So…after a pretty nasty injury and extensive investigations associated with that injury, I now find myself in the situation of being on a statin (atorvastatin 40 mg OD for those who want the finer details) for life.
Disclaimer-I am an MD, specialist, just not in this area!
I was keen to hear from people who are on these drugs in terms of how it has affected their training and racing etc. I have been on mine now for a month but only just able to really get back into training (swimming so far, a little riding) because of my nasty injury. I know muscle cramps is a common side effect, I am just finding I am sore in my shoulders/back a lot more and a lot earlier with swimming than I ever used to be. My cardiologist recommended starting at a low dose, like 5mg and building up from there as tolerated but my primary care doctor went straight to 40 mg…I am taking CoQ10 to help as I heard that is supposed to be good.
Was keen to hear how others have found these drugs and what I can expect going forwards. Feel free to chime in DTOCE…
And please, can we keep this on topic and not go down the plant based diets etc etc…
On atorvastatin 40 mg. No effect at all as far as I can tell. I have some other stuff going on that has lessened endurance training, so maybe it’s hard to tell what it affects there, but have hit the weights pretty hard since going on it and have some of my best lifts ever with no noticeable soreness.
So, usually I have to jump in late in a thread and dispel ‘misinformation’. For this, I’ll highlight comments that I’ve made in other threads through the years. Cardiology continues to evolve and I personally always attempt to practice ‘evidence based medicine’ that is in line with best practices. As always, you should discuss this with your own doctor, doctor.
We have had:
‘Statins and training’
https://forum.slowtwitch.com/...st=last-6643505#last
‘Worried about my heart’
https://forum.slowtwitch.com/...tring=dtoce#p6619853
‘Heart health screening thread’
https://forum.slowtwitch.com/...st=last-7150717#last
That said, these threads all have had some good info and some breakdowns. Anecdotal information is not optimal for best medical practice but can give some insight. The problem is that is can become biased by the few instances rather than rely on information from the masses, or better from the studies which are evidence based and drive changes in practice. There is always variability in the ways medicine is practiced and PCP’s are often very different from Cardiologists. The driving force should be trying to do what is best for the individual patient. My daily life involves ‘risk vs benefit’. There is a place for drug Rx and a bigger place for communication about what we know and why recommendations are made. In reality, it seems there is never enough time to go over all of the questions that come up…
It never surprises me that even those in the medical field want reassurance from ‘triathlete patients’ that they can continue their active lifestyle despite the need for drug therapy. There are so many medical threads here on ST in the tri forum…I have personally had to wrap my head around the possibility of needing to take statin for the rest of my life, but was fortunate enough to get 0’s on my coronary calcium score last year. *(Can’t change my age or family history of premature heart disease…)
In answer to the question,** most active patients tolerate needed statin medicine just fine**. I have quite a lot of patients who have known CAD/with or without revascularization, or risk equivalents like abnormal coronary calcium scores who are on drug therapy and continue to train and race without any issues at all. This list includes: people who do every aerobic sport, including lots of triathletes.
Depending on why you are taking a statin, the path to achieving the desired LDL level can be fast or slow. My patients with ACS (acute coronary syndromes) or AMI (acute MI) have no choice but to begin high intensity statin immediately and we deal with side effects and taper the med as able, when able. Most people placed on a statin take it for primary prevention-not secondary prevention: ie to prevent the first cardiac event. There is often less urgency and additional non-drug Rx can help lower the need for medication. Eating better, exercising regularly (*less of an issue with most, but not all, triathletes) and losing weight helps lower lipid numbers. I usually start low and titrate up to the needed dose to achieve an LDL goal of 40-70 for patients with known CAD or risk equivalents *(this includes any abnormal coronary calcium score or having a CT scan with vascular/coronary calcification). There is no evidence that CoQ10 works via studies, but I do encourage those with myalgia to try it.
Also, since this always comes up and people want to know what the real risk is about competing in triathlon once diagnosed with heart disease…so to be complete, I’ll throw in this one
‘Sudden death in triathlon’
https://forum.slowtwitch.com/...riathlon_P6427784-2/
I do wish you the best!
