Is There An Alternative To Simvastatin As It May Cause A Serious Adverse Reaction?

[Mobi]

Since my aortic valve replacement 8 weeks ago I was told to stop all the drugs I had been taking for years, which I mainly took to reduce my BP and cholesterol levels.

Recently, I feel I have been pretty much obliged to start self-medicating as my BP was unacceptably high and just a simple bit of research revealed that high BP is not at all unusual following such operations and usually treated with drugs.

My surgeon didn’t seem interested, so I started treating myself and have met with mixed success – they have started to work a bit but the jury is still out.

Anyway, on Monday I had extensive blood checks done by a local lab and have found that my cholesterol levels have risen considerably and are now at unacceptable levels, having been under control for many years.

I used to take simvastatin 40mg, (Bestatin 40), but I have now discovered that there could be an adverse reaction between simvastatin and amiodarone which was prescribed for my recent a-fib attacks.

(“…The FDA is notifying the public of the risk of a rare condition of muscle injury called rhabdomyolysis, which can lead to kidney failure or death, when simvastatin is used with amiodarone.”)

So the question is –is there an alternative to simvastatin, as even most of the other drugs are ‘statins’ and may have the same reaction – or not?

Any suggestions or opinions are welcome.

Edited August 7, 2012 by Mobi

[orchis]

sorry to hear that.

however self medicating is imho never a good idea. in your situation i wd research a good doctor and get a second opinion.

Edited August 7, 2012 by orchis

[biggunguy]

beta blockers seem to be used against high blood pressure but increase cholesterol...

i thought you would after such a sugery and to get down BP take alpha blocker...

many herbs are such blockers, and i think they are quite powerful, even so OTC... and DO have side effects...

cant you find a doctor who has a clue?

Edited August 7, 2012 by biggunguy

[Mobi]

sorry to hear that.

however self medicating is imho never a good idea. in your situation i wd research a good doctor and get a second opinion.

I have no desire to self medicate, but there is no doctor here who I trust, or indeed has any experience of post avr surgery - so I am kind of on my own...

Edited August 7, 2012 by Mobi

[Mobi]

beta blockers seem to be used against high blood pressure but increase cholesterol...

i thought you would after such an operation and to get down BP take alpha blocker...

many herbs are such blockers, and i think they are quite powerful, even so OTC... and DO have side effects...

cant you find a doctor who has a clue?

I just don't trust them - the last two have simply Googled - and I can do that for nothing...

I'm not currently taking any beta blockers as these too can interact with the amiodarone and slow my pulse down too much. I am taking ace inhibitors - with mixed results.

Edited August 7, 2012 by Mobi

[biggunguy]

In the liver, CoQ10 is made in a pathway similar to the way cholesterol is made. So when a person is on a statin, which inhibits an important enzyme that makes cholesterol, the CoQ10 pathway is also impaired. It is believed that two important classes of medications, the statins (simvastatin, atorvastatin, pravastatin, lovastatin) and beta blockers (atenolol, metoprolol) decrease (up to 40 %) the production of CoQ10 in the body. Eating antioxidants in Super Foodssuch as pomegranate juice is a good way to replenish CoQ10 in the body. Some experts feel that older patients on statins or beta blockers should take CoQ10 supplements to replace the reduced levels of CoQ10 in cells. Some experts feel that people who have high blood pressure should consider supplementation with CoQ10 as well as Vitamin D3.

http://veemd.wordpre...-deplete-coq10/

People with high cholesterol tend to have lower levels of CoQ10

Edited August 7, 2012 by biggunguy

[Langsuan Man]

Lipitor is now available as a generic named Atorvastatin and should be available in Thailand and may suit your needs

[Sheryl]

Although the data concerned simvastatin and amiodarone, I would hesitate to use any statin as they are all quite similiar in chemical structure and action. The side effect in question is very rare (but also very serious) so there may simply not yet have been enough experience with the newer statins.

