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Correspondence to Professor Maurizio Balestrino, [email protected]
Background
Inhibitors of the 5-hydroxy-3-methylglutaryl-coenzyme A reductase, more commonly known as statins, have earned a major place in the prevention of cardiovascular diseases. By reducing blood cholesterol levels in addition to ‘pleiotropic’ effects, statins reduce the progression of arteriosclerosis and the risk of severe cardiovascular accidents, including myocardial infarction and ischaemic stroke.1–3 Ezetimibe, evolocumab and alirocumab are also available to reduce cholesterol levels; nevertheless, statins remain the first choice.4
Despite robust and consistent evidence demonstrating statin effectiveness in reducing mortality and morbidity from cardiovascular diseases, they are still significantly underprescribed, largely because of fear of their side effects.5 One of the most feared side effects of statins is myopathy, which includes heterogeneous muscular symptoms ranging from asymptomatic elevation of serum creatine kinase (CK) to life-threatening rhabdomyolysis.6 Although rhabdomyolysis is rare, clinically significant muscular symptoms are common. The review by Stroes et al6 reported such symptoms in 7%–29% of patients receiving statins, and in an observational study this percentage rose to 38%.7
Management of statin-induced myopathy includes statin dose reduction, switching to an alternative statin with lower risk or replacing statins with ezetimibe, evolocumab or alirocumab.4 However, it has been shown that the simple administration of the nutritional supplement creatine in addition to the offending statin may mitigate statin-induced myopathy and allows continuation of the effective statin.8 Compared with alternative management strategies, simply adding creatine has the advantage of not requiring interruption of the statin therapy and is much less expensive compared with evolocumab or alirocumab.
In view of the above-described suggestion by Shewmon and Craig,8 creatine supplementation was trialled in a patient with statin intolerance, and it was found to be effective in preventing muscle pain and elevation of serum CK despite reintroduction of statin treatment.
Case presentation
A 66-year-old woman affected by chronic myeloid leukaemia in nilotinib-induced clinical remission was diagnosed with amaurosis fugax in her right eye. Amaurosis fugax is a transient blindness in one eye. It is due to transient eye ischaemia, which is very often caused by ipsilateral carotid stenosis.9 Accordingly, in our patient, the ipsilateral carotid artery was found to be 55% stenotic with an ulcerated plaque, whereas the contralateral carotid artery was...