Please discuss options and any concerns with your MD, and be honest about side effects. Sometimes there is a perceived association with a med that may or may not be valid. Cardiac health is almost always most important for all, although the better we get at treating heart disease, the longer the patients are living and now getting CA…
(I am hopeful that the thread does not devolve)
edited this thread to add these LDL-C studies:
Bigger, broader and better ‘Evidence Based Medicine’ clearly shows that lowering LDL-C is associated with risk reduction and statins are a very useful mechanism for achieving this.
The Cholesterol Treatment Trialists Collaboration-CTT (dec LDL-C 22% less CV events --90,056 pts)
Heart Protection Study-HPS (same benefit in each tertile of baseline LDL–20,536 pts)
PROVE IT, TNT, FOURNIER (more intensive treatment=lower LDL, even fewer events)
above from PROVE IT
MIRACL (Myocardial Ischemia Reduction with Aggressive Cholesterol Lowering), PROVE-IT (PRavastatin Or atorVastatin Evaluation and Infection Therapy) and IDEAL-ACS (Acute Coronary Syndromes) studies outline the benefits of high-dosage atorvastatin therapy started within 24-96 hours, 10 days or 2 months, respectively, of an acute coronary syndrome. Relative to placebo, pravastatin and simvastatin, atorvastatin reduced the risk of death or major cardiovascular events by 16-18%
ASCOT-LLA (Anglo-Scandinavian Cardiac Outcomes Trial-Lipid Lowering Arm), revealed that atorvastatin reduced the relative risk of primary coronary heart disease (CHD) events by 36% (p = 0.0005) compared with placebo in patients with hypertension.
followed by NCEP (National Cholesterol Education Program) committee update-new goal for high risk pts=LDL<70
followed by ACC/AHA Guidelines change in 2013 (tried to be fully evidence based)
ALLIANCE (Aggressive Lipid-Lowering Initiation Abates New Cardiac Events) and GREACE (GREek Atorvastatin and Coronary-heart-disease Evaluation) trials highlight the benefits of atorvastatin in the ‘real world’ setting in patients with stable CHD. Compared with ‘usual’ care, atorvastatin reduced the risk of nonfatal MI by 47-59%
IMPROVE IT Among 18,144 patients, there were 9,545 total PEP events (56% were first events and 44% subsequent events). Total PEP events were significantly reduced by 9% with ezetimibe/simvastatin vs placebo/simvastatin
IDEAL- TNT (Incremental Decrease in End Points Through Aggressive Lipid Lowering) and TNT (Treating to New Targets) trials demonstrate the preventive efficacy of atorvastatin in patients with stable CHD. Relative to simvastatin (in the IDEAL trial) and low-dosage atorvastatin (in the TNT trial), intensive atorvastatin therapy (80 mg/day) reduced the risk of nonfatal myocardial infarction (MI) by 17-22% (p < or = 0.02).
more statin decreasing stroke data
SPARCL (16% reduction in CVA in group without carotid stenosis and in the group with carotid artery stenosis, treatment with atorvastatin was associated with a 33% reduction in the risk of any stroke)
2018 ACC/AHA Guidelines states “This confirms the general principle that ‘lower is better’ for LDL-C”.
2019 European Sociaty of Cardiology Guidelines states “Throughout the range of LDL-C levels, lower is better”.
Table 1
Randomized cardiovascular outcomes study with high intensity LDL-lowering therapy in patients with coronary artery disease.
TrialMean Reduction in LDL Cholesterol; mmol/L (mg/dL)OutcomeRR (95% CI) (per mmol/L)CTT meta-analysis (high-intensity vs. standard statin; subgroup < 2.0 mmol/L) 17]1.71 (66) vs. 1.32 (50)MI, CHD death, stroke, coronary revascularisation0.71 (0.56–0.91)IMPROVE-IT (ezetimibe plus simvastain vs. simvastatin) 12]1.55 (70) vs. 1.40 (54)CV death, MI, stroke, UA, coronary revascularisation0.94 (0.89–0.99)FOURIER (evolocumab plus high-dose statin ± ezetimibe vs. high-dose statin ± ezetimibe) 19]2.37 (92) vs. 0.78 (30)CV death, MI, stroke, UA, coronary revascularisation0.85 (0.79–0.92)ODYSSEY OUTCOMES (alirocumab plus high-dose statin ± ezetimibe vs. high-dose statin ± ezetimibe) 20]2.37 (92) vs. 1.37 (53)MI, CHD death, stroke, UA0.85 (0.78–0.93)
Open in a separate window
CHD, coronary heart disease; CV, cardiovascular; MI, myocardial infarction; UA, unstable angina.
