Connecting the Dots Between Statins and Tendon Injuries

Illustration of Achilles tendon with pain depicted as electric bolts.

Pharmacists are key to communicating the risk of Achilles tendon rupture from statin use.

By Emily Jacobs

One adverse drug reaction may be a coincidence. Three or more adverse reactions in the same patient, however, and most researchers would suspect a link to the medication. Such was the case for one patient who experienced severe tendinopathy after receiving statin therapy.

A 40-year-old male patient was taking rosuvastatin for high cholesterol, but was otherwise healthy and athletic. Six months after starting the statin, he had a complete rupture of his left Achilles tendon during an indoor soccer match. After being taken off the rosuvastatin and receiving surgical repair and physical therapy, the patient was back to normal.

Nine months after the rupture, he resumed rosuvastatin and within a month, began to experience severe tightness and pain in both Achilles tendons. Switching statins did not resolve this tightness. In fact, the patient reported that he could barely walk after only five days on the new statin.

“There was a clear link in our minds, as researchers, that this was statin-induced,” said case report lead author Dr. Nader H. Moniri, associate dean for research at Mercer University College of Pharmacy. “We started looking in the literature, and there were many more case reports that suggest that patients who are on statins can have symptoms ranging from tendonitis to bilateral spontaneous ruptures of the Achilles tendon.”

Additional research is needed to determine whether there is a significant association between statins and Achilles rupture and the possible mechanism behind it. So far, retrospective chart analyses have found no such link.

Pharmacists Can Warn of Potential Side Effects

Moniri was especially concerned with the way a patient may learn—or not learn—about the reported link between statins and tendon injuries. Most statin prescriptions are written by general practitioners, followed by cardiologists. General practitioners, however, are less familiar with the potential link between statin use and tendon rupture.

In Moniri’s case report, the patient’s orthopedic surgeon knew of the reported link between statin use and tendon rupture and brought it to the patient’s attention. The patient’s primary-care provider, however, had been unaware of any such connection. Moniri’s team recently published the case report in the October 2018 issue of Mayo Clinic Proceedings to help inform prescribers and the broader medical community of the possible risk of tendonopathys with statin use. Mercer’s College of Health Professions physical therapy faculty member Dr. Timothy McMahon, physical therapy faculty at Mercer’s College of Health Professions and director of Mercer’s Physical Therapy Clinic, also collaborated on the study.

This recent case report demonstrates pharmacists’ key role in spotting adverse events. Because of their direct contact with patients, pharmacists are often the first to learn about medication effects. Pharmacists can alert patients, prescribers and even researchers to potential adverse events, even from older drugs that are otherwise well-tolerated. If previous studies have not confirmed such events and reports are not widely published, clinicians may not be aware of them.

Lack of communication from patients could be a significant reason why primary-care providers are unaware of the risk of tendon rupture with statin use, Moniri said. “Patients [with tendopathy] may not be making that link. They may be seeing an orthopedic surgeon for tendon issues and there may be a lack of communication back to the general practitioner,” he said. Pharmacists are vital in helping bridge this communication gap and increasing awareness of the potential link between statin use and Achilles tendon diseases, including rupture.

There needs to be some thoughtfulness, both from the prescribers as well as patients. If there is any previous tendinopathy or tendon pain, then perhaps statins should be cautiously used.

Dr. Nader H. Moniri

Real-World Applications

Moniri and his team hope that their published case will make providers more mindful of potential adverse events when prescribing statins to individuals with previous tendinopathy or tendon pain. “Statins are definitely efficacious, so we shouldn’t lean toward not using statins,” he pointed out. Statin alternatives may be recommended for patients who are experiencing tendonitis but also need cholesterol treatment. “There needs to be some thoughtfulness, both from the prescribers as well as patients. If there is any previous tendinopathy or tendon pain, then perhaps statins should be cautiously used.”

In many cases, patients using statins may not experience tendon issues at all. Therefore, it is vital for prescribers and pharmacists to be fully informed about the potential risks of statin use so they can consider the benefits or drawbacks for individual patients.

Case report co-author Dr. Ekta Nayee, who participated in the research as a student pharmacist, drew additional real-world lessons from the research. By examining the existing literature on statin use and tendon injuries, Nayee said she gained a greater understanding of how drugs affect people’s lives. This was a helpful complement to pharmacy school, where education is focused more on drug mechanism.

“Just learning how a drug works is good, but focusing on that alone will not tell you everything you need to know,” Nayee said. “You can just read about it, but when you’re part of it, you can appreciate how much time is put into these things, and you appreciate the role of pharmacists and medication in life.”

Emily Jacobs is a freelance writer based in Toldeo, Ohio.