Statin-Induced Autoimmune Myopathy

Abstract

Statins are one of the most widely prescribed drugs in the world. One of the common side effects of statin use is myopathy. We report a case of statin-induced autoimmune myopathy, which is a variant of statin-induced myopathy. A 56-year-old female with a history of hypertension, hyperlipidemia, cerebral aneurysm status post clipping, and seizure disorder presented with progressive muscle weakness. Her initial laboratory results demonstrated an elevated creatine phosphokinase (CPK) of 17,144 IU/L. The patient’s atorvastatin was discontinued and she was placed on high-rate intravenous fluids; however, despite this, her CPK remained elevated. Patient underwent further blood testing for specific autoimmune etiologies. As there was high concern for autoimmune myositis, she was started on high-dose steroids. Anti-3-hydroxy-3-methylglutaryl-coenzyme A (anti-HMG-CoA) reductase antibody returned strongly positive. While the patient was on steroids, her muscle weakness and CPK level gradually improved. She was discharged on oral steroids. Statin-induced autoimmune myopathy should be considered with high suspicion when there is a significantly elevated CPK level. Discontinuation of statin therapy does not lead to muscle recovery or improvement in the CPK level. Diagnosis is confirmed by positive anti-HMG-CoA reductase autoantibody and a muscle biopsy.

Statin-Associated Myalgia, Myopathy, and Myositis

“…For this reason, patients with statininduced autoimmune myopathy and anti-HMGCR autoantibodies often require chronic immunosuppression to control the disease and prevent flares. 19 Rhabdomyolysis is the most serious type of statininduced myotoxicity and has an incidence of 3.4 per 100,000 patients. 20 It can present with diffuse muscle pain, weakness, low back pain, and flu-like symptoms.…”

“…Unfortunately, the symptoms can progress even after cessation of the statin because the presence of the autoantibodies that recognize HMGCR, the pharmacologic enzyme target of statin therapies, is triggered into a self-sustaining cycle of attacking muscle cells that express HMGCR. For this reason, patients with statin-induced autoimmune myopathy and anti-HMGCR autoantibodies often require chronic immunosuppression to control the disease and prevent flares 19…”

Statin Use in Relation to COVID-19 and Other Respiratory Infections: Muscle and Other Considerations

“…An additional consideration is the potential for both statins and COVID-19 to promote autoimmunity. Autoimmune necrotizing myositis [10][11][12]138] is a feared complication of statin use. (Other autoimmune complications of statins are also reported [139][140][141][142][143]-which can affect muscle [144][145][146][147]-and in some cases, these accompany autoimmune myositis [13][14][15][16]148].)…”

“…Such AEs include, but are not limited to, muscle pain, muscle weakness, and fatigue. Rhabdomyolysis and autoimmune necrotizing myositis specifically have occurred with COVID-19 [6][7][8][9] as they can occur with statins [10][11][12][13][14][15][16]. Based on these and other considerations, the risk side of the risk-benefit ratio should also be considered seriously in deliberations about statin use.…”

Adenosine Triphosphate Exerts Cardioprotective Effect on High-Dose Atorvastatin-Induced Heart Damage in Rats

“…Additional favorable outcomes are decreasing total cholesterol and very low-density lipoproteins while increasing the amount of high-density lipoprotein (HDL) and its receptors [4]. However, in patients receiving atorvastatin, side effects such as creatine phosphokinase elevation, arthralgia, dyspepsia, diarrhea, nausea, nasopharyngitis, insomnia, urinary tract infection have been previously reported [5]. It has been shown that atorvastatin significantly reduces adenosine triphosphate (ATP) levels, which meets a large part of the heart's energy demand [6].…”