1202 Letters DOI 10.1002/art.23917 Tendon rupture and statin therapy: is there a link? Comment on the article by Marie et al To the Editors: We were delighted to read the issue raised by Marie et al in a recent article in Arthritis Care & Research (1). As the authors have rightfully pointed out, the effects of statins on the musculoskeletal system have long been limited to the effects on the muscle. In the last 6 months in our internal medicine practice, we have encountered 3 patients with spontaneous biceps tendon rupture within 1 year of starting statin therapy or changing the dose or type of statin. One patient had bilateral tendon rupture because the statin was not discontinued after the ﬁrst rupture. Another patient started developing tendinitis on the contralateral biceps tendon after rupture on one side, which resolved after discontinuing statin therapy. We would like to point out to the authors that Pﬁzer has mentioned postintroduction reports of tendon rupture as a part of the physician prescribing information (2). The incidence of statin-related tendon complaints is not an issue in France alone. As of 2006, the Food and Drug Administration (FDA) adverse drug effects reporting database had 247 cases of statin-related tendon rupture (3). We believe that many more cases are going unreported because this potential relationship is not commonly known. Regarding the physiologic basis behind this side effect, we ﬁnd the hypothesis of 3-hydroxy-3-hydroxy-3-methylglutaryl-coenzyme reductase A blockers acting as matrix metalloproteinase inhibitors quite attractive and requiring further consideration (4). Certain studies involving functional magnetic resonance imaging looking at these aspects are under consideration. However, we must remember that statins have proven to have morbidity and mortality beneﬁt. It would require more than such a rare side effect to discourage their usage. Coincidentally, we have just ﬁnished a case– control study looking at the use of statins in patients with tendon rupture, the results of which we hope to publish within the next few months and clarify some areas that are still unclear. Abhimanyu Beri, MD Michigan State University East Lansing, MI Saakshi Khattri, MD Staten Island University Hospital Staten Island, NY 1. Marie I, Delafenetre H, Massy N, Thuillez C, Noblet C, and the Network of the French Pharmacovigilance Centers. Tendinous disorders attributed to statins: a study on ninety-six spontaneous reports in the period 1990 –2005 and review of the literature. Arthritis Rheum 2008;59:367–72. 2. Pﬁzer Ireland Pharmaceuticals. Lipitor (atorvastatin calcium) tablets prescribing information. 2007. URL: http://www.pﬁzer. com/ﬁles/products/uspi_lipitor.pdf. 3. Pullatt RC, Gadarla MR, Karas RH, Alsheikh-Ali AA, Thompson PD. Tendon rupture associated with simvastatin/ezetimibe therapy. Am J Cardiol 2007;100:152–3. 4. Turner NA, O’Regan DJ, Ball SG, Porter KE. Simvastatin inhibits MMP-9 secretion from human saphenous vein smooth muscle cells by inhibiting the RhoA/ROCK pathway and reducing MMP-9 mRNA levels. FASEB J 2005;19:804 – 6. DOI 10.1002/art.23918 Reply To the Editors: In their letter, Beri and Khattri described 3 new cases of tendinous disorders attributed to statin therapy. Moreover, these authors interestingly underscored the fact that the FDA has previously mentioned 247 cases of tendon rupture associated with simvastatin and/or ezetimibe (Pullatt RC, Gadarla MR, Karas RH, Alsheikh-Ali AA, Thompson PD. Tendon rupture associated with simvastatin/ezetimibe therapy. Am J Cardiol 2007;100:152–3). In our article, we reported 96 cases of statin-associated tendinous disorders (tendinitis and tendon rupture) from the French Pharmacovigilance database during the period 1990 –2005. These data suggest that statinattributed tendinous complications are rare considering the huge number of statin prescriptions, although only future case–control pharmacoepidemiologic studies will allow determination of actual prevalence/incidence of statin-associated tendinopathy. Nevertheless, both the previous results of the investigators and our ﬁndings strongly highlight the idea that prescribers should be aware of statin-related tendinous complications, particularly in situations at high relevant risk such as a high level of physical exertion, metabolic disorders, and an association with ﬂuoroquinolone treatment or other medications known to increase the toxicity of statins. In these groups of patients who are at risk of developing statin-associated tendon manifestations and who require statins, we suggest that patients should be routinely questioned about symptoms consistent with tendon involvement. Finally, early recognition of tendinous complications related to statins appears to be important in preventing serious sequelae in patients treated with statins. Isabelle Marie, MD Catherine Noblet, PhD Rouen University Hospital 76031 Rouen Cedex, France DOI 10.1002/art.23949 Erratum In the article by Distler et al published in the June 2008 issue of Arthritis Care & Research (pages 867– 875), the title of the Appendix was listed incorrectly. The correct title is Participants and Coauthors of the Delphi Survey. We regret the error.