Sign me up for mild muscle pain? The statins dilemma

Statins are the very common cholesterol-lowering drugs. Many people believe that they cause fierce muscle aching (statin myopathy), and there is a lot of angst about this. Much like vaccine side effects, that fear may be overheated yet based on a seed of truth.

A truly enormous 2022 scientific review of nineteen placebo controlled tests of the side effects of statins tried to settle this question, and I think it does quite a good job of that. Passionate anti-statin activists and cholesterol deniers will disagree. They may have some specific criticisms of this paper, and I am happy to hear those, but I find the evidence quite convincing.

The Cholesterol Treatment Trialists' Collaboration reviewed trials that followed over 30,000 patients for about four years on average. That’s a lot of data! A data set like that makes a typical little musculoskeletal medicine study look like a shack in the shadow of the Burj Khalifa (world’s tallest building).

And what were the results of the mighty statin myopathy review o’ 2022? There was just no major difference in the rates of muscle pain and weakness in people taking statins versus placebo. The researchers did detect a modest myopathy signal in the first year of statin therapy, and with more intensive statin therapy: slightly more myopathy with statins, and mostly mild. Only about one in fifteen cases of allegedly statin-induced myopathy reported by patients were actually related to statins, according to this data and its interpretation, and those cases were mostly pretty tame. The study concludes:

“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.”

But now to play the advocatus diaboli a little.

Who wants a little “mild” muscle pain in their life? Anyone? Anyone? Bueller?

This statin evidence cuts two ways. Cutting one way, it shows a side effect that is quite a bit less serious than the Legend of Statin Associated Myopathy. Cutting the other? It also shows that SAM is clearly still a bit of a jerk that people are understandably reluctant to embrace! One in twenty is not “rare,” and no amount of chronic pain is cool. So even if the paper is technically correct — and I suspect it is — it’s not actually all that reassuring. Even a 5% risk of very mild-but-chronic muscle pain might seem unacceptable to many people, and I know it’s not for me.

This item is quite personal for me. I am sympathetic to anyone afraid of any side effect, but I share this fear, and it is a fear I will have to finally face down very soon. Statins loom large over my life. High cholesterol runs in my family (“familial hypercholesterolemia”), and I am following in my mother’s footsteps particularly: a nasty looking lipid profile despite a fine diet and lots of exercise. I am as strong a candidate for statin therapy as anyone has ever been, and a decision is imminent.

But I also already suffer substantially from serious muscle aching and cramping, unexplained and long term. It’s a very big deal. It has changed my life. And guess how someone with that medical history feels about a 10% chance of making it worse? What does someone already miserable from muscle aches think about flirting with more muscle pain? Even a little! It seems like an unacceptable risk, that’s what! Hard pass. Nope. No way. Hell no!

I have already been told that I “must” start statin therapy, and more prescription pressure is inevitable in an appointment next month. I honestly don’t know what I will choose. This is just about the shortest possible version of this discussion, but the bottom line is that it’s a truly grim dilemma, and there just is no good answer, for me and many others. Which is often the case with pain puzzles.

P.S. “If I had more time, I would have written a shorter letter blog post”

This post isn’t huge, but it’s not small either, despite my best intentions. The blog has been rather quiet for over a week. I was on a trip to visit old friends I haven’t seen since the Before Times. Despite being in travel mode, I kept trying to write brief blog posts to fill in the blanks … and they kept snowballing into something I couldn’t do justice to! Or artfully condense. Even this one has swelled to over 500 words. It’s really hard to be brief about this stuff! Nuance take time.

(The “no time for a shorter letter” quote is not actually from Twain or Cicero or Shaw. It was probably Pascal. QuoteInvestigator.com has a fun investigation of the quote.)