With the rising burden of cardiovascular and cerebrovascular diseases, statins have become the cornerstone of the prevention of cardiovascular and cerebrovascular diseases. What are the conditions that require stopping statins? What should I do if I have an abnormal metric but does not meet the retirement criteria?
At the beginning of 2024, the Chinese Medical Association released the "Chinese Expert Consensus on Community ** Blood Lipid Management (2024)", which elaborates on the harmfulness of dyslipidemia, risk stratification, medication safety, control strategies and other aspects of knowledge. Combined with the relevant content of the 2024 new expert consensus, we now introduce 4 situations that need to be stopped while taking statins.
Scenario 1: Elevated aminotransferases more than 3 times the upper limit of normal.
During statin taking, it is necessary to monitor liver function regularly, and elevated aminotransferases are one of the common adverse reactions of statins. It is generally recommended to perform liver function tests at the beginning of the drug (4-6 weeks after initiation** or dose adjustment) and regular checks during long-term drug use (3-6 months after the blood lipid target is rechecked). The main reason why we want to emphasize the importance of liver function test is that the liver is a "silent" organ, even if the drug has caused adverse effects on the liver, when the transaminase is elevated, there may not be physical discomfort in the short term, but if the problem of elevated transaminase is not found, and still insist on medication, the short-term reversible adverse reaction may become an irreversible drug-induced liver injury problem, and the drug injury to the liver has really become a reality.
An important indicator of liver function status, that is, alanine aminotransferase and aspartate aminotransferase, if through the examination, without the influence of other diseases, one of these two aminotransferase indicators exceeds the upper limit of normal value more than 3 times, all need to stop statin in time, and carry out liver protection**, if necessary, the primary hospital should be transferred to a higher-level hospital in time.
Scenario 2: Total bilirubin is elevated more than 2 times the upper limit of normal.
The increase in total bilirubin is also an important indicator of liver function, and it is also one of the confusions caused by many friends taking statins, some friends do not have an increase in aminotransferases, but there is an increase in the level of total bilirubin, total bilirubin contains the level of direct bilirubin and indirect bilirubin, the increase in this index also indicates important information such as liver lesions or biliary obstruction, and the degree of bilirubin abnormality also indicates the problem of abnormal liver function. Therefore, whether there is a mild elevation of aminotransferases (less than 3 times the upper limit of normal), if there is an abnormal elevation of bilirubin and more than 2 times the upper limit of normal, statins should be discontinued and hepatoprotective therapy should be performed**.
Scenario 3: Creatine kinase levels exceed the upper limit of normal by 4 times.
Regular checks of creatine kinase levels are also important monitoring tools to prevent serious adverse effects of statins. If the creatine kinase level is more than 4 times the upper limit of normal, regardless of whether there is muscle pain or muscle weakness, the drug should be discontinued, and the water intake can be increased in time, and if there may be a risk, the patient should be referred in time**.
Scenario 4: Muscle discomfort or weakness, elevated creatine kinase levels.
If the creatine kinase level is elevated, and it does not reach more than 4 times the upper limit of discontinuation, but at the same time it is accompanied by muscle weakness or muscle discomfort, such as muscle pain and other adverse reactions, statins should also be stopped in time, and if there are friends who are used to exercise, excessive exercise should be stopped, and appropriate water intake should be increased, creatine kinase levels can be rechecked after a week, if muscle pain and other symptoms disappear, creatine kinase levels also return to normal, statin drugs can be resumed or maintained**, if creatine kinase levels do not decrease, Prompt referral** is recommended.
If you take a statin and have abnormal indicators, you don't need to stop the drug.
Should I stop taking statins if my liver function is abnormal, if the aminotransferase level is not more than 3 times higher and the total bilirubin level is not more than 2 times, should I stop taking statins? In this case, you can consider giving priority to reducing the dose of statins, and check for other liver damage** that may exist, such as hepatitis, biliary tract diseases, and the influence of other drugs, etc., and at the same time start liver protection under the guidance of a doctor**, and recheck liver function in time after reducing the dose, if liver function improves, you can further resume the moderate-intensity statin dose, and do regular follow-up and liver function monitoring.
For patients with elevated creatine kinase levels but not more than 4 times, and no symptoms of muscle discomfort, it is recommended that statins should not be stopped, excessive exercise should be suspended, and water intake should be increased moderately, creatine kinase levels should be rechecked after 1 week, and if there is a decrease or recovery, the dose of moderate statin can be resumed or maintained.
Summary:1When taking statins, it is necessary to monitor liver function, cardiac enzymes, and pay attention to whether there are symptoms such as myalgia;
2.When taking statins for a long time, statin-related muscle weakness or muscle discomfort needs to be discontinued when total bilirubin elevates more than 2 times the upper limit of normal, aminotransferases elevate more than 3 times the upper limit of normal, creatine kinase levels exceed 4 times the upper limit of normal, statin-related muscle weakness or muscle discomfort.
3.Statins have a good overall safety profile,** and the benefits far outweigh the adverse effects. When there is a slight adverse reaction during the statin** period, the drug should not be easily stopped, and observation should be strengthened, and food should not be abandoned due to choking. If serious adverse reactions occur, the dose can be reduced or discontinued (Fig. 1).
4.Risks of combination medications: Most statins are metabolized by cytochrome P450 (CYP450), and when combined with other drugs metabolized through this pathway, such as amiodarone, calcium channel antagonists, macrolide antibiotics, antifungal drugs (such as itraconazole, ketoconazole, etc.), cyclosporine, and certain foods (such as grapefruit juice in large quantities), high-dose statins should be avoided when used in combination with these drugs, and adverse effect monitoring should be strengthened. In addition, the combination of statins with gemfibrozil also increases the risk of myopathy and should be avoided.
References: 1] Chinese Expert Consensus Writing Group on Lipid Management in the CommunityChinese Expert Consensus on Lipid Management in the Community (2024)[J].Chinese.
Journal of General Practice, 2024, 23(3): 1-9
2] Wang Zengwu, Liu Jing, Li Jianjun, et al. Guidelines for the management of blood lipids in China (2023) [J].Chinese Journal of Circulation, 2023, 38 (03): 237-271