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Point and Counterpoint |

Rebuttal From Drs Flannery and KrugerRebuttal From Drs Flannery and Kruger FREE TO VIEW

Alexander H. Flannery, PharmD, BCPS; Peter S. Kruger, MBBS, PhD
Author and Funding Information

From the Medical Intensive Care Unit/Pulmonary (Dr Flannery), College of Pharmacy, University of Kentucky HealthCare; Intensive Care (Dr Kruger), Princess Alexandra Hospital, Woolloongabba; and Discipline of Anaesthesiology and Critical Care (Dr Kruger), University of Queensland.

CORRESPONDENCE TO: Alexander H. Flannery, PharmD, BCPS, University of Kentucky HealthCare, 800 Rose St, H110, Lexington, KY 40536; e-mail: alex.flannery@uky.edu


FINANCIAL/NONFINANCIAL DISCLOSURES: The authors have reported to CHEST that no potential conflicts of interest exist with any companies/organizations whose products or services may be discussed in this article.

Reproduction of this article is prohibited without written permission from the American College of Chest Physicians. See online for more details.


Chest. 2014;146(6):1435-1436. doi:10.1378/chest.14-2224
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It is true that no definitive answer exists to this question within the current literature, but we would disagree with the assertion by Drs Mermis and Simpson1 that continued statin use in the ICU is both unsafe and ineffective. Although the randomized trials to date have not consistently shown an improved outcome, multiple studies of the use of various statins in a variety of centers and disease states have failed to demonstrate harm for statin use in the ICU.2

Although the potential adverse effects of statin use in the general population are well described, the possible impact of ceasing established statin therapy in critically ill patients remains unclear. The randomized trials involving statin use in critically ill patients have all diligently monitored for adverse effects with regular assessment of creatine kinase, alanine aminotransferase (ALT), and aspartate aminotransferase (AST) levels. Although the numbers are small for assessing safety, statin use in the ICU has been comparable to placebo for these potential adverse effects. The recent ARDS Clinical Trials Network study found no difference in myopathy; furthermore, neither peak nor trough levels of rosuvastatin were associated with ALT levels.3 Although some differences were reported in AST and ALT levels, these only reached statistical significance on 1 study day (day 7 for AST and day 9 for ALT), and it is debatable whether they were of any clinical significance.3

Caution is noted when observing the small decrease in days free of renal or hepatic failure in the rosuvastatin group, an effect that may be present because of the number of secondary outcomes analyzed. Care must be taken to avoid generalizing results from only one of many trials to guide decisions regarding patient care. Although the rosuvastatin study did not suggest a benefit in the subgroup of patients prescribed statins before the development of ARDS, this subgroup was defined post hoc as patients on statins prior to the development of ARDS who had not received their statin for ≥ 48 h.3 Many statins have short half-lives, and even for the statins with longer half-lives, three or more half-lives may have passed, and as such, the intervention may have more closely resembled reinitiation of a previous therapy rather than continuing therapy with therapeutic levels.

We agree with Drs Mermis and Simpson on a number of points. Statin use in critically ill patients is not as simple as continuing the patient’s outpatient medication. These medications may have real interactions with commonly used medications in the ICU, and dose adjustments may be warranted in specific clinical scenarios. Any use must include careful monitoring for possible adverse effects.

Given the widespread use of statins in the general community, critical care clinicians will continue to face the decision about continuing statin therapy on an almost daily basis. With careful monitoring for potential adverse effects, judicious continued statin therapy is appropriate while we await more definitive evidence. We remain of the opinion that the potential benefits of continued statin therapy in the ICU outweigh the risks. Any future randomized trials of continuing or discontinuing a patient’s prescribed statin upon ICU admission should involve well-defined safety monitoring, including studies of muscle strength and function.

References

Mermis JD, Simpson SQ. Counterpoint: should patients receiving statins prior to ICU admission be continued on statin therapy? No. Chest. 2014;146(6):1433-1435.
 
Flannery AH, Kruger PS. Point: should patients receiving statins prior to ICU admission be continued on statin therapy? Yes. Chest. 2014;146(6):1431-1433.
 
Truwit JD, Bernard GR, Steingrub J, et al; National Heart, Lung, and Blood Institute ARDS Clinical Trials Network. Rosuvastatin for sepsis-associated acute respiratory distress syndrome. N Engl J Med. 2014;370(23):2191-2200. [CrossRef] [PubMed]
 

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References

Mermis JD, Simpson SQ. Counterpoint: should patients receiving statins prior to ICU admission be continued on statin therapy? No. Chest. 2014;146(6):1433-1435.
 
Flannery AH, Kruger PS. Point: should patients receiving statins prior to ICU admission be continued on statin therapy? Yes. Chest. 2014;146(6):1431-1433.
 
Truwit JD, Bernard GR, Steingrub J, et al; National Heart, Lung, and Blood Institute ARDS Clinical Trials Network. Rosuvastatin for sepsis-associated acute respiratory distress syndrome. N Engl J Med. 2014;370(23):2191-2200. [CrossRef] [PubMed]
 
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