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Coenzyme Q10 and statin-induced myalgia
Statin-induced myalgia is common. Although patients with muscle pain due to statin are not at increased risk of rhabdomyolysis, such side effects often result in cessation of therapy. Many have increased cardiovascular risk and should be on statin for the treatment of dyslipidemia. Managing such symptoms can be frustrating for the patient as well as the clinician.
When faced with statin-induced myalgia, it is important to rule out other possible causes of muscle pain such as recent excess physical activity, untreated hypothyroidism or vitamin D deficiency. Holding statin therapy for a time is helpful to prove causation. After symptoms resolve, the statin may be restarted at the same or a lower dose, or another statin be tried instead.
Some patients continue to have recurrence of symptoms with all doses and types of statins. In these individuals, there may be no choice but to consider other forms of lipid-lowering therapy.
Sometimes I am asked: What about using coenzyme Q10?
Coenzyme Q10 or ubiquinone shares the same biosynthetic pathway as cholesterol. Statins, by inhibiting 3-hydroxy-3-methylglutaryl coenzyme A reductase, not only lower cholesterol but also decrease coenzyme Q10. Because coenzyme Q10 participates in the electron-transport chain and prevents oxidative stress, reduction of coenzyme Q10 may predispose individuals to statin-induced myopathy. Some data suggest that patients with statin-induced muscle symptoms have lower levels of serum and intramuscular coenzyme Q10.
However, randomized placebo-controlled studies have been inconclusive. One study comparing 100 mg/day of coenzyme Q10 to 400 IU/day vitamin E showed a 40% reduction in symptoms over the 30-day study. Another study using 200 mg/day for 12 weeks showed no difference. Other studies have also shown inconsistent results.
Because of this, expert guidelines do not recommend the routine use of coenzyme Q10 in the treatment or prevention of statin-induced myalgia. Nevertheless, if I have a patient who believes that coenzyme Q10 enables them to take their statin without symptoms, I do not discourage it. Is this a direct result of therapy or simply placebo effect? The data are not clear. However, there is no known harmful effect of coenzyme Q10, other than cost. When all else has failed, coenzyme Q10 may allow some to continue therapy. The usual recommended dose is 100-200 mg/day.
Ann Intern Med. 2009;150:858-868.