STATIN: Web-based Investigation of Side Effects (STATINWISE)

A Series of Randomised Controlled N-of 1 Trials in Patients Who Have Discontinued or Are Considering Discontinuing Statin Use Due to Muscle-related Symptoms to Assess if Atorvastatin Treatment Causes More Muscle Symptoms Than Placebo

Statins are known to cause rare but serious side effects such as rhabdomyolysis (breakdown of muscle tissue) but many patients stop taking statins due to less severe symptoms, such as muscle pain or fatigue.

This study aims to determine whether symptoms occurring during statin use are caused by statins. The trial will compare patient-reported side effects of statins (20mg atorvastatin) vs. placebo.

Patients will be randomized to alternating treatment blocks of either statin or placebo split into six two-month treatment periods. At the end of each period, patients will be asked to self-report side effects using a website or mobile app.

Study Overview

• Status: Completed
• Conditions: Cardiovascular Disease
• Intervention / Treatment: Drug: Atorvastatin 20mg; Drug: Placebo

Detailed Description

1. INTRODUCTION Statins reduce cardiovascular disease (CVD) risk and are recommended as part of the treatment strategy for primary and secondary prevention of CVD. Although statins are the most commonly prescribed treatment in the UK, there is uncertainty about adverse effects.

   Severe statin adverse effects are rare but there is widespread reporting of less well-defined statin-related symptoms in the media, notably muscle pain and weakness that significantly affect statin users. These reports have been prompted by non-randomised, non-blinded observational studies but have not been confirmed in blinded randomised controlled trials (RCTs). A major limitation of observational studies is lack of blinding: patients taking a medication expect to experience adverse effects and therefore report high levels of symptoms vs. statin-free population. This phenomenon, the "nocebo" effect, leads to bias.

   Many patients believe their muscle symptoms are statin related, leading to therapeutic discontinuation. GPs face challenging decision making when patients present statin related symptoms and there is no diagnostic tool to evaluate statin symptom burden.

   StatinWISE is a N-of-1 trial and offers patients individual study results. Patients are their own control, and therefore optimal treatment can be established. StatinWISE will address some of the criticisms of previous evidence.

2. TRIAL DESIGN i) Randomised, double blind, placebo controlled N-of-1 trial ii) Patients who have stopped or are considering discontinuation of their statin due to muscle symptoms iii) Once-daily oral administration of Atorvastatin (20mg) or placebo iv) Study treatment is 12-months v) IMP in 2-month treatment periods vi) Quantify the occurrence of self-reported muscle symptoms vii) 200 patients will be recruited.

   2.1 RECRUITMENT OF PARTICIPANTS Participants will be recruited directly from GP Practices or by advertising to the public.

   Participating practices will recruit eligible patients from two groups as follows:

   i) Patients who are considering discontinuation of their statin due to muscle symptoms:

   These patients will be invited to take part in the trial when they visit the GP to report muscle symptoms believed to be associated with statins and where the patient/GP is considering stopping statins because of the muscle symptoms. The GP or Research Nurse will approach the patient and give the patient information sheet. If interested, patients will be able to consent and complete the screening visit with the GP or the Research Nurse during this appointment or it can be arranged for another suitable time.

   ii) Patients who have stopped taking a statin in the last 3 years due to muscle symptoms:

   A search of the practice electronic records will be performed by the Research Nurse on a two-monthly basis for one year (or until recruitment targets are reached) to identify potentially eligible patients. All screened patients will be documented on a screening log. The list will be reviewed by the GP to confirm clinical eligibility before patients are invited to take part. A letter inviting them to attend a screening visit, accompanied with the patient information sheet for the patient to consider, will be sent by the trial team from their GP practice. Contact details of the Research Nurse will be provided should the patient have any questions. A reply slip will be enclosed for the patient to complete if they wish to attend the screening visit, which will be returned to the Clinical Trials Unit (CTU), during which the trial will be explained, and they will have the opportunity to ask questions. Patients will be sent a letter of invitation to consider participation up to a maximum of three times.

   iii) Patients who contact the CTU from advertising: Patients who contact the CTU in response to advertising material will be sent a letter to request their GP details on a reply slip. Following receipt of these documents the CTU will contact their GP with their consent. The GP will be asked to confirm that the patient is potentially suitable for the trial and to provide brief clinical information to allow eligibility to be assessed. This information will then be provided to the GP surgery responsible for recruiting the patient.

