Electronic letters to:

Research:
Markus G. Mohaupt, Richard H. Karas, Eduard B. Babiychuk, Verónica Sanchez-Freire, Katia Monastyrskaya, Lakshmanan Iyer, Hans Hoppeler, Fabio Breil, and Annette Draeger
Association between statin-associated myopathy and skeletal muscle damage
CMAJ 2009; 181: E11-18E [Abstract] [Full text] [PDF]
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Electronic letters published:

[Read eLetter] Response to Dr. Stein
Annette Draeger   (8 September 2009)
[Read eLetter] Response to Dr. Miller
Annette Draeger   (8 September 2009)
[Read eLetter] puzzled at the lack of mention of Co Enzyme Q10 reduction by statins as likely key contributor.
nathan B Stein   (11 August 2009)
[Read eLetter] fear mongering
David B Miller   (10 July 2009)

Response to Dr. Stein 8 September 2009
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Annette Draeger

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Re: Response to Dr. Stein

draeger{at}ana.unibe.ch Annette Draeger

Thank you for your comment on our statin-myopathy study. We are aware that Co Q10 supplementation is a controversial issue.

However, the authors of two recent reviews (Marcoff & Thompson, JACC, 2007; Schaars & Stalenhoef, Curr Opin Lipidol 2008) did not unequivocally recommend supplementation. Since we do not have own data, we cannot contribute to the discussion.

Yours sincerely Annette Draeger

Conflict of Interest:

None declared
Response to Dr. Miller 8 September 2009
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Annette Draeger

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Re: Response to Dr. Miller

draeger{at}ana.unibe.ch Annette Draeger

Thank you for your letter in response to our article on statin-associated myopathy.

In observational studies, the rate of myalgia in statin-treated patients has been shown to be around 10-15% (Bruckert et al., Cardiovasc Drugs Ther 2005). This rate is mentioned in the Introduction of our paper.

Everybody who is familiar with the literature on statin-associated myopathy is aware of a discrepancy between the number of patients developing myopathy in numerous prospective statin studies (no difference between statin and placebo) and observational studies (10% of patients develop myopathy). And as you pointed out yourself, the risk of developing myopathy is considerably increased in patients who present with multiple comorbidities and receive medication which interferes with the metabolism of statins. However,this myopathy risk group (the old and sick) does not meet the selection criteria and is therefore always carefully excluded from prospective studies, which explains the difference in numbers.

Since we intended to investigate patients suffering from statin-associated myopathy, we selected those who were clinically diagnosed to suffer from statin-induced myopathy, which means that we included patients who received concomittant medication. However, we matched these patients with a control group which likewise received concomittant medication, yet did not present with myopathy (see Table 1). We were highly impressed by the editors of CMAJ who were incredibly thorough in checking these cases. They requested - and received - baseline data of each individual patient, which included every single drug administered. It was their choice not to include this substantial documentation in the published version. The reader is therefore referred to the overview in Table 1. Drug interactions, in particular the effects of glucocorticoids, are discussed on page E17. Since the structural and molecular data is very novel, more room was given to the discussion of these findings.

With the selection criteria clearly stated and concomittant medication disclosed, we fail to see why our study should be considered "deeply flawed". Or indeed more "flawed" than numerous existing studies, which are based on a fraction of the number of our carefully documented cases.

We also regret the lurid reports by the popular press, however, we must decline all responsibility. Tabloids publish what they want, regardless of the scientific source.

Yours sincerely Annette Draeger

Conflict of Interest:

None declared
puzzled at the lack of mention of Co Enzyme Q10 reduction by statins as likely key contributor. 11 August 2009
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nathan B Stein
Psychiatrist

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Re: puzzled at the lack of mention of Co Enzyme Q10 reduction by statins as likely key contributor.

nathan.stein{at}doctors.org.uk nathan B Stein

I was very surprised to see no mention whatsoever in your article of the fact that many patients on statins end up with muscle weakness and muscle pains which are reversed by the supplementation of Co enzyme Q10, and that this can progress to Myositis, or go straight to myositis.

Co Q10 is made in the body as part of the same reaction that makes Cholesterol.

Statins block the production of both, and CoQ10 is a vital ingredient in the mitochondriae of the muscle cells, for the production of energy for muscle contraction.

Muscle weakness caused by statin induced muscle weakness may appear immediately or months down the line, depending on several factors s/a pre- existing levels, dose of Statins, age etc...

I was disgusted to learn about it first from Doctors writing from the world of complementary medicine, and not from the medical journals. They provided solid scientific support for their assertion. These are scientifically proven facts, and there seems to be such a conspiracy of silence about it, that most GP's are unaware of the link! The truth is, there is no money in it for the drug companies, as Co Q 10 cannot be patented! Dr N B Stein, Manchester, UK, Psychiatrist.

Conflict of Interest:

None declared
fear mongering 10 July 2009
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David B Miller
vancouver island health authority

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Re: fear mongering

dmiller.endocrinology{at}shaw.ca David B Miller

Congratulations CMAJ on adding to the fear of myopathy with statin therapy based on the article by Mohaupt et al. In this pathology study of statin myopathy nowhere is it mentioned how frequent statin myopathy might be. And in the groups with statin myopathy 12 of 15 (former users) and 26 of 29 (current users) were concurrently taking drugs (immunosuppressants, macrolides, etc.) known either to cause myopathy themselves or increase the risk of myopathy with statin therapy due to competition for the P450 enzymes. So, what comes out in the popular press: "Cholesterol pills can be a pain" - Victoria Times-Colonist; "Statins suspected: muscle pain side effect could be permanent" - Vancouver Province and; "Cholesterol drugs linked to long-lasting muscle injury" - Vancouver Sun. Nowhere is there a discussion in the popular press that the "long-lasting" muscle injury was in patients who had stopped taking the drug for a median of 12 weeks, nor how common the problem might be. And nowhere in the CMAJ article is there a discussion of how the results could be entirely due to other drugs or a drug-drug interaction. Why didn't the reviewers and editors of CMAJ ask to see more results on patients with myopathy just on statins? That would have been a much more scientifically valid study. For now, patients will be stopping medications without physician supervision or questioning their physicians judgement and recommendations based on a deeply flawed study.

David Miller MD FRCPC Cert Endo Head, Endocrinology, Vancouver Island Health Authority

Conflict of Interest:

None declared