Thanks for the awesome reply DTOCE, I was hoping you would chime in.
How this all came about: fractured tibia, ct showed some arterial calcification, suggested CT coronary angiogram with calcium score obviously. Calcium score of 2, angiogram showed some soft plaques (nothing occlusive) hence the recommendation to start statins. Lipid profile was crap unfortunately.
My primary care doctor is not really in tune with endurance athletes and just started me on 40mg straight up. It has been fine as I have hardly been able to train but now I am swimming I just seem to be constantly sore in the shoulders, not something I have dealt with (no pun intended) before.
Am only 45 but this injury is nasty and I am faced with potentially never doing a tri again as am not sure if I will ever be able to run! Just hoping these shoulders will settle, but so far a month in I am not seeing much improvement in the myalgia.
My advice would be to try not to focus too much on the side effetcs of your statin medication. Sure, statins can cause the side effects you Mentorin nur there is extensive research indicating a big nocebo component to them. Maybe your shoulder is sore from the Swimming Break you probably had with your extensive leg injury. The more you focus on the side effects by doing research etc the more the nocebo components plays a role. And as you dont have many alternatives in keeping your cholesterol in check, there is no positive uphand from finding out statins are not for you.
In other words, I would worry much more about the condition requiring you to take the statins and not about Potential side effects from them. My Impression is you got it the other way around.
My advice would be to try not to focus too much on the side effetcs of your statin medication. Sure, statins can cause the side effects you Mentorin nur there is extensive research indicating a big nocebo component to them. Maybe your shoulder is sore from the Swimming Break you probably had with your extensive leg injury. The more you focus on the side effects by doing research etc the more the nocebo components plays a role. And as you dont have many alternatives in keeping your cholesterol in check, there is no positive uphand from finding out statins are not for you.
In other words, I would worry much more about the condition requiring you to take the statins and not about Potential side effects from them. My Impression is you got it the other way around.
Thanks for the feedback…I am well familiar with nocebo effects especially in my area of work.
It is not as you state unfortunately…the condition requiring the statins is relatively minor and not something that would bother me for about 15 years if I did not treat it. There are some unique side effects to statins and dosing etc is important.
Amnesia,
There is much good info on this thread but I will add my own experience as that seems to be what you asked for.
FWIW, I have been on various brands /doses of statins for almost ten years now. At the same time I have been taking a low dose aspirin daily as well. I tend to have both cramping and muscle pain since I started taking statins.
My experience is that my body does not react to all statins/doses in the same way. One year I ran a spring marathon. After I experienced muscle soreness. In the past, after running a marathon, the muscle soreness would last 2 to 3 days. After this race the muscle soreness did not go away for over two weeks. After consulting with my Doc we decided to stop the statins. Immediately the muscle soreness went away.
I have also experienced severe hamstring cramps since being on statins. This can happen both while running, the middle of the night while sleeping and occasionally in the pool while swimming.
Since then we have experimented with different brands and different doses and found what seems to work for me.
Good luck
Steve
A few years ago, I was put on Atorvastatin (don’t remember the dosage), and after a few weeks I started experiencing temporary extreme weakness and burning in my legs. This would come typically after driving, I would get out of my car, walk a few dozen yards, and then it would hit. I would have to stand still and wait for about a minute to recover, and then I was fine. I told my cardiologist, and he immediately took me off it, and the problem disappeared right away. Last year I was put back on a lower dose (10mg), and have not noticed anything unusual…
Last year I started on Atorvastatin 10mg and ended up with near constant pain in my glutes and calves. Switched to Lovastatin 10mg. Glute pain went away quick but calf pain lasted a few months.