   2.2 DRUG MANUFACTURE, BLINDING AND SUPPLY OF TRIAL MEDICATION Atorvastatin will be purchased on the open market. Placebo will be manufactured specially to match the IMP. Capsules and packaging will be identical in appearance for both IMP and placebo. DBcaps® capsules have a unique locking mechanism to help with assuring the integrity of the blind will be used for over encapsulation of both active and placebo treatments. The blinding process will involve encapsulating the active tablet, complete removal of the original manufacturer's label and replacement with the clinical trial label bearing the randomisation number which will be used as the pack identification. Outer pack labelling will be identical for IMP and placebo and will be in compliance with regulations.

   2.3 DATA COLLECTION Baseline data will be collected at each GP practice and will be entered directly online to the trial database provided by the LSHTM CTU. Follow up data will be collected directly from each patient at the end of each two-month period.

   Patients will choose their most suitable method of data collection:

   i) Bespoke mobile app which will require patients to use their own smartphone ii) On-line database using a computer, phone or tablet iii) Paper forms which they will receive by post at the same time with their trial treatment and which they can complete iv) Contact by phone. Trial staff will telephone the patient on each data collection day and complete the questionnaire based on the patient answers.

   Only data outlined on the baseline, follow up, end of trial and adverse events data forms will be collected as part of this trial database.

   END OF TRIAL DATA Patients will receive their individual results at the beginning of month 14 and have a telephone or face-to-face appointment to discuss these results. At month 15, trial staff will contact the patient to document their decision on statin use and whether their results helped reach this decision. This will be the last data collection point of the trial.

3. OUTCOME MEASURES

   Primary outcome:

   Self-reported 'muscle symptoms', defined as pain, weakness, tenderness, stiffness or cramp to the body of any intensity.

   The primary outcome will be assessed by the mean difference in VAS scores (range 0 to 100) between statin and placebo treatment periods, estimated via a linear mixed model.

   Secondary outcomes:

   • Participant belief about the cause of their muscle symptoms, the site of muscle symptoms, how the muscle symptoms affected the participant and information about any other symptoms.
   • Adherence to medication
   • Participant's decision about statin treatment following the trial
   • Whether they found their own trial result helpful.
4. ANALYSIS

Individual N-of-1 trials:

The purpose of these is to inform individual patients of the effect of the IMP on their muscle symptom score. The analysis and presentation of individual level results will be developed in collaboration with Patient and Public Involvement (PPI) groups and will include a range of graphical summaries and statistical analyses to identify the most informative presentation of individual results.

Combined analysis of N-of-1 trials

Primary analysis:

To estimate the population level estimate of the trial treatment in VAS muscle symptom score, data from each N-of-1 trial will be aggregated to form a powerful dataset, using an intention-to-treat approach.

Patients who enter data on muscle symptoms at least once during a treatment period with the IMP and at least once during a treatment period with placebo will be included in the primary analysis.

The primary analysis will be a linear mixed model for VAS muscle symptom score with random effects for participant and treatment. Residual errors will be modelled using a first-order auto-regressive error structure within each treatment period to account for correlation between the 7 daily measurements, with robust standard errors to account for non-normality of the VAS scores. Although VAS muscle symptom scores are unlikely to be exactly normally distributed, analysing such data using normal-based methods is likely to be a sufficiently robust approach.

All tests will be two-sided. P<0.05 will be considered statistically significant.

Secondary analyses:

Secondary outcomes will be analysed in a similar manner to the primary outcome, omitting the auto-regressive correlation structure since these secondary outcomes are measured once per treatment period.

Descriptive statistics will be used to summarise adherence to randomised treatment, and their relationship to the IMP and placebo periods.

The adherence to randomised treatment will underpin an efficacy analysis based around an instrumental variables approach. Because these analyses require much stronger assumptions than the intention-to-treat analysis above, the results of the efficacy analysis will be presented and interpreted as a secondary analysis.

The secondary outcomes include a single binary measure of whether the participant reports having muscle symptoms during that treatment period. This will be combined with the follow-up question pertaining to attribution, to obtain a single binary measure of whether the participant reports having muscle symptoms that they attribute to the study medication. These two binary outcome measures will be assessed using a logistic mixed model with random participant and treatment effects.

The investigators will relate the patients' decision regarding future statin use, and whether or not the participant found their own result helpful in making their subsequent treatment decisions, to their individual estimated effect of the IMP.

Subgroup analyses:

There are no priori subgroup analyses planned.

