Table 5.

Recommendations to prevent myopathy complications (summary of recommendations according to NLA 84, ACC/AHA/NHLBI 86, Ballantyne 88 and manufacturers)

Before treatment

• Inform the patient about the risks and symptoms of myopathy and of interacting drugs

• Evaluate muscle symptoms before starting therapy and measure CK if the patient reports muscular symptoms

• Obtain CK baseline in patients at high risk of muscle injury by statins and/or on medications that might affect statin metabolism (see Tables 3 and 4). If pretreatment CK is elevated >five times the ULN, repeat CK measurement within 5 to 7 days. If CK is >five-fold ULN in patients with risk factors, do not start statin therapy

• No recommendation is currently given (by CPIC) on whether or not SLCO1B1 genotyping should be performed in any patient prior to receiving simvastatin

During treatment

• Obtain CK in patients who develop muscular symptoms

• See Figure 3

• If genotyping is available, restrict the use of 80 mg dose of simvastatin to patients under long term therapy (12 months or more) without muscular symptoms who are carriers of the rs4149056 TT genotype 45

ACC, American College of Cardiology; AHA, American Heart Association; CK, creatine kinase; CPIC, Clinical Pharmacogenomics Implementation Consortium; NHLBI, National Heart, Lung and Blood Institute; NLA, National Lipid Association; SLCO1B1, solute carrier organic anion transporter 1B1; ULN, upper limit of normal.