Myalgias: Although clinical trials show a relatively low incidence of myalgias due to statin use, recent literature indicates that real world patients (including the types who would have been screened out of the clinical trials) have a much higher incidence of muscular symptoms.

For high risk patients who have myalgias due to statins, James recommends that her patients first try a lower potency statin. If they are symptomatic even after trying a second agent, she adds Coenzyme Q10 (dosed at 200 mg daily) to see if that alleviates the symptoms and makes the medication more tolerable. Coenzyme Q10 is not well studied and potential adverse effects are unknown.

In contrast to the Annals of Internal Medicine findings, Heidi James finds that around 30% of her patients trialed on statins experience myalgias, and the majority of those have symptom relief when stopping therapy.

A 2014 review suggested no increase in myalgias for patients receiving statins versus those on placebo. According to this report, myalgias are considered nuisance adverse reactions or random events. Joy, Tisha R., et al. "N-of-1 (single-patient) trials for statin-related myalgia." Annals of internal medicine 160.5 (2014): 301-310. PMID: 24737272

Iatrogenic diabetes: In Peters’ expert opinion, statins can affect glucose uptake and cause a slight increase in glucose levels. Patients who are on the spectrum of diabetes, such as those with pre-diabetes, may have an increase in glucose levels that tips towards diabetes. In high risk patients, the benefits of statins, in terms of the reduction in cardiovascular events, outweighs the risks associated with a small increase in glucose levels.