pain is just as real and unpleasant as any other I’d imagine.
> 
> I’m not sure how much work has been done on how to reduce nocebo effects?


Or to increase placebo effects. It is known that placebos can work (to some extent) even when people know that they're taking a placebo. So just knowing that what you're feeling is likely (or certainly) nocebo probably isn't sufficient.

This page suggests "There has been little work published on examining how the nocebo effect can be reduced." but continues to offer some suggestions.






						The nocebo effect:  what is it, why is it important and how can it be reduced? - bpacnz
					






					bpac.org.nz


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## everydayupsanddowns (Sep 1, 2022)

Thanks @Bruce Stephens 

I’m a couple of weeks into Atorvastatin, and so far so nothing to speak of. Fingers crossed it stays that way!


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## 42istheanswer (Sep 2, 2022)

everydayupsanddowns said:


> We understand so little about how nocebo and placebo effects work unfortunately.
> 
> Placebo improvements in symptoms are real and have been measured in studies if i remember right. Plus they are scalable - people get more improvement if the therapy is more ‘medically’ (eg bigger dose, or injection vs tablet).
> 
> ...


Interestingly the placebo effect even works on babies. The generally prevailing theory is that parent/carer is calmed/has reduced anxiety by feeling like they’re giving something that helps, which then calms the baby as they pick up on parental/carer mood, thus reducing symptoms like crying and irritability.


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## Eddy Edson (Sep 2, 2022)

Pattidevans said:


> The human body is an amazing machine and it produces cholesterol for a purpose, we know so little about interfering with chemicals and I feel we should not "blanket" prescribe any drugs whatsoever.  The cognitive function interference is well documented, after all cholesterol is a building block for every cell in the body, in particular brain cells.  So I regret @Eddy Edson I must disagree with you that these drugs should be distributed like sweeties.


I don't think that statins should be distributed like sweeties. Actually, I don't think that sweeties should be distributed like sweeties.

Also, you are wrong about cognitive function intereference being "well documented"; the opposite is true. And serum cholesterol isn't necessary for cell activity.


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## Eddy Edson (Sep 2, 2022)

Bruce Stephens said:


> Or to increase placebo effects. It is known that placebos can work (to some extent) even when people know that they're taking a placebo. So just knowing that what you're feeling is likely (or certainly) nocebo probably isn't sufficient.
> 
> This page suggests "There has been little work published on examining how the nocebo effect can be reduced." but continues to offer some suggestions.
> 
> ...


There's quite a bit published but FWIW from what I've seen it mainly comes down to common sense of the type nicely summarised in that NZ piece.  Plus some IMO dubious-looking psychology pieces.

I really think that practitioners taking more care and probably being better educated is a good place to attack the problem, but that's just another comon sense-type view.


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## void (Sep 15, 2022)

I took statins for years AIUI because it's standard treatment for all diabetics. No attributable ill effects for a long time. I got muscle aches all right but attributed that to just getting old. I was put on muscle relaxants for the pain because I'd really tense up when falling asleep and I couldn't really sleep. Bought a memory foam matress, too. It was only after not taking them for a week or so for some reason, then taking them again that I noticed the causal relationship. Stopped taking the statin, no more need for said muscle relaxants.

I'm a bit worried not taking them because the baseline CVD risk factor for diabetics is it's as if they've already had a heart attack. I've been reading up on the flushing version of niacin as an alternative but now see that it's not recommended on the NICE website so not sure what to do. My chol/trig readings are ok but they could be better.


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## Eddy Edson (Sep 16, 2022)

void said:


> I took statins for years AIUI because it's standard treatment for all diabetics. No attributable ill effects for a long time. I got muscle aches all right but attributed that to just getting old. I was put on muscle relaxants for the pain because I'd really tense up when falling asleep and I couldn't really sleep. Bought a memory foam matress, too. It was only after not taking them for a week or so for some reason, then taking them again that I noticed the causal relationship. Stopped taking the statin, no more need for said muscle relaxants.
> 
> I'm a bit worried not taking them because the baseline CVD risk factor for diabetics is it's as if they've already had a heart attack. I've been reading up on the flushing version of niacin as an alternative but now see that it's not recommended on the NICE website so not sure what to do. My chol/trig readings are ok but they could be better.