• Study Type: Interventional
• Enrollment (Actual): 200
• Phase: Phase 4

Contacts and Locations

Study Locations

• United Kingdom
  • Bicester, United Kingdom, OX26 6AT
    • Bicester Health Centre
  • Bridgend, United Kingdom, CF 31 2PQ
    • Oak Tree Surgery
  • Bromley, United Kingdom, BR2 9GT
    • Bromley Common Practice
  • Chester, United Kingdom, CH66 3SP
    • Great Sutton Medical Centre
  • Chislehurst, United Kingdom, BR7 6DB
    • Woodlands Practice
  • Chorley, United Kingdom, PR7 2DH
    • Regent House Surgery
  • Colchester, United Kingdom, CO2 7GH
    • Creffield Medical Centre
  • Dereham, United Kingdom, NR20 4QA
    • Mattishall & Lenwade Surgeries
  • Doncaster, United Kingdom, DN12 3JW
    • Conisbrough Group Practice
  • Doncaster, United Kingdom, DN4 0TG
    • Scott Practice
  • Doncaster, United Kingdom, DN5 0AT
    • Bentley Surgery
  • Edgware, United Kingdom, HA8 0AP
    • Oak Lodge Medical Centre
  • Great Yarmouth, United Kingdom, NR31 8RW
    • Falkland Surgery
  • Grimsby, United Kingdom, DN34 4GB
    • Freshney (Littlefields) Green Primary Care Centre
  • Heysham, United Kingdom, LA3 2LE
    • Bay Medical Group
  • Hoveton, United Kingdom, NR12 8DU
    • Hoveton and Wroxham Medical Centre
  • Ilford, United Kingdom, IG1 2SF
    • Mathukia's Surgery
  • Kendal, United Kingdom, LA9 6SA
    • Station House Surgery
  • Lancaster, United Kingdom, LA1 1RP
    • Queen Square Medical Practice
  • Liverpool, United Kingdom, L69 3GF
    • Brownlow Health
  • London, United Kingdom, EC1M 6BQ
    • William Harvey Heart Centre
  • London, United Kingdom, N17 8AH
    • Tottenham Health Centre
  • London, United Kingdom, N19 3YU
    • Hornsey Rise Health Centre
  • London, United Kingdom, NW3 1LR
    • Keats Medical Practice
  • London, United Kingdom, NW3 2QU
    • Hampstead Group Practice
  • London, United Kingdom, NW5 1TR
    • Parliament Hill Medical Centre
  • London, United Kingdom, NW6 1TP
    • West Hampstead Medical Centre
  • London, United Kingdom, NW9 5XT
    • Everglade Medical Practice
  • London, United Kingdom, SE10 9GB
    • Vanbrugh Group Practice
  • London, United Kingdom, SE11 4HJ
    • Hurley Clinic
  • London, United Kingdom, SE16 7JX
    • Albion Street Practice
  • London, United Kingdom, SE21 8AU
    • Paxton Green Group Practice
  • London, United Kingdom, SE4 2LA
    • Honor Oak Group Practice
  • London, United Kingdom, SW12 8EU
    • Open Door Surgery
  • London, United Kingdom, SW15 4AA
    • Mayfield Surgery
  • London, United Kingdom, SW16 2ST
    • The Exchange Surgery
  • London, United Kingdom, SW16 5LS
    • Streatham Common Practice
  • London, United Kingdom, SW8 2JB
    • Riverside Medical Practice
  • London, United Kingdom
    • Watling Medical Centre
  • Lowestoft, United Kingdom, NR33 8LG
    • Rosedale Surgery
  • Mitcham, United Kingdom, CR4 3HS
    • Mitcham Family Practice
  • Neath, United Kingdom, SA11 5AL
    • Vale of Neath
  • Nelson, United Kingdom, BB9 5RZ
    • Pendle View Medical Centre
  • Norwich, United Kingdom, NR15 2UY
    • Long Stratton Medical Partnership
  • Rhyl, United Kingdom, LL18 1DA
    • Clarence Medical Centre
  • Ripon, United Kingdom, HG4 1HL
    • North House Surgery
  • Selby, United Kingdom, YO8 9AJ
    • Beechtree Surgery
  • Snaith, United Kingdom, DN14 9DY
    • Snaith & Rawcliffe Medical Group (The Marshes Surgery)
  • Swansea, United Kingdom, SA3 4AJ
    • Kings Road Surgery
  • Swansea, United Kingdom, SA6 7AQ
    • Strawberry Place Surgery
  • Thetford, United Kingdom, IP24 2AG
    • School Lane Surgery
  • Thornton Heath, United Kingdom, CR7 7JN
    • Brigstock & South Norwood Partnership
  • Thornton-Cleveleys, United Kingdom, FY5 2TZ
    • Village Practice Thornton
  • Thornton-Cleveleys, United Kingdom, FY5 3LF
    • Cleveleys Group Practice
  • Wallington, United Kingdom, SM6 0HY
    • Wallington Family Practice
  • Windermere, United Kingdom, LA23 2EG
    • Windermere & Bowness Surgery
  • Wrexham, United Kingdom, LL12 9NP
    • Hope Family Medical Centre
  • York, United Kingdom, YO1 7NP
    • Jorvik Gillygate Practice