I am on Crestor 20mg no issues at all but a doctor in the med tent at Ironman world championship told me to stop taking it 3 days before before the race can lead to cramps
.
What a terrific response by dtoce.
Amnesia,
I am also a cardiologist, and have developed a number of cholesterol medications in my career—including having designed and run a statin intolerance study.
I agree very much with what dtoce said, and also happy to provide a few tips that you might consider also—please make sure to partner with your physician(s), since you should smartly question anything provided on a public we forum.
- Partner with your doc, as you are. You can also see a cardiologist who specializes in “statin intoleranceâ€â€”these do exist! Given triathlon is important for your quality of life, taking this extra measure is a reasonable choice.
- It appears unclear whether you are having statin myalgia (only symptoms) or statin myopathy (with or without injury measured by significant increased in muscle enzymes (ie, CK)). The latter means taking some more deliberate steps. Measuring CK is not considered routine management of statin associated muscle symptoms unless severe, as you know, but I think you can make the argument this is a special case in extremely impactful activities for your quality of life. An empathic doctor should work with you on this.
- There are some medical conditions that may predispose to statin myalgia/myopathy, which might be subclinical. For example, hypothyroidism and Vitamin D deficiency—these are very easy to check and low hanging fruit to address.
- There are very effective ways of managing statin choice and administration schedule to improve your symptoms. For example, change to daily fluvastatin or pravasatin, which are associated with lower muscle symptoms. I have personally found switching to weekly (or 2-3 times weekly depending upon LDL-C goals) rosuvastatin works quite well, and can resolve symptoms in the majority of patients.
Good luck!
Edit.
Realizing how patronizing it might sound advising another doctor to “partner with your docâ€â€”I didn’t mean for it to come across that way. As physicians we tend to be tempted self-diagnose and self-treat-I know I have been guilty of it!
4x heart bypass . Bata blocker, ace inhibitor, statin. I am 1.5 years out . I have been racing (cycling) I have beaten people who beat me before surgery. I do have to warm up really REALLY good before a race. Raced 5 months after surgery and have never stopped. I am 65.
I posted this before and some jerk accused me of not eating correctly before the heart attack. I do not ever post now. I decided to respond this one time to try to help.
What a terrific response by dtoce.
Amnesia,
I am also a cardiologist, and have developed a number of cholesterol medications in my career—including having designed and run a statin intolerance study.
I agree very much with what dtoce said, and also happy to provide a few tips that you might consider also—please make sure to partner with your physician(s), since you should smartly question anything provided on a public we forum.
- Partner with your doc, as you are. You can also see a cardiologist who specializes in “statin intoleranceâ€â€”these do exist! Given triathlon is important for your quality of life, taking this extra measure is a reasonable choice.
- It appears unclear whether you are having statin myalgia (only symptoms) or statin myopathy (with or without injury measured by significant increased in muscle enzymes (ie, CK)). The latter means taking some more deliberate steps. Measuring CK is not considered routine management of statin associated muscle symptoms unless severe, as you know, but I think you can make the argument this is a special case in extremely impactful activities for your quality of life. An empathic doctor should work with you on this.
- There are some medical conditions that may predispose to statin myalgia/myopathy, which might be subclinical. For example, hypothyroidism and Vitamin D deficiency—these are very easy to check and low hanging fruit to address.
- There are very effective ways of managing statin choice and administration schedule to improve your symptoms. For example, change to daily fluvastatin or pravasatin, which are associated with lower muscle symptoms. I have personally found switching to weekly (or 2-3 times weekly depending upon LDL-C goals) rosuvastatin works quite well, and can resolve symptoms in the majority of patients.
Good luck!
Edit.
Realizing how patronizing it might sound advising another doctor to “partner with your docâ€â€”I didn’t mean for it to come across that way. As physicians we tend to be tempted self-diagnose and self-treat-I know I have been guilty of it!
All amazing advice thanks.
For the moment, just FYI-I have halved my atorvastatin dose over the weekend and see how it feels with swimming this week. (FYI thyroid and Vit D are all good).
Question-if switching to weekly or 2-3 times weekly rosuvastatin, what dose would you normally recommend and is there any advice around dosing and exercise? I have not looked at the various half lives etc, but was just wondering if there was recommendations around when to dose and exercise.
