.png)
Pharmaceutical therapy is very commonly used in the treatment of hyperlipidemia and coronary artery disease (CAD). Among available treatments, cholesterol-lowering medications known as statins are the most widely prescribed. More than 92 million American adults use statin medications to reduce cholesterol levels and lower cardiovascular risk.
Statins work by blocking a key enzyme in liver cells called HMG-CoA reductase. This enzyme is required for the liver to synthesize cholesterol. Moreover, when liver cholesterol production decreases, the liver senses this change and increases the number of LDL (low-density lipoprotein) receptors on its surface. These receptors remove LDL cholesterol from the bloodstream and bring it into the liver for processing and elimination. The overall result is a reduction in circulating LDL cholesterol levels.
In addition to statins, several other classes of lipid-lowering medications reduce cholesterol through different biological mechanisms. However, not every person with elevated cholesterol requires medication. With proper assessment, I find many of my patients do not require medication.
For individuals without active coronary artery disease or known atherosclerotic cardiovascular disease, coronary artery imaging can be used to help determine whether statin therapy is necessary. This approach can reduce unnecessary statin use. Patients with elevated LDL cholesterol but a low coronary artery calcium score, and without other significant risk factors, can avoid statin therapy. I also like to use a newer version called Cleerly, which also measures soft plaque in the heart arteries.
The published medical literature shows some variability in reported statin side effects. That said, statins can increase the risk of diabetes, cause elevations in liver enzymes, and lead to muscle pain or weakness, a condition known as myopathy. In rare cases, severe muscle injury such as rhabdomyolysis, which involves the breakdown of muscle tissue, can occur.
Certain medications can increase the risk of muscle-related side effects when taken alongside statins. These include amiodarone; antifungal medications in the azole class; fluoroquinolone antibiotics such as ciprofloxacin; macrolide antibiotics such as azithromycin and erythromycin; as well as sildenafil, warfarin, digoxin, and other drugs. For this reason, medication review is important for anyone using statin therapy.
There are ongoing studies examining the relationship between statin use and the risk of dementia and physical disability in adults aged 70 years and older. In addition, in 2012, the U.S. Food and Drug Administration approved safety labeling changes for statins that included reports of memory loss and confusion. These cognitive effects were found to be reversible once the statin medication was discontinued.
For individuals taking statins, supplementation with coenzyme Q10 (CoQ10) is considered prudent. Statins inhibit HMG-CoA reductase, and this same biochemical pathway is responsible for the liver’s production of CoQ10. As a result, statin therapy reduces CoQ10 levels in the body.
CoQ10 is a nutrient-like compound that functions as an antioxidant and plays a critical role in cellular energy production, particularly in muscle tissue. One proposed explanation for why up to 27.8% of statin users experience myopathy is that CoQ10 depletion leads to impaired muscle energy metabolism and reduced vitamin E production.
Research has shown that statins significantly lower CoQ10 levels in both the bloodstream and muscle tissue. It is also important to note that CoQ10 relies on LDL particles for transport throughout the bloodstream, meaning that reductions in LDL cholesterol may further limit CoQ10 delivery to tissues.
A systematic review of clinical studies demonstrates that CoQ10 supplementation improves statin-associated muscle symptoms. For individuals taking a statin medication, a daily dose of 200 mg of CoQ10, taken with a meal, is recommended.
References
Ahmad, Khoula, Naelijwa J Manongi, Ramkumar Rajapandian, Sajida Moti Wala, Esraa M Al Edani, Essa A Samuel, and Ana P Arcia Franchini. 2024. “Effectiveness of Coenzyme Q10 Supplementation in Statin-Induced Myopathy: A Systematic Review.” Cureus 16 (8): e68316. https://doi.org/10.7759/cureus.68316.
Banach, Maciej, Corina Serban, Sorin Ursoniu, Jacek Rysz, Paul Muntner, Peter P. Toth, Steven R. Jones, et al. 2015. “Statin Therapy and Plasma Coenzyme Q10 concentrations—A Systematic Review and Meta-analysis of Placebo-controlled Trials.” Pharmacological Research 99 (July): 329–36. https://doi.org/10.1016/j.phrs.2015.07.008.
Research, Center for Drug Evaluation And. 2016. “FDA Drug Safety Communication: Important Safety Label Changes to Cholesterol-lowering Statin Drugs.” U.S. Food And Drug Administration. January 19, 2016. https://www.fda.gov/drugs/drug-safety-and-availability/fda-drug-safety-communication-important-safety-label-changes-cholesterol-lowering-statin-drugs#:~:text=Memory%20loss%20and%20confusion%20have,the%20bottom%20of%20the%20page.
Ruscica, Massimiliano, Nicola Ferri, Maciej Banach, Cesare R Sirtori, and Alberto Corsini. 2022. “Side Effects of Statins: From Pathophysiology and Epidemiology to Diagnostic and Therapeutic Implications.” Cardiovascular Research 118 (17): 3288–3304. https://doi.org/10.1093/cvr/cvac020.
