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Can We Confirm the Nocebo Effect of Statins and Muscle Pain?

  • Authors: News Author: Steve Stiles; CME Author: Charles P. Vega, MD
  • CME / ABIM MOC / CE Released: 4/9/2021
  • Valid for credit through: 4/9/2022, 11:59 PM EST
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This activity is intended for all primary care clinicians, cardiologists, endocrinologists, and other physicians who prescribe statins.

The goal of this activity is to assess the risk for myalgia associated with statins.

Upon completion of this activity, participants will:

  • Analyze the efficacy of coenzyme Q10 in improving muscle pain associated with statins
  • Evaluate the relationship between statins and muscle symptoms in a series of n-of-1 trials
  • Outline implications for the healthcare team


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News Author

  • Steve Stiles

    News Editor, | Medscape Cardiology


    Disclosure: Steve Stiles has disclosed no relevant financial relationships.

CME Author

  • Charles P. Vega, MD

    Health Sciences Clinical Professor of Family Medicine
    University of California, Irvine School of Medicine
    Irvine, California


    Disclosure: Charles P. Vega, MD, has disclosed the following relevant financial relationships:
    Served as an advisor or consultant for: GlaxoSmithKline

Editor/Nurse Planner

  • Hazel Dennison, DNP, RN, FNP-BC, CHCP, CPHQ, CNE

    Associate Director, Accreditation and Compliance
    Medscape, LLC


    Disclosure: Hazel Dennison, DNP, RN, FNP-BC, CHCP, CPHQ, CNE, has disclosed no relevant financial relationships.

CME Reviewer

  • Esther Nyarko, PharmD

    Associate Director, Accreditation and Compliance
    Medscape, LLC


    Disclosure: Esther Nyarko, PharmD, has disclosed no relevant financial relationships.

Medscape, LLC staff have disclosed that they have no relevant financial relationships.

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Can We Confirm the Nocebo Effect of Statins and Muscle Pain?

Authors: News Author: Steve Stiles; CME Author: Charles P. Vega, MDFaculty and Disclosures

CME / ABIM MOC / CE Released: 4/9/2021

Valid for credit through: 4/9/2022, 11:59 PM EST


Clinical Context

Up to 10% of patients treated with statins may experience symptoms of muscle pain or weakness, and one of the proposed mechanisms for statin-induced muscle symptoms is their effect in reducing levels of coenzyme Q10 (CoQ10). CoQ10 has thus grown in popularity as a means to reduce the adverse effects of statins, but not all research has been supportive of its efficacy. To address this issue, Qu and colleagues performed a meta-analysis of 12 randomized controlled trials of CoQ10 treatment among adults receiving statins. The results of their study were published in the October 2, 2018, issue of the Journal of the American Heart Association.[1]

Compared with placebo, CoQ10 was associated with significant improvements in muscle pain, weakness, cramping, and tiredness. These improvements appeared to be independent of the dose or duration of treatment with CoQ10. However, serum levels of creatine kinase were similar in the CoQ10 and placebo groups.

CoQ10 is an option to ameliorate complications of statin treatment, but there has been a question of causation related to statin use and muscle symptoms. The current study addresses this issue by enrolling patients with a past history of statin-induced muscle symptoms to a trial of statin vs placebo.

Study Synopsis and Perspective

Another randomized trial, on the heels of the recently published SAMSON trial, has concluded -- many would say confirmed -- that statin therapy is no more likely than placebo to "cause" muscle pain in most patients who report such symptoms while receiving the drugs.

Affected patients who sorely doubt that conclusion might possibly embrace statins, researchers say, if the new trial's creative methodology could somehow be applied to them in clinical practice.

The recent SAMSON trial made waves in November 2020 by concluding, with some caveats, that about 90% of the burden of muscle symptoms reported by patients receiving statins may be the result of a nocebo effect; that is, they are attributed to the drugs, perhaps as a result of negative expectations, but are not actually caused by them.

