SAMS Management Algorithm in text

This is a text description of the SAMS management algorithm image shown here.

This image shows a diagram of the SAMS (statin-associated muscle symptoms) management algorithm, which is a flow chart that depicts the best practice diagnosis and management of these symptoms in patients who experience them.

Beginning at the top, there is an arrow on the left labelled ‘From SAMS Assessment Guide’, pointing towards a box on the right labelled ’Patient has suspected statin-associated muscle symptoms (SAMS)’.

A single line that leads down from the box divides into two separate lines, one on the left and one on the right, which connect to two boxes. Here the stream divides into two, depending on patient test results and symptoms.

The left hand box is labelled ‘CK < 5 x ULN; Cease statin for 2–4 weeks’. The right hand box is labelled ‘CK > 5 x ULN OR CK elevation with muscle weakness,a Cease statin for at least 6–8 weeks until CK within normal range’.

  • CK = creatine kinase, ULN = upper limit of normal
  • Note a reads ‘CK > ULN and weakness demonstrated upon physical examination’

The right hand box has a line that points further to the right towards a smaller third box labelled ‘Refer urgently if rhabdomyolysis is suspected based on symptoms, CK, creatinine and urinalysis for myoglobinuria’. There is an exclamation mark in a triangle located over its top left corner, as rhabdomyolysis is a very serious condition.

Coming out of the bottom of the main left and right boxes is a line that turns towards the middle and joins into one common line.

This common line divides again into two separate arrows that point towards two boxes, one on the left and one on the right. Here the stream divides in two, according to whether patients’ symptoms continue or improve.

The left hand box is labelled ‘Symptoms continue’, and the right hand box is labelled ‘Symptoms improve’.

Symptoms continue

The left hand ‘Symptoms continue’ box has an arrow that points down to a box labelled ‘Investigate other causes of muscle symptoms and manage appropriately’.

This box has an arrow that points down to a box labelled ‘Resume statin’.

The ‘Resume statin’ box has an arrow pointing down to a wide box that sits across the whole width of the diagram, labelled ‘Aim for target LDL-C using the maximum tolerated dose of statin and/or other lipid-modifying medicine’. 

This is the end of the algorithm for patients whose management followed this path.

Symptoms improve

The right hand ‘Symptoms improve’ box has an arrow that points down to a box labelled ‘Resume original statin at reduced dose OR switch to different statin’.

From this box a line pointing downwards divides into two separate arrows that point downwards left and right to two boxes. Here the stream divides according to whether patients’ symptoms recur or do not recur.

Symptoms do not recur

The left hand box is labelled ‘Symptoms do not recur’. A line leads to another box labelled ‘Continue statin regimen’. From it, another arrow points downwards to the full width box labelled ‘Aim for target LDL-C using the maximum tolerated dose of statin and/or other lipid-modifying medicine’. 

This is the end of the algorithm for patients whose management followed this path.

Symptoms recur and/or CK > 5 x ULN

The right hand box under the ‘Resume original statin’ box is labelled ‘Symptoms recur and/or CK > 5 x ULN’. From it is an arrow pointing down to a box labelled: Cease statin until symptoms resolve and/or CK within normal range.

This box has an arrow pointing down to a box labelled ‘Switch to low-dose potent statin, for example rosuvastatin 5 mg, OR trial intermittent dosing, for example once or twice weekly, alternate day’.

Here the stream divides again, according to whether patient’s symptoms recur or do not recur. 

Symptoms do not recur

One arrow points left, towards the box labelled ‘Symptoms do not recur’ from the previous stream. Patients whose management follows this path proceed to the end of the algorithm as described above.

Symptoms recur

Another arrow leads down from the ‘Switch to low-dose potent statin’ box towards a box labelled ‘Symptoms recur’.

The ‘Symptoms recur’ box has an arrow pointing down to a box labelled ‘Switch to non-statin lipid-modifying medicine, for example ezetimibe’.

This box has an arrow pointing down to the same box described earlier, labelled: 'Aim for target LDL-C using the maximum tolerated dose of statin and/or other lipid-modifying medicine'. 

This is the end of the algorithm for patients whose management followed this path.

Acknowledgements

Developed based on the 2012 Therapeutic Guidelines: Cardiovascular and 2016 European Society of Cardiology/European Atherosclerosis Society Guidelines for the management of dyslipidaemias, with input from experts:

Assoc Prof David Colquhoun, Prof Ian Hamilton-Craig, Prof Mark Harris, Assoc Prof Karam Kostner, Prof Leonard Kritharides, Prof Mark Nelson, Dr Daniel Scherer, Assoc Prof David Sullivan, Prof Andrew Tonkin, Mr Garth Birdsey, Dr Chris Helms