Location
Philadelphia, PA
Start Date
30-4-2025 1:00 PM
End Date
30-4-2025 4:00 PM
Description
Background: Statins are a widely used class of drugs that have been found to be safe and effective in treating hypercholesterolemia. Used for both primary and secondary prevention, statins inhibit HMG-CoA reductase, inhibiting a vital step in cholesterol production. Statin-associated muscle symptoms (SAMS) are a clinical spectrum defined as muscle pain, discomfort, and/or weakness with or without elevated CK levels. This spectrum ranges from minimal myalgias to severe statin-associated immune-mediated necrotizing myopathy (IMNM). It is known that myocytes have upregulated levels of HMG-CoA reductase in the presence of statin use. While the exact pathophysiology of statin associated IMNM has yet to be elucidated, it is proposed that the antibodies targeted against HMG-CoA reductase damage the myocytes in which HMG-CoA reductase is upregulated. For those with severe deficits, rehabilitation can be helpful to restore and preserve function as severe proximal muscle weakness can result in reduced mobility, difficulty with activities of daily living thus preventing a safe return home.
Case description: This patient is a 58-year-old male with a past medical history including hypertension, hyperlipidemia, hypothyroidism, pre-diabetes, IBS, and OSA presented to Tower Health Rehabilitation Hospital with the diagnosis of SINAM. Prior to his symptoms, he was independent, living alone, working as a mail carrier. In August 2024, he had elevated liver function tests with minor stiffness. Three months later, his liver function tests worsened, and he was having increased stiffness and lower extremity weakness. His weakness progressed and in January 2025, began affecting his bilateral proximal upper extremities. At this time, he was admitted to Reading Hospital with suspected statin induced myopathy and concern for rhabdomyolysis given his markedly elevated CK levels. His statin was discontinued and was recommended to follow up as an outpatient with Neurology for EMG testing. Myositis antibodies were sent, and his HMG-CoA reductase antibodies resulted positive. One month later, he was evaluated by out-patient neurology and his symptoms were markedly worse- he had multiple falls at home and was unable to stand up without a two person assist. Given his difficulty ambulating, he was admitted as an inpatient for prompt immunologic treatment. His symptoms minimally improved following completion of IVIG and IV Solumedrol. He was started on daily Prednisone and was admitted for inpatient rehabilitation given his significant change from baseline functional status.
Discussion: Diagnosis can be difficult, especially considering the gradual onset of vague symptoms potentially presenting years after statin initiation. It is known that early intervention with medical therapies including IVIG and IV steroids are vital to preserving and improving muscle function, so swift diagnosis is key for maximal patient recovery. Statin-associated IMNM is a rare complication of statin use but should be considered in all statin users presenting with proximal weakness affecting functioning regardless of statin onset time. Treating this diagnosis requires a multi-disciplinary approach to facilitate restoring function and quality of life.
Embargo Period
5-29-2025
Included in
Statin-Associated Immune Mediated Necrotizing Myopathy: A Case Report
Philadelphia, PA
Background: Statins are a widely used class of drugs that have been found to be safe and effective in treating hypercholesterolemia. Used for both primary and secondary prevention, statins inhibit HMG-CoA reductase, inhibiting a vital step in cholesterol production. Statin-associated muscle symptoms (SAMS) are a clinical spectrum defined as muscle pain, discomfort, and/or weakness with or without elevated CK levels. This spectrum ranges from minimal myalgias to severe statin-associated immune-mediated necrotizing myopathy (IMNM). It is known that myocytes have upregulated levels of HMG-CoA reductase in the presence of statin use. While the exact pathophysiology of statin associated IMNM has yet to be elucidated, it is proposed that the antibodies targeted against HMG-CoA reductase damage the myocytes in which HMG-CoA reductase is upregulated. For those with severe deficits, rehabilitation can be helpful to restore and preserve function as severe proximal muscle weakness can result in reduced mobility, difficulty with activities of daily living thus preventing a safe return home.
Case description: This patient is a 58-year-old male with a past medical history including hypertension, hyperlipidemia, hypothyroidism, pre-diabetes, IBS, and OSA presented to Tower Health Rehabilitation Hospital with the diagnosis of SINAM. Prior to his symptoms, he was independent, living alone, working as a mail carrier. In August 2024, he had elevated liver function tests with minor stiffness. Three months later, his liver function tests worsened, and he was having increased stiffness and lower extremity weakness. His weakness progressed and in January 2025, began affecting his bilateral proximal upper extremities. At this time, he was admitted to Reading Hospital with suspected statin induced myopathy and concern for rhabdomyolysis given his markedly elevated CK levels. His statin was discontinued and was recommended to follow up as an outpatient with Neurology for EMG testing. Myositis antibodies were sent, and his HMG-CoA reductase antibodies resulted positive. One month later, he was evaluated by out-patient neurology and his symptoms were markedly worse- he had multiple falls at home and was unable to stand up without a two person assist. Given his difficulty ambulating, he was admitted as an inpatient for prompt immunologic treatment. His symptoms minimally improved following completion of IVIG and IV Solumedrol. He was started on daily Prednisone and was admitted for inpatient rehabilitation given his significant change from baseline functional status.
Discussion: Diagnosis can be difficult, especially considering the gradual onset of vague symptoms potentially presenting years after statin initiation. It is known that early intervention with medical therapies including IVIG and IV steroids are vital to preserving and improving muscle function, so swift diagnosis is key for maximal patient recovery. Statin-associated IMNM is a rare complication of statin use but should be considered in all statin users presenting with proximal weakness affecting functioning regardless of statin onset time. Treating this diagnosis requires a multi-disciplinary approach to facilitate restoring function and quality of life.