Dear Dr. Roach: I am a 74-year-old woman who has been on 40 mg of atorvastatin for years. During the past year or two, I started feeling tired all the time. I did have spurts of energy at times, but mostly everything started feeling like an effort.
It got so bad this past year that I avoided anything needing much effort. I’d cancel meetings and gatherings with friends because of the effort. I was sleeping as much as 12 hours a night and taking naps for a couple of hours, but I was still exhausted. When I told my doctor how enervated I felt all the time, she told me to go off atorvastatin for a week and report back to her.
Within a day, I was hopping around like the energizer bunny! After a week of reporting back to her, she told me to take half of a tab instead of a whole. For several months, this worked, then I started sliding back into that enervated state. Within several weeks, I had almost no energy and was back to long sleeps and not going out because just the thought of washing my hair made me want to cry.
I spoke to my doctor again, and she told me to go off of it completely. Again, by the next day, I was full of energy. I know this is an important medication, and my research indicates that there aren’t a lot of alternatives. Do you have any suggestions?
H.W.
Adverse effects from medications can be due to a pharmacological effect or from an expectation that the drug will cause a side-effect (called the “nocebo effect”). In any given person, it can be impossible to determine what is causing the adverse effect.
It’s a bit odd that this effect appeared after taking the medication for years. Both types of adverse effects usually happen soon after starting the medication.
But atorvastatin can certainly cause fatigue. Between 1% and 4% of people who take atorvastatin report fatigue (although “enervation” is a wonderful word for it). Women are more likely to have this side-effect. When I see this in my patient, I will usually try a different type of statin drug.
Atorvastatin is a “lipophilic” type of statin, meaning that the medicine can easily go into the cells and brain across the blood-brain barrier. The blood-brain barrier is a set of tight junctions inside the cells that line the blood vessels and supportive brain cells, and it keeps many medicines outside of the central nervous system. Lipophilic statins are much more likely to have effects on brain function than hydrophilic statins like rosuvastatin, which do not easily enter the brain.
My usual recommendation is to stay off any statin for at least two weeks, then restart a different one. I prefer rosuvastatin because it is very potent and inexpensive, but there is another hydrophilic statin called pravastatin.
In my opinion, you shouldn’t stay on atorvastatin, and it is likely that changing to a different statin will stop this serious side effect. If the next type of statin also causes this, there are non-statin treatments to reduce heart disease risk, such as bempedoic acid.
Dr. Roach regrets that he is unable to answer individual letters, but will incorporate them in the column whenever possible. Readers may email questions to [email protected]
