Journal Article

Patients experiencing statin-induced myalgia exhibit a unique program of skeletal muscle gene expression following statin re-challenge

Williams, Robert W., Gerling, Ivan C., Vera, Santiago R., Fish-Trotter, Hannah, Mozhui, Khyobeni, Childress, Richard D., Elam, Marshall B., Majumdar, Gipsy, Raghow, Rajendra

2017

Overview

Statins, the 3-hydroxy-3-methyl-glutaryl (HMG)-CoA reductase inhibitors, are widely prescribed for treatment of hypercholesterolemia. Although statins are generally well tolerated, up to ten percent of statin-treated patients experience myalgia symptoms, defined as muscle pain without elevated creatinine phosphokinase (CPK) levels. Myalgia is the most frequent reason for discontinuation of statin therapy. The mechanisms underlying statin myalgia are not clearly understood. To elucidate changes in gene expression associated with statin myalgia, we compared profiles of gene expression in skeletal muscle biopsies from patients with statin myalgia who were undergoing statin re-challenge (cases) versus those of statin-tolerant controls. A robust separation of case and control cohorts was revealed by Principal Component Analysis of differentially expressed genes (DEGs). To identify putative gene expression and metabolic pathways that may be perturbed in skeletal muscles of patients with statin myalgia, we subjected DEGs to Ingenuity Pathways (IPA) and DAVID (Database for Annotation, Visualization and Integrated Discovery) analyses. The most prominent pathways altered by statins included cellular stress, apoptosis, cell senescence and DNA repair (TP53, BARD1, Mre11 and RAD51); activation of pro-inflammatory immune response (CXCL12, CST5, POU2F1); protein catabolism, cholesterol biosynthesis, protein prenylation and RAS-GTPase activation (FDFT1, LSS, TP53, UBD, ATF2, H-ras). Based on these data we tentatively conclude that persistent myalgia in response to statins may emanate from cellular stress underpinned by mechanisms of post-inflammatory repair and regeneration. We also posit that this subset of individuals is genetically predisposed to eliciting altered statin metabolism and/or increased end-organ susceptibility that lead to a range of statin-induced myopathies. This mechanistic scenario is further bolstered by the discovery that a number of single nucleotide polymorphisms (e.g., SLCO1B1, SLCO2B1 and RYR2) associated with statin myalgia and myositis were observed with increased frequency among patients with statin myalgia.

• Publisher: Public Library of Science,Public Library of Science (PLoS)
• Subject: Activation / Aged / Analysis / Angina pectoris / Apoptosis / Biology and Life Sciences / Biosynthesis / Cardiovascular disease / Catabolism / Cellular stress response / Cholesterol / Creatinine / CXCL12 protein / Deoxyribonucleic acid / DNA / DNA repair / Female / Gene expression / Gene Expression Regulation - drug effects / Gene Regulatory Networks - drug effects / Guanosine triphosphatases / H-Ras protein / Health risk assessment / Health sciences / Humans / Hydroxymethylglutaryl-CoA Reductase Inhibitors - adverse effects / Hypercholesterolemia / Immune response / Immune system / Inflammation / Leukocytes, Mononuclear - drug effects / Leukocytes, Mononuclear - metabolism / Male / Medicine and Health Sciences / Metabolic pathways / Metabolism / Middle Aged / MRE11 protein / Muscle pain / Muscle, Skeletal - drug effects / Muscle, Skeletal - metabolism / Muscles / Musculoskeletal system / Myalgia / Myalgia - chemically induced / Myalgia - genetics / Myalgia - physiopathology / Myositis / p53 Protein / Pain / Pathogenesis / Patients / Pharmacology / Polymorphism, Single Nucleotide / Polypeptides / Preventive medicine / Principal components analysis / Protein biosynthesis / Reductase / Regeneration / Repair / Risk factors / Robust control / Rodents / Ryanodine receptors / Senescence / Single-nucleotide polymorphism / Skeletal muscle / Statins / Veterans