Did you know that statins can cause chronic pain syndrome?

Statins (simvastatin, atorvastatin, rosuvastatin, etc.) are very common drugs, widely used to control elevated cholesterol levels in the population and thus decrease cardiovascular risk in specific groups of patients.

Although they are generally well tolerated, statins can cause various side effects, the most frequent being chronic pain syndrome associated with muscle injury, which manifests with muscle fatigue and joint and muscle pain. According to different studies, this syndrome affects between 20% and 30% of patients taking statins (Figure 1).

The mechanism by which this effect is produced (in addition to other adverse hepatic and cardiovascular effects) is linked to the pharmacological activity, through the inhibition of the HMG-CoA reductase enzyme, which blocks the cholesterol synthesis chain. Unfortunately, this mechanism also inhibits the synthesis of Coenzyme Q10 (CoQ10), which is needed for the correct aerobic functioning of muscles and other parts of the body (2).

CoQ10 deficiency results in an increased production of free radicals, which 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, coenzyme Q10 is indispensable for health.

What is its clinical presentation?

The degree of muscle involvement is highly variable, ranging from mild pain and scarce muscle fatigue to severe cases of muscle destruction, which can be life-threatening, as well as intermediate cases of elevated muscle enzymes (CPK) and low performance, weakness or exaggerated fatigue (Figure 2).

Predisposing factors such as advanced age, female sex, presence of previous muscular pathology, association with certain drugs, etc. have been found and are reflected in Figure 3. The people most affected by statin myopathy manifest a genetic dimorphism that makes them more vulnerable to this pathology (3, 4).

What is the differential diagnosis and treatment?

In order for the Pain Unit specialist to establish the diagnosis of muscle pain due to statins, a scale with the following assessment items is used (Figure 4).

Read Now 👉  Origin of the Pain Units: in search of the most comprehensive treatment possible

In severe cases, the statin used may be withdrawn or the patient may be switched to another statin that is better tolerated (usually the more lipophilic statins such as atorvastatin or simvastatin are worse tolerated than the more hydrophilic ones such as rosuvastatin). Lower doses of the drug can also be used.

Given that low CoQ10 levels have been found in all patients treated with statins, the association of CoQ10 preparations has been suggested in all of them. 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 the practice of associating CoQ10 is consistent with theory and is gaining adherents in clinical practice (5, 6). Nutrition and sports medicine specialists systematically recommend their use to improve clinical symptoms (improvement in at least 50% of patients) and sports performance efficiency.

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.

One study suggests that previous vitamin D deficiency sensitizes these patients to muscle pain (7). Low vitamin D levels are also associated with myalgia, even if patients do not take statins. In these cases it is necessary to prescribe vitamin D supplementation.

Treatment

We treat with coQ10 in all symptomatic patients on statin therapy and add, if necessary, a course of vitamin D, based on clinical improvement and the existence of adverse effects of these treatments. Due to 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 during the last two years.