Letter to the Editor
Polyneuropathy by statins: case report
Polineuropatía por estatinas: descripción
a Internship of Complementary Internship in Internal Medicine, Medical Service of the Hospital Center of the West, Unit of Torres Vedras, Portugal
b Hospital Assistant of Internal Medicine, Medical Service of the Hospital Center of the West, Unit of Torres Vedras, Portugal
c Hospital Assistant Graduate of Internal Medicine, Medical Service of the Hospital Center of the West, Unit of Torres Vedras, Portugal
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"<span class="elsevierStyleTextfn">Letter to the Editor</span>" "titulo" => "Polyneuropathy by statins: case report" "tieneTextoCompleto" => true "saludo" => "<span class="elsevierStyleItalic">Dear Editor</span>," "paginas" => array:1 [ 0 => array:2 [ "paginaInicial" => "378" "paginaFinal" => "379" ] ] "autores" => array:1 [ 0 => array:4 [ "autoresLista" => "Yenny Shirley Ruiz Anzola, Liliana Simões, Sérgio Borges" "autores" => array:3 [ 0 => array:4 [ "nombre" => "Yenny Shirley" "apellidos" => "Ruiz Anzola" "email" => array:1 [ 0 => "shirleyyra@gmail.com" ] "referencia" => array:2 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">a</span>" "identificador" => "aff0005" ] 1 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">*</span>" "identificador" => "cor0005" ] ] ] 1 => array:3 [ "nombre" => "Liliana" "apellidos" => "Simões" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">b</span>" "identificador" => "aff0010" ] ] ] 2 => array:3 [ "nombre" => "Sérgio" "apellidos" => "Borges" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">c</span>" "identificador" => "aff0015" ] ] ] ] "afiliaciones" => array:3 [ 0 => array:3 [ "entidad" => "Internship of Complementary Internship in Internal Medicine, Medical Service of the Hospital Center of the West, Unit of Torres Vedras, Portugal" "etiqueta" => "a" "identificador" => "aff0005" ] 1 => array:3 [ "entidad" => "Hospital Assistant of Internal Medicine, Medical Service of the Hospital Center of the West, Unit of Torres Vedras, Portugal" "etiqueta" => "b" "identificador" => "aff0010" ] 2 => array:3 [ "entidad" => "Hospital Assistant Graduate of Internal Medicine, Medical Service of the Hospital Center of the West, Unit of Torres Vedras, Portugal" "etiqueta" => "c" "identificador" => "aff0015" ] ] "correspondencia" => array:1 [ 0 => array:3 [ "identificador" => "cor0005" "etiqueta" => "⁎" "correspondencia" => "Corresponding author." ] ] ] ] "titulosAlternativos" => array:1 [ "es" => array:1 [ "titulo" => "Polineuropatía por estatinas: descripción" ] ] "resumenGrafico" => array:2 [ "original" => 0 "multimedia" => array:7 [ "identificador" => "fig0005" "etiqueta" => "Fig. 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 1524 "Ancho" => 1250 "Tamanyo" => 103532 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">Electromyography of the lower limbs: axonal peripheral polyneuropathy with marked sensorial predominance.</p>" ] ] ] "textoCompleto" => "<span class="elsevierStyleSections"><p id="par0005" class="elsevierStylePara elsevierViewall">The adverse effects of statins are infrequent, transient and of low severity, although these drugs are responsible for a low percentage of cases of peripheral neuropathy.<a class="elsevierStyleCrossRef" href="#bib0060"><span class="elsevierStyleSup">1</span></a></p><p id="par0010" class="elsevierStylePara elsevierViewall">The statin polyneuropathy is an uncommon entity that is defined as a neuropathy secondary to the use of statins. May occur at any time, however, its highest incidence is from the fourth month of use of statins, and increases with prolonged use.<a class="elsevierStyleCrossRefs" href="#bib0065"><span class="elsevierStyleSup">2,3</span></a></p><p id="par0015" class="elsevierStylePara elsevierViewall">It is considered a class effect, without variations between the different statins, however, it is “dose-dependent”.<a class="elsevierStyleCrossRef" href="#bib0055"><span class="elsevierStyleSup">4</span></a></p><p id="par0020" class="elsevierStylePara elsevierViewall">There are only specific data on its prevalence, the remaining data being the result of very few clinical studies. The diagnosis is clinical and neurophysiological.</p><p id="par0025" class="elsevierStylePara elsevierViewall">Studies have shown that after discontinuation of the pharmacological agent, symptoms usually disappear, usually within the first week up to a maximum of 6 months,<a class="elsevierStyleCrossRef" href="#bib0050"><span class="elsevierStyleSup">5</span></a> and will be confirmed with symptomatic reappearance after reintroduction of statins.