For reference, this summarises NHS' lipid management guidance: https://www.england.nhs.uk/aac/wp-c...ondary-prevention-of-cardiovascular-disea.pdf

For management of statin intolerance, it refers to this: https://www.england.nhs.uk/aac/wp-c...8/Statin-intolerance-pathway-January-2022.pdf

My guess is that this may be too labour intensive & complicated for over-stretched GP settings, but I'd suggest that getting yr head around it might be worthwhile prep for getting your doc to take appropriate action. 

FWIW, I follow a bunch of lipid experts (real ones, not Internet experts) on twitter etc and the consensus these days appears to be that people should be started on ezetimibe plus a statin at a lower dosage than if you're taking just the statin.  This has similar lipid effects with generally fewer statin side effect risks. You'll see in the NHS guidance that this approach is recommended there only after jumping through multiple other hoops, so maybe a difficult outcome to achieve, but perhaps worth pushing for.

On the other hand, if the problem is actually a nocebo effect then the statin dosage might not matter, because in that case simply taking a pill you think is a statin causes the problems, regardless of what the pill actually is.  That the problem goes away when you stop taking the pill and returns when you take it again, doesn't rule out nocebo effects: in high quality studies, the same thing occurs when the patients are given placebos they think are statins. 

 In any case, whether nocebo or not, yr doc should be taking it seriously and working on strategies to achieve good lipid outcomes regardless. Getting yr head around the guidance etc might be useful to induce and help yr doc to do that.


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## void (Sep 16, 2022)

Eddy Edson said:


> For reference, this summarises NHS' lipid management guidance: https://www.england.nhs.uk/aac/wp-c...ondary-prevention-of-cardiovascular-disea.pdf
> 
> For management of statin intolerance, it refers to this: https://www.england.nhs.uk/aac/wp-c...8/Statin-intolerance-pathway-January-2022.pdf
> 
> My guess is that this may be too labour intensive & complicated for over-stretched GP settings, but I'd suggest that getting yr head around it might be worthwhile prep for getting your doc to take appropriate action.


My GP tried with an alternative, at lower dose. The problem took 3 days to re-manifest itself. I think they'll have something to say about it when my next review happens in a few weeks.


Eddy Edson said:


> FWIW, I follow a bunch of lipid experts (real ones, not Internet experts) on twitter etc and the consensus these days appears to be that people should be started on ezetimibe plus a statin at a lower dosage than if you're taking just the statin.  This has similar lipid effects with generally fewer statin side effect risks.


please can you share their @ ? i do use twitter, like an RSS though. I don't participate in it.


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## Eddy Edson (Sep 16, 2022)

void said:


> My GP tried with an alternative, at lower dose. The problem took 3 days to re-manifest itself. I think they'll have something to say about it when my next review happens in a few weeks.
> 
> please can you share their @ ? i do use twitter, like an RSS though. I don't participate in it.


Same here, mainly.

Some lipidology types plus metabolism, nutrition, cardio people I've found interesting on lipds:

Thomas Dayspring  @drlipid
Danielle Belardo @DBelardoMD
Spencer Nadolsky @DrNadolsky
Gil Carvalho @NutritionMadeS3
Ethan Weiss @ethanjweiss
Daniel Drucker @DanielJDrucker


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## Eddy Edson (Sep 16, 2022)

void said:


> My GP tried with an alternative, at lower dose. The problem took 3 days to re-manifest itself. I think they'll have something to say about it when my next review happens in a few weeks.


Cool, sounds like they have you well on the path to consider statin alternatives. If they don't raise it I can guess you can quizz them about why not following the NHS guidance: ezetimibe or inclisiran or bempedoic acid or a PCSK9 inhibitor. Lots of options ...


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## void (Sep 16, 2022)

thanks


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