C.      Insulin resistance:

• Lipophilic statins may have adverse metabolic consequences that include impaired insulin secretion and promotion of insulin resistance.
• Hydrophilic statins

·        pravastatin improves insulin sensitivity in some patients

·        rosuvastatin

does not change insulin sensitivity in patients with metabolic syndrome or familial combined hyperlipidemia. However, it increases the incidence of type 2 diabetes. Interestingly, rosuvastatin increases the rate of onset of new diabetes in a dose-dependent manner

D.      Muscle-related symptoms and rhabomyolysis:

• Statin toxicity, as assessed by CK elevations and rhabdomyolysis in randomized trials, also appears to be dose-dependent but not related to the degree to which plasma LDL-C is reduced. In the PRIMO study, muscle-related symptoms occurred with the various regimens as follows:
• Fluvastatin XL 40 mg - 5.1%
• Pravastatin 40 mg- 10.9%
• Atorvastatin 40 to 80 mg- 14.9%
• Simvastatin 40 to 80 mg- 18.2%.
• thus the PRIMO study suggests that fluvastatin and pravastatin have less muscle related symptoms compared to other statins in this particular study

Key Notes

Therefore, if concern about muscle reated symptoms then use of water soluble statins (pravastatin, rosuvastatin) or modified release fluvastatin are treatment options if a previous statin was stopped because of muscle related symptoms (not rhabdomyolysis where further statin treatment is contraindicated).

References:

2018 ACC/AHA Guideline on the Treatment of Blood Cholesterol

ISRN Pharmacology: Volume 2013, Article ID 146579, 7 pages

UMHS Lipid Therapy Guideline, May 2014

Cardiovascular Diabetol. 2005; 4: 7. Published online 2005 Jun 3. doi: 10.1186/1475-2840-4-7