Statins (atorvastatin, simvastatin, rosuvastatin, etc.) are very common drugs, widely used to control elevated cholesterol levels in the population and decrease cardiovascular risk in specific groups of patients.
Although they are generally well tolerated, statins can cause different side effects, the most frequent being chronic pain syndrome associated with muscle injury, which manifests with joint and muscle pain and muscle fatigue. According to different studies, this syndrome affects between 20 and 30% of patients taking statins.
The mechanism by which this effect (and other adverse cardiovascular and hepatic effects) is produced is implicit in the pharmacological activity, through the inhibition of the HMGCoA-reductase enzyme, blocking the cholesterol synthesis chain. Unfortunately, this mechanism also inhibits the synthesis of Coenzyme Q10 (CoQ10), which is necessary for the correct aerobic functioning of muscles and other parts of the body.
CoQ10 deficiency results in an increased production of free radicals that can lead to muscle damage and cause myalgia or myopathy. Either by maintaining the correct functioning of the electron transport chain within the mitochondria of each cell of the organism in the form of ubiquinone or by counteracting the damaging effect of oxidative stress in the form of ubiquinol, it is understood that coenzyme Q10 is indispensable for health.
Clinical presentation
The degree of muscle involvement is highly variable, ranging from mild pain and little muscle fatigue to severe, life-threatening muscle destruction, with intermediate symptoms of elevated muscle enzymes (CPK) and low performance, weakness or exaggerated fatigue.
Predisposing factors have been found, such as female sex, advanced age, presence of previous muscle pathology and association with certain drugs. The people most affected by statin myopathy have a genetic dimorphism that makes them more vulnerable to this pathology.
Differential diagnosis and treatment
In order to establish the diagnosis of muscle pain due to statins, a scale with the following assessment items is used.
In severe cases, the withdrawal of the statin used or the change to another better tolerated statin, usually the more lipophilic ones such as atorvastatin or simvastatin, are less well tolerated than the more hydrophilic ones such as rosuvastatin, or lower doses of the drug are used.
Given that low CoQ10 levels have been found in all persons treated with statins, the association of CoQ10 preparations has been suggested in all patients. The data in the literature are not consistent, probably due to the use of variable doses of CoQ10 or non-comparable bioavailability of the product.
But what is certain is that the practice of associating CoQ10 to these patients is consistent with theory and is gaining followers in clinical practice (5, 6). Specialists in nutrition and sports medicine systematically recommend their use because of the improvement in clinical symptoms (improvement in at least 50% of patients) and in the efficiency of sports performance.
Athletes treated with statins and suffering from muscle pain presented alterations in muscle performance (greater muscle fatigue) and alterations in the muscle oxygenation chain compared to those who did not take statins.
An interesting study suggests that previous vitamin D deficiency sensitizes for the presentation of muscle pain in these patients. Low vitamin D levels are also associated with myalgia even if patients do not take statins. Vitamin D supplementation should be prescribed in these cases.
Treatment
We use coQ10 treatment in all symptomatic patients on statin therapy, adding a course of vitamin D if necessary, based on clinical improvement and the absence of adverse effects of these treatments. Given the differences in presentation and bioavailability of the different preparations on the market, we use the BlissQ10 presentation, with which we have obtained optimal results over the last two years.