Elevación de la Creatina Quinasa —CK— y de las Aminotransferasas

Pregunta clínica 14

En la población adulta con dislipidemia en tratamiento farmacológico, ¿cuál es la estrategia más adecuada para detectar efectos adversos (elevación de la creatina quinasa —CK— y de las aminotransferasas), y cada cuánto debe realizarse?

Respuesta a la pregunta

Los efectos secundarios musculares severos como la rabdomiólisis están asociados al uso de estatinas, pero son muy raros (66). Los efectos más leves, como la miositis o las mialgias, también asociados al uso de estatinas como monoterapia (67), son significativamente más comunes cuando se usan estatinas en esquema intensivo, al compararlos con esquema moderado (68). A pesar de ello, los potenciales be­neficios de la terapia con estatinas en esquema intensivo superan los riesgos en los pacientes de alto riesgo.

Hay diferencias estadísticamente significativas en la incidencia de la elevación de los niveles de AST y ALT, tanto al comparar estatinas contra placebo (66) como al comparar estatinas en esquema intensivo frente a moderado (68). Sin embargo, se discutió dentro del grupo que la implicación clínica de estos hallazgos no se conoce.

No hay datos suficientes que permitan evaluar adecuadamente el impacto de la te­rapia combinada en la incidencia de efectos adversos (61). Sin embargo, tampoco es claro un beneficio clínico de dichas combinaciones, por lo cual no parece adecuado recomendar su uso; menos aún, tomando en cuenta el mayor costo de esta práctica.

Recomendaciones

1 En la población adulta con dislipidemia en tratamiento farmacológico se sugiere administrar estatinas en esquema moderado en quienes, teniendo indicación de estatinas en esquema intensivo, presenten las siguientes condiciones pre­disponentes a efectos adversos:

• Comorbilidades múltiples o serias, inclu­yendo alteración de la función hepática o de la renal.
• Historia de intolerancia previa a estatinas o enfermedades musculares.
• Elevaciones inexplicadas de AST o de ALT superiores a tres veces el límite superior de la normalidad.
• Uso concomitante de otros medicamentos que afecten el metabolismo de las estatinas (por ejemplo, fibratos).
• Tener más de 75 años de edad, según el ba­lance riesgo-beneficio y las preferencias del paciente.

2 En pacientes con dislipidemia con indicación de tratamiento en esquema moderado que pre­senten condiciones predisponentes para desa­rrollar efectos adversos se sugiere discutir con ellos la relación riesgo-beneficio. Si se inicia el tratamiento, se debe hacer un seguimiento clí­nico estricto.

3 En la población adulta con dislipidemia con tratamiento farmacológico no se sugiere hacer mediciones rutinarias de los niveles de CK en personas que reciben terapia con estatinas.

4 En la población adulta con dislipidemia en tra­tamiento farmacológico se sugiere medir los ni­veles de CK en personas que presenten síntomas musculares durante la terapia con estatinas. Los síntomas incluyen mialgias, debilidad o fatiga generalizada.

5 En la población adulta con dislipidemia en tratamiento farmacológico se sugiere medir los niveles basales de CK en personas asintomáticas, pero que presenten alguna de las siguientes condiciones:

• Historia personal o familiar de intolerancia a las estatinas.
• Enfermedad muscular.
• Uso concomitante de medicamentos que alteren el metabolismo de las estatinas (por ejemplo, fibratos).

6 En la población adulta con dislipidemia en tra­tamiento farmacológico no se sugiere hacer me­diciones rutinarias de AST y de ALT en todas las personas que van a iniciar manejo con estatinas.

7 En la población adulta con dislipidemia en tra­tamiento farmacológico se sugiere hacer medi­ciones de los niveles de ALT al inicio de la terapia si el paciente tiene alguna condición clínica co­mo síndrome metabólico, historia de abuso del alcohol y de uso de medicamentos que alteren el metabolismo de las estatinas (por ejemplo, fibratos) o que sean hepatotóxicos.

8 En la población adulta con dislipidemia se sugiere hacer mediciones de los niveles de AST y de ALT si se presentan síntomas sugestivos de toxicidad he­pática, tales como:

• Fatiga o debilidad inusuales.
• Pérdida del apetito.
• Dolor abdominal.
• Aparición de ictericia.

Punto de buena práctica clínica

• Es deseable que todo el personal de salud conozca el potencial de los efectos adversos de los medicamentos hipolipemiantes, y que dicho potencial se discuta con cada paciente.

En el anexo 2 se presentan los algoritmos sobre tamización, evaluación del riesgo cardiovascular, tratamiento, monitoreo y seguimiento en dislipidemias.

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