The new trial, StatinWISE (Statin Web-based Investigation of Side Effects), which is triple the size but similar in design and conducted parallel to SAMSON, similarly saw no important differences in patient-reported muscle symptom prevalence or severity during administration of atorvastatin 20 mg/day or placebo, in withdrawal from the study resulting from such symptoms, or in patient quality of life.

The findings also support years of observational evidence that argues against a statin effect on muscle symptoms except in rare cases of confirmed myopathy, as well as results from randomized trials such as ODYSSEY ALTERNATIVE and GAUSS-3, in which significant muscle symptoms in "statin-intolerant" patients were unusual, note StatinWISE investigators in their report, published online February 24 in BMJ, with lead author Emily Herrett, PhD, from the London School of Hygiene and Tropical Medicine, United Kingdom.[3-5]

"I'm hoping it can change minds a bit and reassure people. That was part of the reason we did it, to inform this debate about harms and benefits of statins," principal investigator Liam Smeeth, MBChB, PhD, from the same institution, said during a virtual press conference on the trial conducted by the UK nonprofit Science Media Centre.

"In thinking through whether to take a statin or not, people can be reassured that these muscle symptoms are rare; they aren't common. Aches and pains are common, but are not caused by statins," said Dr Smeeth, who is senior author on the trial publication.

Another goal of the 200-patient study, he said, was to explore whether patients who had experienced muscle symptoms on a statin but were willing to explore whether the statin was to blame could be convinced, depending on what they learned in the trial, to continue receiving the drugs.

It seemed to work: two thirds of the participants who finished the study "decided that they would actually want to try starting statins again, which was quite amazing," he said.

But there was a "slight caveat," Dr Smeeth observed. "To join our trial, yes, you had to have had a bad experience with statins, but you probably had to be a little bit open to the idea of trying them again. So, I can't claim that that two thirds would apply to everybody in the population."

Because StatinWISE entered only patients who had reported severe muscle symptoms on a statin but had not showed significant enzymatic evidence of myopathy, all had either taken themselves off the statin or were "considering" it. The study had also excluded anyone with "persistent, generalized, unexplained muscle pain" regardless of any statin therapy.

"This was very deliberately a select group of people who had serious problems taking statins. This was not a random sample by any means," Dr Smeeth said.

"The patients in the study were willing to participate and take statins again," suggesting they "may not be completely representative of all those who believe they experience side effects with statins, as anyone who refused to take statins ever again would not have been recruited," observed Tim Chico, MBChB, MD, from the University of Sheffield, United Kingdom, in a Science Media Centre press release on StatinWISE.

Still, even among this "supersaturated group of people" selected for having had muscle symptoms when receiving statins, Dr Smeeth said at the briefing, "in almost all cases, their pains and aches were no worse on statins than they were on placebo. We're not saying that anyone is making up their aches and pains. These are real aches and pains. What we're showing very clearly is that those aches and pains are no worse on statins than they are on placebo."

Rechallenge Is Possible

Some people are more likely than others to experience adverse reactions to any drug, "and that's true of statins," Neil J. Stone, MD, from Northwestern University, Chicago, Illinois, told | Medscape Cardiology. But StatinWISE underscores that many patients with muscle symptoms on the drugs can be convinced to continue with them rather than stop them entirely.

"The study didn't say that everybody who has symptoms on a statin is having a nocebo effect," said Dr Stone, vice chair for the multisociety 2018 Guideline on the Management of Blood Cholesterol, who was not involved with StatinWISE.[6]

"It simply said," allowing for some caveats, "that a significant number of patients may have symptoms that don't preclude them from being rechallenged with a statin again, once they understand what this nocebo effect is."

In addition, Dr Stone said, "it amplifies the 2018 guidelines, with their emphasis on the clinician-patient discussion before starting therapy," by showing that statin-associated muscle pain is not necessarily caused by the drugs and is not a reason to stop them.

"That there is a second study confirming SAMSON is helpful, and the results are helpful because they say many of these patients, once they are shown the results, can be rechallenged and will then tolerate statins," Steven E. Nissen, MD, from the Cleveland Clinic, told | Medscape Cardiology.

