{"id":1292,"date":"2017-05-01T12:17:32","date_gmt":"2017-05-01T12:17:32","guid":{"rendered":"http:\/\/stg-blogs.bmj.com\/bmjebmspotlight\/?p=1292"},"modified":"2017-08-21T10:18:23","modified_gmt":"2017-08-21T10:18:23","slug":"primary-care-corner-with-geoffrey-modest-md-statin-myopathy-and-vitamin-d-deficiency","status":"publish","type":"post","link":"http:\/\/stg-blogs.bmj.com\/bmjebmspotlight\/2017\/05\/01\/primary-care-corner-with-geoffrey-modest-md-statin-myopathy-and-vitamin-d-deficiency\/","title":{"rendered":"Primary Care Corner with Geoffrey Modest MD: Statin myopathy and vitamin D deficiency"},"content":{"rendered":"

by Dr Geoffrey Modest<\/strong><\/p>\n

\n

A recent editorial provided reasonably convincing evidence that there is a relationship between low vitamin D levels and statin associated muscle symptoms, SAMS (see Glueck CJ. Atherosclerosis. 2017; 256: 125). See article for the references.<\/p>\n

 <\/p>\n

Details\/summary of data:<\/p>\n

— one study showed an inverse relationship between CK levels and vitamin D levels in patients on simvastatin, independent of symptoms<\/p>\n

— a non-blinded study with high-dose vitamin D to normalize serum levels found that up to 95% of 134 patients with SAMS were free of muscle symptoms on reinstating statins, and this\u00a0continued for\u00a0up to 24 months later (the last time point measured)<\/p>\n

— another trial of 150 patients with SAMS with a median vitamin D of 21ng\/ml and given vitamin D supplements found that 87% were successfully able to restart their statins and remain symptom-free for 24 months<\/p>\n

— a meta-analysis of 2420 patients documented that vitamin D levels tend to be lower in patients with SAMS;\u00a0several other studies have confirmed that in patients with SAMS and low vitamin D levels, repleting\u00a0the vitamin D levels leads to about 90% being able to tolerate rechallenge with statins<\/p>\n

 <\/p>\n

Commentary:<\/p>\n

— SAMS is quite frequent, varies somewhat depending on the statin use\/dose, but is reported in about 10% of patients.<\/p>\n

— Myopathy is also a reasonably common symptom of vitamin D deficiency<\/p>\n

— there are\u00a0studies<\/a>\u00a0which suggest that even those with intolerable muscle symptoms from 3 or more statins, only 43% had muscle symptoms on rechallenge (and 27% had muscle symptoms only on placebo, 17% had symptoms to neither drug). ie, there is likely a pretty big placebo effect. Though the 90+% success rates with vitamin D noted above\u00a0are a bit eye-popping.<\/p>\n

—\u00a0so, a provocative editorial. Clearly, especially in light of the potentially large\u00a0placebo effect, and in light of the importance of statins in preventing clinical cardiovascular outcomes, there should be a well-designed randomized control trial to assess the true benefit of vitamin D repletion in\u00a0those with SAMS who are\u00a0vitamin D deficient. It is notable in several of the uncontrolled studies, increasing vitamin D even in patients\u00a0with levels in the low 20 ng\/ml range was effective, which is actually above what the Endocrine Society defines as deficient, <20 ng\/ml. so, it makes sense in future\u00a0RCTs to look at those patients who have SAMS and with 25-OH vitamin D levels <30 ng\/ml or so\u00a0to see if vitamin D supplementation helps, or perhaps in all-comers to see if\u00a0there is a 25-OH vitamin D threshold.\u00a0\u00a0The meta-analysis mentioned above found that the difference in vitamin D levels in those with and without SAMS was 28 vs 35 ng\/ml.<\/p>\n

 <\/p>\n

Bottom line: statins are important for many patients, SAMS is common as is vitamin D deficiency, there are likely other benefits from vitamin D sufficiency anyway, vitamin D supplementation is pretty benign and inexpensive, so to me it seems reasonable at this point to try vitamin D supplementation in patients who are intolerant of statins because of SAMS, even if there baseline levels seem pretty good.<\/p>\n

 <\/p>\n

see\u00a0here<\/a>\u00a0for an array of blogs on vitamin d.<\/p>\n

 <\/p>\n<\/div>\n","protected":false},"excerpt":{"rendered":"

Statin myopathy and vitamin D deficiency […]<\/p>\n

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