A 68-year-old woman complains of diffuse, severe myalgia. She reports stiffness, heaviness, and cramping, which are most marked in her thighs and calves. The heaviness and discomfort result in a sensation of weakness as well. She rates the pain as 8 on a scale of 1 to 10; it is severe enough to prevent her from doing activities of daily living at least some of the time.

HISTORY

The patient has chronic hypertension, currently managed with an angiotensin-converting enzyme inhibitor and a diuretic taken on alternate days. She has had atrial fibrillation for about 2 years, which is very well controlled with amiodarone. About 6 months earlier, her low-density lipoprotein (LDL) cholesterol level was found to be 270 mg/dL; atorvastatin, 40 mg/d, was started. There is a strong family history of vascular disease, including stroke.

PHYSICAL EXAMINATION

This small, slight (50 kg, 1.58 m) woman is in no acute distress. Heart rate is 78 beats per minute and irregular; respiration rate, 14 breaths per minute; and blood pressure, 110/74 mm Hg. She has no tendinous or palpebral xanthomas, and no carotid bruits are audible. Chest is clear; atrial fibrillation is evident. The liver and spleen are not enlarged. Results of a neurological examination are normal; reflexes are symmetrical and strong. No swelling, tenderness, or warmth is noted in any muscle group.

LABORATORY RESULTS

Hemoglobin level and results of a serum chemistry panel are normal. Creatine kinase (CK) level is 19 U/L (normal, 30 to 135 U/L). A fasting lipid panel reveals a total cholesterol level of 168 mg/dL, a high-density lipoprotein cholesterol level of 49 mg/dL, and an LDL cholesterol level of 83 mg/dL. Triglyceride levels are normal.

Which of the following statements about this patient is the most accurate?
A. An attempt should be made to lower the atorvastatin dosage while maintaining reasonable control of the LDL cholesterol level.
B. Because her CK levels are not elevated, no changes in medication or dosage are required.
C. High-dose corticosteroid therapy should be started.
D. She is at low risk for statin-related myopathy.
E. She has severe statin-induced myopathy; consequently, she is ineligible for therapy with any agent in this class.

 

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