Statin guidelines should give best statin

Editor—Manuel et al show that guidelines on statin treatment should focus on people with the highest risk of coronary heart disease.1 However, concerns about the optimal choice of statins remain. A recent meta-analysis (n = 71 108) of randomised controlled trials has shown that the occurrence of myalgia is less common with fluvastatin, pravastatin, and simvastatin than atorvastatin (odds ratio 0.28, 95% confidence interval 0.18 to 0.44; 0.43, 0.36 to 0.51; 0.23, 0.19 to 0.28; respectively).2 This observation could also be supported by Japanese postmarketing surveys for both atorvastatin and pitavastatin.3,4 For example, atorvastatin had an increased risk of musculoskeletal adverse events including the elevations of serum creatine phosphokinase as an important indicator of rhabdomyolysis compared with pitavastatin in Japanese common clinical practice (atorvastatin 144/4805, pitavastatin 154/7930; risk ratio 1.54, confidence interval 1.23 to 1.93; P = 0.0001 by using the Mann-Whitney U test).3,4 This difference was shown between atorvastatin and pitavastatin, although pitavastatin at 1 mg, 2 mg, 4 mg seems to be as efficacious as atorvastatin at 10 mg, 20 mg, 40 mg in the rate of reduction of low density lipoprotein cholesterol.3 Thus, the rate of muscle related adverse events differs among statins.2 The common shared belief is that the cause of myotoxity with statins is dose dependent.5 We therefore think that lower doses of statin can be tolerated without the risk of muscle related adverse events. Given that the efficacy in reducing low density lipoprotein cholesterol and cholesterol is the same respectively for atorvastatin 20 mg and 40 mg, pitavastatin 2 mg and 4 mg, rosuvastatin 2.5 mg and 10 mg, and simvastatin 40 mg and 80 mg,2,5 lower doses of statins should be chosen in terms of optimal disease management.