A Newly Identified Statin Toxicity

SOURCE: Mammen AL. Statin-associated autoimmune myopathy. N Engl J Med 2016;374:664-669.

Statins, when appropriately dosed and used within FDA labeling, are generally safe medications, and provide significant cardiovascular risk reduction for patients presenting with elevated cardiovascular risk due to dyslipidemia, hypertension, or previous cardiovascular events. A minority of patients treated with statins develop myalgias. Clinicians resolve most of these cases with dose adjustment, switching statin, or removal of an interacting substance (e.g., grapefruit juice with simvastatin).

Statin-associated autoimmune myopathy (SAM) is a rare disorder (estimated at two to three/100,000 treated patients). It may occur at any time during the course of statin treatment and is characterized by muscle pain, progressive proximal muscle weakness, and elevations in creatine kinase levels (> 10 x ULN). Biopsy shows muscle-cell necrosis as well as autoantibodies against HMG-CoA reductase.

When disease is mild, statin cessation sometimes is sufficient to allow recovery; however, combination immunosuppressive treatment (e.g., prednisone + methotrexate) is suggested for moderate-severe cases, progressing to triple therapy (e.g., rituximab) if the initial combination treatment is insufficiently efficacious.

Most cases of SAM treated in a timely fashion with immunosuppressive therapy produce favorable outcomes. Clinicians in all specialties providing care to statin-treated patients must be cognizant of this newly recognized disorder.

Who Should Receive Diabetes/Prediabetes Screening?

SOURCE: Laiteerapong N, Cifu AS. Screening for prediabetes and type 2 diabetes mellitus. JAMA 2016;315:697-698.

In October 2015, the United States Preventive Services Task Force (USPSTF) published its first update on screening for diabetes/prediabetes since 2008. Its recommendations apply to overweight or obese adults 40-70 years of age, although the group also endorsed consideration of extending the reach of the screening umbrella to include younger patients or patients with lower body mass index for those with a family history of diabetes, gestational diabetes, polycystic ovary syndrome, or ethnic/racial minorities. The USPSTF recommended screening every three years, using any one or more of the following tests: A1c, fasting glucose level, or glucose tolerance test.

Although treating persons with prediabetes (using diet, exercise, medication, or combined treatments) delays progression to diabetes, it remains to be seen whether such early identification actually reduces clinical events. Clinical trial outcomes have found no significant reduction in mortality when diabetes-screened populations were compared with unscreened subjects.

With modest differences, the USPSTF recommendations are similar to those of the American Diabetes Association and the American Association of Clinical Endocrinologists. The USPSTF recommendation received a “B” rating, as, “There is high certainty that the net benefit is moderate or there is moderate certainty that the net benefit is moderate to substantial.”

Chronic Fatigue Syndrome and Serious Adverse Outcomes

SOURCE: Roberts E, Wessely S, Chalder T, et al. Mortality of people with chronic fatigue syndrome: A retrospective cohort study in England and Wales from the South London and Maudsley NHS Foundation Trust Biomedical Research Centre (SLaM BRC) Clinical Record Interactive Search (CRIS) Register. Lancet 2016;387:

Small, uncontrolled clinical case series have suggested that patients who suffer from chronic fatigue syndrome (CFS) incur greater risks of heart failure, cancer, and overall mortality. A recently published report provides great reassurance this is not the case.

According to Roberts et al, CFS is characterized by persistent or relapsing fatigue, along with at least four other symptoms such as memory loss, poor concentration, joint pain, and tender glands. They reviewed data compiled from a United Kingdom registry that included 2,147 CFS cases.

During seven years of follow-up, there was no difference in all-cause mortality rates or cancer-specific mortality. On the other hand, there was a quite substantial increased risk for suicide among CFS patients.

Depression and anxiety previously have been established as common comorbidities for patients with CFS. The marked increased risk for suicide in CFS patients suggests clinicians should enhance their vigilance for CFS and promptly intervene with patients who screen positive for depression.