"They were able to get two thirds of those completing the trial into long-term treatment, which I think is obviously very admirable and very important," said Dr Nissen, who was GAUSS-3 principal investigator but was not associated with StatinWISE.[4]

"I think it is important, however, that we not completely dismiss patients who complain of adverse effects. Because, in fact, there probably are some people who do have muscle-related symptoms," he said. "But you know, to really call somebody statin-intolerant, they really should fail 3 statins, which would be a very good standard."

In his experience, said Patrick M. Moriarty, MD, who directs the Atherosclerosis and Lipoprotein-Apheresis Center at the University of Kansas Medical Center, Kansas City, perhaps 80% to 90% of patients who believe they are statin-intolerant because of muscle symptoms are actually not statin-intolerant at all.

"I think a massive amount of it is supratentorial," Dr Moriarty, who was not part of StatinWISE, told | Medscape Cardiology. It comes directly from "what they heard, what they read, or what they were told, and at their age, they're going to have aches and pains."

Value of the N-of-1 Trial

Dr Smeeth and colleagues framed StatinWISE in part as a test of a strategy for overcoming nocebo-based aversion to statins. One goal was to see whether these methods might be helpful in practice for convincing patients who want to reject statins because of muscle symptoms to give the drugs another chance.

In StatinWISE, patients were individually assigned to take atorvastatin or placebo in randomized order with multiple blinding during each of 6 successive 2-month periods, so that they were on receiving or the other agent half the time. They rated their symptoms at the end of each period.

The trial in composite was, as the publication states, "a series of randomized, placebo-controlled n-of-1 trials." SAMSON followed a similar scheme, except, as previously reported, it had specified 4 months of atorvastatin, 4 months of placebo, and 4 months with patients receiving neither statin nor placebo.[2]

StatinWISE "provides a useful approach (the n = 1 study) that could be used in real life to help patients understand the cause of their own possible side effects, which could also be applied to medications other than statins," Dr Chico added in the Science Media Centre release.

"I often encounter people who have a firmly held view that statins cause muscle pains even when they haven't taken these medications themselves, and I hope that this study may help change this view and make them willing to try such an 'experiment,' " he said.

Others are not sure an experiment resembling an n-of-1 trial would be practical or effective when conducted in routine practice.

More efficient and useful, Dr Moriarty noted, would be for physicians to nurture a close relationship with patients, one that could help transform their negative feelings about statins into a willingness to accept the drugs. "This is a trust you have to build; these are human beings."

He said getting the patient's confidence is critical. "You have to explain the pluses and minuses of getting treatment, of the 30% reduction in cardiovascular events that occur with the statin. You don't go 'testing this and that.' I think it's more about getting them on board."

No Statin Effect on Muscle Symptoms

Patients in StatinWISE were recruited from 50 primary care practices in England and Wales from December 2016 to April 2018, the report notes; their mean age was 69 years and 58% were men. Of the 200 patients, 151 recorded muscle-symptom scores for at least 1 statin period and 1placebo period, and so were included in the primary-endpoint assessment.

The mean muscle symptom score was lower when receiving statin therapy than placebo (M=1.68, SD= 2.57), but there was no significant difference in adjusted analysis (mean difference, −0.11 (95% confidence interval [CI], −0.36 to 0.14; = .40).

Statins showed no significant effect on development of muscle symptoms overall, it was reported, with an odds ratio (OR) of 1.11 (99% CI, 0.62-1.99). Nor was there an effect on "muscle symptoms that could not be attributed to another cause" (OR, 1.22; 95% CI, 0.77-1.94).

Of the 80 withdrawals during the study for any reason, 43% occurred when the patient was receiving the statin, 49% when the patient was receiving placebo, and 9% after randomization but before either statin or placebo had been initiated. Of those, 32 withdrawals were a result of "intolerable muscle symptoms," says the report. But withdrawal occurred about as often when receiving statin therapy as off the drug, at 9% and 7%, respectively, throughout the 1-year study.