Thanks for this.
4x heart bypass . Bata blocker, ace inhibitor, statin. I am 1.5 years out . I have been racing (cycling) I have beaten people who beat me before surgery. I do have to warm up really REALLY good before a race. Raced 5 months after surgery and have never stopped. I am 65.
I posted this before and some jerk accused me of not eating correctly before the heart attack. I do not ever post now. I decided to respond this one time to try to help.
Yep. That feedback is really uncalled for and unwelcome.
The plant based zealots can go a bit overboard at times.
I’m not an MD.
Did you have a coronary calcium scan? Personally, I would not go on a statin without seeing the results of one first.
Hi Amnesia,
This is where we move away from evidence-base medicine. As you are aware, the CV outcomes trials for statins were evaluated with on-label regimens, which were daily administration. However, the totality of evidence strongly supports the LDL hypothesis, and intermittent regimens, so long as LDL is efficaciously reduced, should translate into reduced CV events.
There are so many permutations of intermittent statin regimens, and are in balance with what you can tolerate versus your LDL-C goals. This is why partnering with an experienced lipidologist who specializes in statin intolerance can help. Your case is even more special because your regimen needs to fit an endurance athlete’s lifestyle (I refuse to believe your tibia fracture can permanently set you back! We will cheer you from the sidelines to start running again once recovered!!!). Again, with the usual caveats to take anything a stranger online will say with a grain of salt and to partner with your doc:
- Since your presentation is primary prevention and not secondary prevention due to ACS, it means you can probably afford to go “low and slowâ€.
- Depending upon your level of intolerance: if very intolerant, might start with 2.5 mg or 5 mg rosuvastatin once weekly. If you can tolerate, can start or titrate to twice weekly (eg. Mon/Thurs) or 3 times weekly (eg. Mon/Wed/Fri) 2.5 to 5 mg rosuvastatin. Switching to fluvastatin or pravastain is also on the table if the above does not work. Also, you can further titrate rosuvastatin dose to achieve your goals or add ezetimibe help achieve LDL-C goals if needed. PCSK9 inhibitors are also available, but is much more expensive and not sure if it is cost-effective for you.
- The elimination half-life of rosuvastatin is ~19 hours. It will take about 3-5 doses on whichever regimen to achieve “steady-stateâ€, to see where you land before making further changes or titrations. Suffice to say, intermittent regimens will result in higher “peak trough fluctuations†in plasma concentration. You can leverage this peak trough fluctuation to your benefit in terms of timing your exercise sessions!
- I would take the statin at night (ie, before bedtime). While long duration statins like rosuvastatin tend to allow time of administration at any time of day, you are trying to get the most “bang for your buckâ€â€”most cholesterol synthesis occurs at night, which means at least on those days you take the statin, the highest concentrations of the nightly-administered statin occurs at the time when it is most needed. Taking the statin at night also gives you a practical way to manage exercise… next bullet
- Taking the statin at night on an intermittent regimen means the daytimes on the days you take the statin are “trough†or nadir levels of statin in your body and may be the ideal days for your higher intensity exercise sessions. For example, if you are due to take your statin Monday night, Monday morning could be you higher intensity or longer training session day.
- Preface—this is REALLY anecdotal and NOT evidence-based: but for really big exercise days, eg a triathlon race, you might consider pausing your statin for 3 or more days before (which is >3 elimination half-lives). Big races result in CK releases (or muscle injury pattern) in even healthy people without medical conditions, and people on statins are shown to have even higher CK releases. SInce you are in the primary prevention category, you might consider this since races are few and far in between and should not unduly affect your overall “time under the curve†on LDL-C reduction.
Take care and good luck!
you guys are terrific. i have added this to our HOT FORUM TOPICS. if you don’t know about this, hunt for it, it’s on this page a couple of times, turn down the arrow, you’ll see a bunch of cool navigational helps, including on the medical end of things.
I’m not an MD.
Did you have a coronary calcium scan? Personally, I would not go on a statin without seeing the results of one first.