Niaspan (high does niacin) may be an alternative provided your liver function is OK. Liver enzymes need to be periodically monitored when on it (same is true for statins and many other drugs, actually) and main side effect is a hot flash for which reason it is advised to take just before sleep so that you won't feel it.

If it does not work you may have to use a statin. The side effect you are concerned about is extremely rare. But can certainly try niaspan first if no contraindication.

Given that you have had arrythmias and are on an antiarrhythmic, should definitely not take a beta blocker without first consulting a cardiologist.

In fact I think you should consult a good cardiologist for guidance in both the cholesterol-lowering and hypertensive regimens, even though it likely will require a trip to Bangkok. At this point you need a cardiologist, not a cardiac surgeon as the problems are not directly related to the surgery.

Up to the cardiologist but my guess is he might start you on an ACE inhibitor like enalapril. It is advantageous in diabeteics and also seems to enhance the effectiveness of amiodarone.

But please do see a cardiologist, your problems (AF, hypertension, hyperlipedemia, diabestes and recent aortic valve replacement) are complex and cannot be viewed independent of each other, nor is their management a job for any but a very highly skilled and up to date specialist, which none of us on this board are.

Even a top cardiologist may shrug off the rhabdo risk of combining a statin with amiodarone as it is rare and Thai medical culture tends to ignore unlikely risks. But you can simply be firm and state that you do not want to risk it and inquire about the feasibility of using Niaspan instead. If the doc you see trained and worked in the west for some time he will not be too taken aback by a patient being assertive and knowledgeable.

[AyG]

I have no desire to self medicate, but there is no doctor here who I trust, or indeed has any experience of post avr surgery - so I am kind of on my own...

There's no doctor here you trust - but you're prepared to take advice from random strangers on the Internet? Incredible.

If you don't trust the first doctor you meet, try another and another until you find one you're comfortable with. And if you really can't find one in Thailand, consider going back to your home country.

[JAS21]

Hi Mobi

I'm on Simvastatin 40mg AND Ezetimibe 10mg ... not many people use both. Ezetimibe (Ezetrol) works differently to a statin but does basically the same thing ... so maybe read up on it. The two bomb my cholesterol down. Ezetrol is about 1100Baht a month or a little more.

ACE Inhibitor ... I'm on Ramipril, actually only take 2.5mg was on 5mg before I came here but it lowered my blood pressure too much so felt light headed sometimes when I stood up from sitting, still do a bit but just put up with it. I thought that Ramipril was THE ACE INHIBITOR ... READ the HOPE STUDY ... as I understand it the study was cut short and 'everyone' was given Ramipril. I have been on it since 2003. I buy a box of 100 at a time.

I am also on Clopidogrel long term, again unusal ... I use Apolets. It's now nearly 20 years since my MI and Bypass. As they say here Good Luck.

And yes I take CoQ10, the form that older people take ... not the basic CoQ10

[biggunguy]

i would think, thailand can permit doctors from elsewhere to practise here, if they solely treat non-thais...

what is the reason, sense, that a doctor has to speak thai?

there is a huge expat community, and a lot of tourists, which could be treated by them...

as there is a massive language problem with thai doctors or a lot of farangs encounter other problems, it would only be fair...

and further - i am wondering, what regulations cambodia or burma have on practising western doctors?

if it is easy (easier) for them to work there, then it might be very quickly shift all "medical hub" dreams to the bin...

[lopburi3]

I also am on above type medications: Lipitor 40mg and Ezetrol (same drug as Ezetimibe) 10mg with Lipitor at night and Exetrol in morning with LDL down to 62 in last test (never lower than 80's before). But also a lot of salad eating.

[meatboy]

hi mobi sorry to hear your having a few problems,i was on 80mg.of simvastatin for 6years but i suffered badly with soar joints i could hardly walk,so before i had by pass surgery and the valve replacement my doc.put me on ezetimibe and lipitor both to be taken at the same time it worked,but after my surgery i moved here ezetimibe was very exspensive so i went back on bestatin taking 20mg a day cholestral level has been good.try and find a good cardiologist with a degree obtained in uk.or usa.