Participation Criteria

Eligibility Criteria

• Ages Eligible for Study: 16 years and older (Child, Adult, Older Adult)
• Accepts Healthy Volunteers: No
• Genders Eligible for Study: All

Description

Inclusion Criteria:

• Adults (aged 16 and over)
• Prescribed statin treatment in the last 3 years
• Stopped OR considering stopping statin treatment due to muscle symptoms
• Provided fully informed consent.

Exclusion Criteria:

• Any previously documented serum alanine aminotransferase (ALT) levels at or above three times the upper limit of normal;
• Have persistent, generalised, unexplained muscle pain (whether associated or not with statin use) and have creatinine kinase (CK) levels greater than 5 times the upper limit of normal
• Any contraindications listed in the IMP SPC
• Should not be using atorvastatin 20mg daily in the opinion of the general practitioner.

Study Plan

How is the study designed?

Design Details

• Primary Purpose: Other
• Allocation: Randomized
• Interventional Model: Crossover Assignment
• Masking: Quadruple

Number of Arms

2

Arms and Interventions

Participant Group / Arm	Intervention / Treatment
Active Comparator: Atorvastatin 20mg; Atorvastatin to be taken daily in 2 month treatment periods, 3 treatment periods in 12 months	Drug: Atorvastatin 20mg; Atorvastatin and matching placebo to be taken in a randomised order for 12 months; Other Names: Lipitor, Atorva; Drug: Placebo; Atorvastatin and matching placebo to be taken in a randomised order for 12 months; Other Names: Microcrystalline Cellulose
Placebo Comparator: Placebo - Microcrystalline Cellulose; Placebo to be taken daily in 2 month treatment periods, 3 treatment periods in 12 months	Drug: Atorvastatin 20mg; Atorvastatin and matching placebo to be taken in a randomised order for 12 months; Other Names: Lipitor, Atorva; Drug: Placebo; Atorvastatin and matching placebo to be taken in a randomised order for 12 months; Other Names: Microcrystalline Cellulose

What is the study measuring?

Primary Outcome Measures

Outcome Measure	Measure Description	Time Frame
Muscle Symptoms	Patient reported muscle symptoms (pain, weakness, tenderness, stiffness or cramp).	Every 8 weeks for 12 months in total

Secondary Outcome Measures

Outcome Measure	Measure Description	Time Frame
Patient belief of statin effects, medication adherence	Relationship between individual trial result and patient decision whether to continue statins long term.	at 15 months post randomisation

Collaborators and Investigators

• Sponsor: London School of Hygiene and Tropical Medicine
• Collaborators: National Institute for Health Research, United Kingdom
• Investigators: Study Director: Haleema Shakur, RN, London School of Hygiene and Tropical Medicine

Publications and helpful links

General Publications

• Herrett E, Williamson E, Brack K, Beaumont D, Perkins A, Thayne A, Shakur-Still H, Roberts I, Prowse D, Goldacre B, van Staa T, MacDonald TM, Armitage J, Wimborne J, Melrose P, Singh J, Brooks L, Moore M, Hoffman M, Smeeth L; StatinWISE Trial Group. Statin treatment and muscle symptoms: series of randomised, placebo controlled n-of-1 trials. BMJ. 2021 Feb 24;372:n135. doi: 10.1136/bmj.n135.

Study record dates

Study Major Dates

• Study Start (Actual): September 1, 2016
• Primary Completion (Actual): August 8, 2019
• Study Completion (Actual): August 8, 2019

Study Registration Dates

• First Submitted: May 13, 2016
• First Submitted That Met QC Criteria: May 23, 2016
• First Posted (Estimate): May 24, 2016

Study Record Updates

• Last Update Posted (Actual): August 16, 2019
• Last Update Submitted That Met QC Criteria: August 15, 2019
• Last Verified: August 1, 2019

More Information

Terms related to this study

• Additional Relevant MeSH Terms: Cardiovascular Diseases; Molecular Mechanisms of Pharmacological Action; Enzyme Inhibitors; Antimetabolites; Anticholesteremic Agents; Hypolipidemic Agents; Lipid Regulating Agents; Hydroxymethylglutaryl-CoA Reductase Inhibitors; Atorvastatin
• Other Study ID Numbers: ISRCTN30952488