</p><p id="par0030" class="elsevierStylePara elsevierViewall">This in relation to the case of 65-year-old female, with a history of hypertension, dyslipidemia, hiatus hernia, had been medicated for 13 years with pantoprazole 40<span class="elsevierStyleHsp" style=""></span>mg, alendronate sodium 70<span class="elsevierStyleHsp" style=""></span>mg/5600<span class="elsevierStyleHsp" style=""></span>IU, and in the last 4 years she was associated with her prescription irbersartan/hydrochlorothiazide and atorvastatin 10<span class="elsevierStyleHsp" style=""></span>mg.</p><p id="par0035" class="elsevierStylePara elsevierViewall">Observed in external consultation of orthopedics for painful complaints of lower limbs. In the course of the examinations performed, an electromyography of the lower limbs was characterized by an axonal Peripheral Polyneuropathy of marked predominance (<a class="elsevierStyleCrossRef" href="#fig0005">Fig. 1</a>), and was referred to the Internal Medicine consultation.</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><p id="par0040" class="elsevierStylePara elsevierViewall">The overall laboratory evaluation performed did not present any alterations and therefore ruled out medical pathology.</p><p id="par0045" class="elsevierStylePara elsevierViewall">Because of no evidence of metabolic changes and suspected adverse effects, atorvastatin therapy was discontinued.</p><p id="par0050" class="elsevierStylePara elsevierViewall">Four months later, significant improvement in symptoms was observed, with improvement of the PNE target signals. At six months she did not show changes in the physical examination and electromyographically revealed a significant improvement over the previous electromyographic study.</p><p id="par0055" class="elsevierStylePara elsevierViewall">She was followed up for another year without recurrence of symptoms with clear improvement of the objective signs in the objective examination or new alterations. The statin was not reintroduced after the reversal of symptoms at the patient's express wish.</p><p id="par0060" class="elsevierStylePara elsevierViewall">After one year of follow-up, she underwent a new electromyographic study without alterations.</p><p id="par0065" class="elsevierStylePara elsevierViewall">The entity may occur at any time with a peak incidence from the fourth month of use of statins, and increased risk with its prolonged use.</p><p id="par0070" class="elsevierStylePara elsevierViewall">It is considered a class effect, without variations between the different statins, however it is dose dependent.</p><p id="par0075" class="elsevierStylePara elsevierViewall">The diagnosis is clinical and is characterized by a chronic, insidious evolution, with clinically sensitive distal predominance and acute or subacute presentation.</p><p id="par0080" class="elsevierStylePara elsevierViewall">The symptoms are unspecific, namely, tremor, vertigo, memory loss, paresthesia, dysesthesia, insomnia, depression and/or pain.</p><p id="par0085" class="elsevierStylePara elsevierViewall">It can be verified with electrophysiological studies that present characteristic alterations of axonal sensorimotor neuropathy in two or more peripheral nerves, with a marked prolongation of the mean F wave latency.</p><p id="par0090" class="elsevierStylePara elsevierViewall">Another way to verify this entity is a therapeutic test, which cannot be performed in all cases. This therapeutic test consists of the suspension of the drug until the symptoms disappear and the reintroduction of the same to confirm the reappearance of the clinic. This is a test that is widely used in clinical studies, but it is rarely seen in clinical terms because of its ethical and risk–benefit implications.</p><p id="par0095" class="elsevierStylePara elsevierViewall">Symptom reversion occurs one week after drug withdrawal, with a complete reversal in less than 6 months, which leads to careful study of the statin/peripheral polyneuropathy relationship and its benefit–risk.</p></span>" "pdfFichero" => "main.pdf" "tienePdf" => true "multimedia" => array:1 [ 0 => array:7 [ "identificador" => "fig0005" "etiqueta" => "Fig. 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 1524 "Ancho" => 1250 "Tamanyo" => 103532 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">Electromyography of the lower limbs: axonal peripheral polyneuropathy with marked sensorial predominance.</p>" ] ] ] "bibliografia" => array:2 [ "titulo" => "References" "seccion" => array:1 [ 0 => array:2 [ "identificador" => "bibs0015" "bibliografiaReferencia" => array:5 [ 0 => array:3 [ "identificador" => "bib0055" "etiqueta" => "4" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Lipid lowering drugs prescription and the risk of peripheral neuropathy: an exploratory case–control study using automated databases" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:6 [ 0 => "G. 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