[CaptHaddock]

Niaspan (high does niacin) may be an alternative provided your liver function is OK. Liver enzymes need to be periodically monitored when on it (same is true for statins and many other drugs, actually) and main side effect is a hot flash for which reason it is advised to take just before sleep so that you won't feel it.

After taking lipitor for about 5 years I stopped because painful side effects appeared and then switched to Niacin, "enduracin" from www.endur.com. In the US niaspan is the prescription formulation of niacin and more expensive than enduracin. Niacin has kept my lipid levels in the good to optimum range for the past five years. You have to monitor liver enzymes and niacin can cause an elevation of blood glucose although I haven't had that experience. In the US few doctors have experience with niacin and I think probably there are even fewer in Thailand. Anyway, I recommend people consider niacin instead of statins.

[Sheryl]

i would think, thailand can permit doctors from elsewhere to practise here, if they solely treat non-thais...

what is the reason, sense, that a doctor has to speak thai?

there is a huge expat community, and a lot of tourists, which could be treated by them...

as there is a massive language problem with thai doctors or a lot of farangs encounter other problems, it would only be fair...

and further - i am wondering, what regulations cambodia or burma have on practising western doctors?

if it is easy (easier) for them to work there, then it might be very quickly shift all "medical hub" dreams to the bin...

In order to be licensed to practice here a doctor must pass the qualifying exam which is in Thai. Few foreign doctors are able to do that, as it calls for a very high level of written Thai proficiency. But there are a small number who have.

[Mobi]

Although the data concerned simvastatin and amiodarone, I would hesitate to use any statin as they are all quite similiar in chemical structure and action. The side effect in question is very rare (but also very serious) so there may simply not yet have been enough experience with the newer statins.

Niaspan (high does niacin) may be an alternative provided your liver function is OK. Liver enzymes need to be periodically monitored when on it (same is true for statins and many other drugs, actually) and main side effect is a hot flash for which reason it is advised to take just before sleep so that you won't feel it.

If it does not work you may have to use a statin. The side effect you are concerned about is extremely rare. But can certainly try niaspan first if no contraindication.

Given that you have had arrythmias and are on an antiarrhythmic, should definitely not take a beta blocker without first consulting a cardiologist.

In fact I think you should consult a good cardiologist for guidance in both the cholesterol-lowering and hypertensive regimens, even though it likely will require a trip to Bangkok. At this point you need a cardiologist, not a cardiac surgeon as the problems are not directly related to the surgery.

Up to the cardiologist but my guess is he might start you on an ACE inhibitor like enalapril. It is advantageous in diabeteics and also seems to enhance the effectiveness of amiodarone.

But please do see a cardiologist, your problems (AF, hypertension, hyperlipedemia, diabestes and recent aortic valve replacement) are complex and cannot be viewed independent of each other, nor is their management a job for any but a very highly skilled and up to date specialist, which none of us on this board are.

Even a top cardiologist may shrug off the rhabdo risk of combining a statin with amiodarone as it is rare and Thai medical culture tends to ignore unlikely risks. But you can simply be firm and state that you do not want to risk it and inquire about the feasibility of using Niaspan instead. If the doc you see trained and worked in the west for some time he will not be too taken aback by a patient being assertive and knowledgeable.

Thank you Sheryl.

I too was thinking that as Lipitor was also a statin it might have a similar effect to simvastatin when taken with amiodarone, which was why I started this thread, having ruled out alternative statins like lipitor..

I used to take Niaspan, which was prescribed by my diabetes specialist, together with simvastatin. I only stopped because the pharmacies in Pattaya no longer stock it. I have no idea why. If anyone is getting this drug in Pattaya, I would appreciate any info.

There is definitely some adverse interactions when taking statins or beta blockers with amiodarone, that much is certain.

