A practical algorithm for the management of patients with statin-associated muscle symptoms.

Statin-associated muscle symptoms (SAMS) are the most frequent clinically relevant adverse effects of statins causing discontinuation of statin treatment, and subsequent increase in cardiovascular events. The incidence of SAMS in clinical practice is 5-10%. Clinical manifestations of SAMS are highly heterogeneous and range from mild weakness, cramps, and muscle pains to the very rare and severe rhabdomyolysis. The most common type of SAMS (>80%) is muscle pains without or with mild increase in creatine kinase. The management of patients with SAMS is a clinical challenge. A strategic approach involving clinical assessment, patients' reassurance regarding statin safety, and reintroduction of low statin dose (daily or alternate scheme) combined with nonstatins (ezetimibe first and if required, the addition of alirocumab or evolocumab) will allow the majority of them to achieve meaningful low-density lipoprotein-cholesterol reductions.