"This study provides further evidence through the lived experience of individuals that muscle pains often attributed to statins are not due to the drug," said Sir Nilesh J. Samani, MBChB, MD, medical director for the British Heart Foundation, as quoted in the Science Media Centre press release.

"The use of each patient as their own control in the trial provides a powerful way of distinguishing the effect of a statin from that of taking a pill," he said. "The findings should give confidence to patients who may be concerned about taking statins."

StatinWISE was funded by the National Institute for Health Research-Health Technology Program and sponsored by the London School of Hygiene and Tropical Medicine. The authors declare that they have "no financial relationships with any organizations that might have an interest in the submitted work in the previous 3 years; no other relationships or activities that could appear to have influenced the submitted work." Dr Smeeth reports receiving grants from GlaxoSmithKline and personal fees for advisory work from GlaxoSmithKline and AstraZeneca. Dr Stone reports no industry relationships or other disclosures. Dr Nissen reports that his center has received funding for clinical trials from AbbVie, AstraZeneca, Amgen, Cerenis, Eli Lilly, Esperion, Medtronic, MyoKardia, Novartis, Pfizer, The Medicines Company, Silence Therapeutics, Takeda, and Orexigen; that he is involved in these trials but receives no personal remuneration; and that he consults for many pharmaceutical companies but requires them to donate all honoraria or fees directly to charity so that he receives neither income nor a tax deduction. Dr Chico, Dr Moriarty, and Dr Samani have disclosed no relevant financial relationships.

BMJ. 2021;372:n135.

Study Highlights

  • Study participants were recruited from general practices in the United Kingdom. All participants had stopped a statin or were considering stopping a statin during the past 3 years because of muscle symptoms.
  • Participants with a history of persistent, unexplained muscle pain were excluded from study participation, as were those with a previous history of significant increase in serum transaminase or creatine kinase levels.
  • Participants were randomly assigned to receive atorvastatin 20 mg daily or placebo during 6 two-month periods alternating between the 2 study treatments. The primary study outcome was muscle symptoms such as pain, weakness, or stiffness. These were recorded with a daily self-report from patients on a scale of 0 to 10, with 10 being the most severe pain.
  • Researchers also examined physical function and quality-of-life measures.
  • Participants who completed the study were unblinded to their results, and they were asked whether they had or would restart statins again.
  • 200 participants were recruited into the study. The mean age was 69.1 years, 58% of participants were men, and 70% of participants had a history of cardiovascular disease. The median total cholesterol concentration was 5.3 mmol/L.
  • Study adherence was good. Pill counts revealed that more than 80% of participants took the study medication at least most of the time, 151 participants completed at least one measurement of muscle pain when receiving both atorvastatin and placebo, and there were nearly 400 treatment periods completed for both statin and placebo during the total study period.
  • The mean muscle symptom scores in comparing the statin and placebo groups were 1.68 and 1.85, respectively, a nonsignificant difference. Most muscle symptoms were noted in the lower extremities.
  • The incidence of muscle symptoms was similar in the 2 groups as well. Physical function and quality-of-life scores were also similar in comparing the statin and placebo groups.
  • 113 participants learned about their individual study data and 66% reported that they had already resumed or intended to restart statin therapy. Even among the 15% of participants with higher symptom scores when receiving the statin vs the placebo, more than half said that they would restart a statin.
  • 80 participants in total withdrew from the study. Rates of study withdrawal were 43% during a statin period and 49% during a placebo period. There were no serious adverse events related to study treatment.

Clinical Implications

  • In a previous meta-analysis, CoQ10 was associated with lower rates of muscle pain, weakness, cramping, and fatigue compared with placebo among adults receiving statins.
  • In the current study, rates of muscle symptoms were similar during statin and placebo treatment periods among participants with a history of muscle symptoms thought to be secondary to statin use. Physical function and quality-of-life measures were also similar between the statin and placebo groups, and most participants were willing to restart statins after the trial.
  • Implications for the healthcare team: The healthcare team should listen with empathy to patients with possible statin-induced muscle symptoms. But they should also look for other causes of muscle pain and try to maintain statin therapy, particularly among patients at high risk for cardiovascular events.

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