Free Statin intolerance app by American College of Cardiology is a great resource

A familiar clinic visit for most internists, family practitioners, and cardiologists is the discussion about statin side effects. While some have been debunked, myopathy remains a challenging issue. What makes it tough is teasing out real statin-related myopathy from the plethora of other things that can cause aches & pains.

This tool from the ACC aims to address the issue of statin intolerance, specifically statin myopathy.

The app opens to a home screen with three options: Evaluate, Follow-Up, and Compare.

The Evaluate section walks through a “risk calculator” of the major considerations when evaluating someone with potential statin-related myopathy like the type of pain, relationship to statin initiation, risk factors such as other medications & age, and lab abnormalities. There is a list of labs you could consider ordering though more guidance on there on which ones should be ordered when would be helpful.

I expected some sort of risk score or qualitative assessment (e.g. low, medium, high) based on the design but what you get is basically a chart saying which parts of the history go for or against statin myopathy. There’s no specific guidance or suggestion about what to do next other than saying it’s a risk/benefit decision.

 

In Follow-Up, we tap on current decision point e.g. doing a follow-up visit after stopping the statin at the last visit vs. after reinitiating a low-dose statin at the last visit. The advice in this section is more direct and practical. If we’re seeing our patient after having stopped atorvastatin at the last visit and symptoms resolved, then restart a lower dose. If we’re seeing them after failing low-dose atorvastatin on a re-challenge, try a different statin. Practical suggestions are made to consider factors like metabolism or lipophilicity – if they failed a drug that is lipophilic, try one that isn’t.

Things missing here were recommendations on follow-up timing. Also not discussed really is lab testing in follow up.

In the Compare tab, we get detailed information on a range of statins like half life, metabolic pathway, lipophilicity, and more. There is also a feature letting you enter in whether the patient is on a potentially interacting medication. If there’s an interaction, you can then change the statin choice to see if there’s a better option. While I didn’t see this as terribly useful as an interaction checker (given the ubiquity of that feature in EMRs and in other apps), it was useful as a list of medications to be on the look out for when prescribing statins in general.

Some notable features that were missing here were shareable patient information on statin side-effects (real and bogus) and a side-by-side drug comparison option.

Overall, the app contains a fair amount of practical and useful information; also included are links to a wide range of lipid-related resources. As an in-clinic resource, I found it to be a bit too cumbersome to use regularly as a decision support tool. It is however a great educational tool, if used periodically or even just read outside of clinic visits, on how to perform the evaluation for statin myopathy and manage these patients subsequently.