Should one take a supplement with statins? The point about side effects and possible benefits

Statins are one of the most widely used categories of drugs in the world. They are recommended for anyone who has had a heart attack, stroke or other ischaemic event, to reduce the likelihood of a further episode. These drugs can also be prescribed as a preventive measure for people who, for genetic reasons or the sum of other factors, are considered to be at high risk and in whom diet and exercise are not sufficient to lower blood cholesterol values. Treatment should be continued for life, but some patients discontinue it because of undesirable effects on the muscles. Some suggest that these could be avoided with coenzyme Q10 supplements, but there is no solid evidence that this is the case.

The active ingredients of these drugs (atorvastatin, fluvastatin, lovastatin, pitavastatin, rosuvastatin and simvastatin) can reduce the risk of cardiovascular disease by several mechanisms, for example by removing LDL-cholesterol from the blood, lowering triglyceride levels and exerting anti-inflammatory activity that helps protect artery walls. Their main effect, however, is the inhibition of an enzyme known as HMG-CoA reductase (in its extended form, hydroxy-methylglutaryl-coenzyme A reductase), which is essential for the hepatic synthesis of cholesterol: in fact, only 20% of cholesterol is derived from foods of animal origin, while 80% is endogenous, i.e., produced by the body itself. The same chemical reaction inhibited by statins also serves to produce ubiquinone, known as coenzyme Q10, an important mediator in the supply of energy to cells. It has been estimated in the past that levels of this substance already halve within the first month of treatment with statins. For this reason, coenzyme Q10 supplements have been tried in combination with drugs, hoping to counteract the muscular disorders that can occur in those undergoing this treatment. The same may happen to those taking fermented red rice supplements, as their efficacy depends on the fact that they contain a natural statin, monacolin K.

Like all medicines, statins can cause undesirable effects, usually mild, which are often resolved by changing the molecule or adjusting the dose. The best known, however, although not the most frequent, are weakness, leg pain and muscle cramps. In the most severe cases, the muscle may suffer worse damage called rhabdomyolysis. It is estimated that muscular disorders really only occur in about 5% of cases, but the emphasis placed over time on this undesirable effect means that many people attribute disorders of another nature to the therapy: a recent meta-analysis of the literature estimates that only one in 15 of those reported are really attributable to the drugs. And there is speculation that a 'nocebo effect' may sometimes occur, the opposite of the better known 'placebo effect': just as we may benefit from an intervention that we think is beneficial, so we may convince ourselves that statins cause us muscle pain because we know they can.

The effectiveness of coenzyme Q10 against these muscular symptoms, however, is doubtful. In this respect, there are few, mostly dated studies involving a few dozen patients, which are insufficient to draw meaningful conclusions: some show an advantage, others do not. A meta-analysis that pooled these results concluded that there was no evidence of a benefit. In order to verify that the discouraging result was not due to insufficient dosage, a subsequent study was conducted, in which higher than normal daily doses of coenzyme Q10 were compared with placebo, i.e. 600 mg per day against the usual recommended 100 mg. Again, however, no differences were observed in terms of muscle pain between those taking the supplement or the placebo. Finally, it should be remembered that many heart patients are on anticoagulant therapy with drugs such as warfarin, the efficacy of which may be reduced through interaction with coenzyme Q10. If you decide to take it, therefore, it is always best to consult your doctor first.

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