See above…calcium score of 2 so low risk, but you don’t see the soft plaques on a calcium score, which is why if you can you need to get a CT coronary angiogram, and that is what showed the soft plaques and hence the reason for the statin.
Hi Amnesia,
This is where we move away from evidence-base medicine. As you are aware, the CV outcomes trials for statins were evaluated with on-label regimens, which were daily administration. However, the totality of evidence strongly supports the LDL hypothesis, and intermittent regimens, so long as LDL is efficaciously reduced, should translate into reduced CV events.
There are so many permutations of intermittent statin regimens, and are in balance with what you can tolerate versus your LDL-C goals. This is why partnering with an experienced lipidologist who specializes in statin intolerance can help. Your case is even more special because your regimen needs to fit an endurance athlete’s lifestyle (I refuse to believe your tibia fracture can permanently set you back! We will cheer you from the sidelines to start running again once recovered!!!). Again, with the usual caveats to take anything a stranger online will say with a grain of salt and to partner with your doc:
- Since your presentation is primary prevention and not secondary prevention due to ACS, it means you can probably afford to go “low and slowâ€.
- Depending upon your level of intolerance: if very intolerant, might start with 2.5 mg or 5 mg rosuvastatin once weekly. If you can tolerate, can start or titrate to twice weekly (eg. Mon/Thurs) or 3 times weekly (eg. Mon/Wed/Fri) 2.5 to 5 mg rosuvastatin. Switching to fluvastatin or pravastain is also on the table if the above does not work. Also, you can further titrate rosuvastatin dose to achieve your goals or add ezetimibe help achieve LDL-C goals if needed. PCSK9 inhibitors are also available, but is much more expensive and not sure if it is cost-effective for you.
- The elimination half-life of rosuvastatin is ~19 hours. It will take about 3-5 doses on whichever regimen to achieve “steady-stateâ€, to see where you land before making further changes or titrations. Suffice to say, intermittent regimens will result in higher “peak trough fluctuations†in plasma concentration. You can leverage this peak trough fluctuation to your benefit in terms of timing your exercise sessions!
- I would take the statin at night (ie, before bedtime). While long duration statins like rosuvastatin tend to allow time of administration at any time of day, you are trying to get the most “bang for your buckâ€â€”most cholesterol synthesis occurs at night, which means at least on those days you take the statin, the highest concentrations of the nightly-administered statin occurs at the time when it is most needed. Taking the statin at night also gives you a practical way to manage exercise… next bullet
- Taking the statin at night on an intermittent regimen means the daytimes on the days you take the statin are “trough†or nadir levels of statin in your body and may be the ideal days for your higher intensity exercise sessions. For example, if you are due to take your statin Monday night, Monday morning could be you higher intensity or longer training session day.
- Preface—this is REALLY anecdotal and NOT evidence-based: but for really big exercise days, eg a triathlon race, you might consider pausing your statin for 3 or more days before (which is >3 elimination half-lives). Big races result in CK releases (or muscle injury pattern) in even healthy people without medical conditions, and people on statins are shown to have even higher CK releases. SInce you are in the primary prevention category, you might consider this since races are few and far in between and should not unduly affect your overall “time under the curve†on LDL-C reduction.
Take care and good luck!
Thanks Jae K, this is fantastic advice.
FYI-15 year specialist anaesthetist here (using our down under vernacular here rather than the USA system of Anesthesiologist!). Mainly clinical and part academic with a clinical professorship, so understand the PK aspects of what you are talking about re dosing and half lives etc.
I really appreciate your advice. I am not sure if there is a cardiologist in my area that has a special interest in statin intolerance but I will make some enquiries. So far, with a dose reduction by 50%, I have to say I am feeling less general muscle aching, but I will know more by the end of the week once we reach a new steady state and have some more swimming under my belt.
you guys are terrific. i have added this to our HOT FORUM TOPICS. if you don’t know about this, hunt for it, it’s on this page a couple of times, turn down the arrow, you’ll see a bunch of cool navigational helps, including on the medical end of things.
Thanks Dan,
This is very valuable medical information that you will absolutely struggle to find easily elsewhere (all the little pointers about how to manage the dosing and how to manage them around racing etc).