So yesterday I went to see my cardiologist, showed him my elevated blood pressure and high cholesteral, and he prescribed 20 Mg (1/2 tab) of atorvastatin (Lipitor) and 25 mg (1/2 tab) of atenolol daily, in addition to my amlodipine 10mg, and 2 x 5mg of ramipril daily which I was already taking.

My research has revealed that low doses of these drugs, (statins and beta blockers), are probably OK when taken with amiodarone and this is what he has prescribed, so maybe he knows what he is doing!

He thinks I will have to take amiodarone for 6 months but he will probably reduce it from 400mg to 200 mg daily in a couple of weeks, all being well.

Another issue is my INR level. On Monday I had it checked by a local lab and they told me it was 2.0 which is at the bottom end of the acceptable range. Yesterday I had it checked at the hospital and they said it was 1.6 - too low! So the doc has adjusted my warfarin dose, but I was wondering how it could drop so fast in 2 days, or was one of the results faulty?

The jury is still out on my cardiologist but I will stay with him for the time being. It is so hard to keep starting again with a new doc, as it seems to take them forever to get up to speed, and take things seriously. I think they assume I will be here today, gone tomorrow and its not worth their effort, as treating these chronic issues has to be done over time with constant monitoring.

[jrtmedic]

Occasionally I come here to read the posts. I continue to be surprised that people bring really quite complex medical issues to an on line forum!

Sheryl is an extremely brave lady and she goes places where I would fear to tread! She attempts to offer some sound advise but I wonder how often notice of what she says is taken?

Some of the advise offered here is at best misguided and often potentially hazardous !

Despite what some believe Dr.Google is not your best friend! If anyone feels they MUST seelk medical advise from the internet then please go to http://www.mayoclinic.com/ where authorative advise is available for free ! ( I have no financial or other interest in the Mayo clinic)

Recently I had an interesting conversation with with a Thai physician(who speaks very good English).

She told me that her Thai patients could never be cured unless they were supplied with a number of different coloured pills and a bottle of liquid medicine.!

This lady's views on her foreign patients was worrying. (I should mention that this physician undertook post graduate education in the UK and is a Fellow of the Royal College of Physicians)

She described people who were aggressive, bullying.demanding and very suspicious. When I voiced my shock and disbelief she went on to claim she had found it necessary to suggest that some found another physician because she did not believe it would ever be possible to form a constructive, theraputic relationship with these people.

My own view is that such people should pack their bags and go home where, of course, they will be guaranteed first class care.

Edited August 9, 2012 by jrtmedic

[Bagwan]

Occasionally I come here to read the posts. I continue to be surprised that people bring really quite complex medical issues to an on line forum!

Sheryl is an extremely brave lady and she goes places where I would fear to tread! She attempts to offer some sound advise but I wonder how often notice of what she says is taken?

Some of the advise offered here is at best misguided and often potentially hazardous !

Despite what some believe Dr.Google is not your best friend! If anyone feels they MUST seelk medical advise from the internet then please go to http://www.mayoclinic.com/ where authorative advise is available for free ! ( I have no financial or other interest in the Mayo clinic)

Recently I had an interesting conversation with with a Thai physician(who speaks very good English).

She told me that her Thai patients could never be cured unless they were supplied with a number of different coloured pills and a bottle of liquid medicine.!

This lady's views on her foreign patients was worrying. (I should mention that this physician undertook post graduate education in the UK and is a Fellow of the Royal College of Physicians)

She described people who were aggressive, bullying.demanding and very suspicious. When I voiced my shock and disbelief she went on to claim she had found it necessary to suggest that some found another physician because she did not believe it would ever be possible to form a constructive, theraputic relationship with these people.

My own view is that such people should pack their bags and go home where, of course, they will be guaranteed first class care.

Snipped quote :-

She told me that her Thai patients could never be cured unless they were supplied with a number of different coloured pills and a bottle of liquid medicine.!

Unquote

If that lady doctor could convince me that she genuinely believed this I should look for another doctor. What arrant nonsense. When I met my Thai wife she was suffering from tuberculosis and her doctor said that she had a life expectancy of about 3 months. She took one pill every day for 5 months and was then pronounced cured. No pretty coloured water and all that BS. Whether she believed the doctor who said that now she would eventually recover or that she believed me when I said I would not allow her to die is a moot point. That said, a very vivacious and attractive lady professor Kathy Sykes (was UK's youngest professor at one time) carried out a worldwide survey of eminent surgeons, physicians, acupuncturists, faith healers, hypnotists, masseurs, herbalists, witch doctors and juju men and came up with the conclusion that an important factor in a patients recovery was directly related to the the strength of the faith and confidence that the patient had in who was treating them. A highly proficient doctor with qualifications gathered in the US where she worked for a number of years at different hospitals, and now practices at Bumrungrad, who treated me for a potentially fatal body malfunction and subsequently became a friend of mine, agreed totally with this premise.

Although great advancements have been made because of the breaking down of DNA and what follows from this in applying future treatments at the micro level, and the excellent work of neurologists, we are still scratching the surface of human capabilities. It is commonly accepted that for most of us our brains are in a state of idling. How else do you explain people like Einstein and other geniuses? They have the same equipment as you or I but they have somehow harnessed the latent power available within us, available to all of us incidentally. I have great confidence in the bodies ability to heal itself and mental attitude has a lot to do with this. The doctors that I deal with are all too happy to explain to me what is wrong and why. Although adamant that I have a need to know, my attitude is that of 'try to help me understand' and is it not part of human nature to help those in need? If it bolsters their ego to display and impart some of their knowledge to a layman, what of it? By some strange subconscious process that I don't even begin to understand, when I understand what is amiss with my body my facilities work to my will to return my body to a normal physical state. In a nutshell, the doctor and appropriate medications and my will to continue to live combine to overcome what has gone out of kilter. No doctor that I have ever consulted has cared to disagree with me about this.

I believe that there is more to being an efficient and effective doctor than having the ability to correctly diagnose and apply appropriate and relevant treatment to a patient. In the UK medical students are made fully aware that a sympathetic and confidence building approach, commonly called the bedside manner, is very much part of the job. It might be thought as getting the patient onside and becoming part of the team involved in the healing process. I see little evidence that this approach is common amongst Thai practitioners. Could it be that many doctors consider that their patients are so ignorant that they wouldn't understand what they are told? Or that Thai people are imbued with so much kreng jai that they dare not question a doctor? In cases of over prescription if all the symptoms are treated and the patient is comfortable how is a doctor to know if the root cause of problems has been eliminated?

[Bagwan]

This is interesting reading.

http://www.dailymail.co.uk/health/article-513729/The-NHS-spent-74m-new-heart-pill-makers-knew-didnt-work-How-COULD-happen.html

The jury may be still out but would you trust Big Pharma? Money No.1?

[biggunguy]

Recently I had an interesting conversation with with a Thai physician(who speaks very good English).

She told me that her Thai patients could never be cured unless they were supplied with a number of different coloured pills and a bottle of liquid medicine.!

ahahaha… the spirits that i called…or is it "the pot calling the kettle black"?

its the doctors, who force down the pills to their patients…

its them, who propagate, it must be chemical pharma developed stuff

plants, herbs, fruits and vegetables are more and more researched…

and they almost always prove to be more powerful and effective in the treatment…

after decades of making up stuff like "adhd", they are now complaining that people want colored pills...

[jrtmedic]

Bagwan

Being a simple man I did not understand most of you post.

Look out for the exclamation marks they sometimes convey humour !

I hope you recover your sense of humour soon.

Edited August 9, 2012 by jrtmedic

[jrtmedic]

I am sure your correct. Keep taking the veggies. Look out for the exclamation marks they sometimes convey humour !

[nickcar]

Hi Mobi,

I have been on Bestatin 40 mg for some years now. I was started on amiodarone in april last year when att fib stated. 200mg twice a day for 2 weeks, then 200 mg once a day for a week then 100g a day 5 days a week. I was not worried about the Bestatin as the amiodarone document seed to suggest it was only dangerous at 80 mg.

My yearly medical x-ray suggested some slight change in lung. After some months my lung doctor had me do a lung function test and the results suggested the amiodarone had caused some slight lung damage. The lung doctor consulted with the cardiologist who them chaged me onto a drug called tambocore instead of the amiodarone. The cardiologist feels that the 80 mg Aspirin i take is adequate for blood thinning as i have quite rare att fib attacks.

My elder brother was diagnosed with att fib about the same time as me. His symptoms much worse. He takes solitol regularly and tambocor when he has an attack that wont go away.

So cardiologists treatment can vary hugely. My guy reckons that eventually it will become permenant at which time one has to consider surgery. My reading suggests that cardiologists are beginning to think that occasional attacks are tolerable but depends very much on symptoms. - mine are very minor.

What do you take for blood thinning?

Cheers

Nick

[Mobi]

Hi Nick, thanks for your post as it was most intersting and informative.

Here is an excerpt of the advice issued by the American FDA:

"This risk is dose-related and increases when a dose of simvastatin greater than 20 mg per day is given with amiodarone. A revision of the simvastatin labeling in 2002 described an increased risk of rhabdomyolysis when amiodarone is taken with simvastatin doses greater than 20 mg daily. However, the FDA continues to receive reports of rhabdomyolysis in patients treated concurrently with amiodarone and simvastatin, particularly with simvastatin doses greater than 20 mg daily. Prescribers should be aware of the increased risk of rhabdomyolysis when simvastatin is prescribed with amiodarone, and they should avoid doses of simvastatin greater than 20 mg per day in patients taking amiodarone."

So as far as I can see, the risk is from a dosage of 20mg or more, not 80 mg as suggested in your post.

I had my aortic valve replaced with a synthetic metal one 8 weeks ago so I will be on warfarin for the rest of my life and do not take aspirin.

Also, my a-fib is directly attributable to the avr operation and my heart is expected to settle down within 6 months to a year and not be subject to any more arrhythmias after that. My doc has told me that I need will need to take amiodarone for 6 months, (currently 400mg a day, but soon to be reduced to 200 mg), and then stop completely. So I do not have your chronic condition (which you indicate may worsen), but hopefully, just a temporary condition.

As I wrote in my previous post, I am currently taking a low dosage 20mg of Lipitor, (another statin similar to Bestatin), and I should be OK as it is well below the FDA safety limit. Whether it is sufficient to lower my cholesterol remains to be seen, but worse case scenario is that I can increase the dose, once I am finished with amiodarone

Tambocore seems to be yet another drug that controls a-fib; thanks for the name, as I may ask my doc about it.

Yes, you can choose a cardiologist and each one will give you a different set of meds. Seems to be a bit of a lottery, and personal preferences, which is the reason that I maintain a high degree of cynicism about what i am prescribed and why I take such a close interest. These days I don't believe any one doctor to be the font of all knowledge of drugs and what interacts adversely with what. I like to think I can read the FDA warnings and Mayo clinic published medical papers as well as most Thai doctors, if indeed they read them at all...

As a matter of interest, are your specialists in Thailand or elsewhere?

[nickcar]

H mobi,

Apologies for the very slow reply. Hope your health is still OK.. Yes I have lived here for years and my specialists are Thai. I worked at Bunrungrad for years so I go there. I have AF attacks about once every 8 months and as soon as I take an extra tambocore it goes away. I have virtually no symptoms so only know I am having an attack if I take my pulse.. I have been diagnosed with a lung condition called Pulmonary Fibrosis which is very nasty - no treatment available. However my condition seems to be very slow but they reckon was temporarily aggravated by the amiodarone, Apart from the doctors diagnosis I seem to be still in the great health I always have been. Probably a result of my debauched youth HaHa. I admit I don't drink as much spirits as I used to but still drink 3 to 5 glasses of wine a day.

Cheers

Nick