Should I take coenzyme Q10 with a statin?

From: www.jaapa.com

Lanae Williams, MPAS, PA-C;, John Bradford, MPAS, PA-CDecember 01, 2006

As heart disease continues to be the leading cause of death in America, statins are increasingly popular in current medical therapy. Statins, or 3-hydroxy-3-methylglutaryl coenzyme A (HMG-CoA) reductase inhibitors, are most commonly used to treat hyperlipidemia and as preventive therapy for coronary artery disease and stroke. Additionally, statins may benefit those with Alzheimer's disease, cancer, renal disease, osteoporosis, multiple sclerosis, macular degeneration, glaucoma, or rheumatoid arthritis.1

The most common side effects associated with statin use include constipation, diarrhea, dizziness, headaches, rashes, and upset stomach. Typically these resolve with time. More serious, but less common, adverse events are liver problems and myopathy, which can range from slight myalgias to severe rhabdomyolysis resulting in kidney failure and death.2 Preventing statininduced myopathy is one focus of coenzyme Q10 (CoQ10, or ubiquinone) use. With statin prescriptions on the rise and a vast amount of information available through the Internet, patients are asking more questions about taking CoQ10 supplements.

The statin-coenzyme Q10 connection
CoQ10 is a fat-soluble compound vital for a number of processes related to energy metabolism. It also acts as an antioxidant scavenger. The compound is present in virtually all cells, with the highest levels in the heart, brain, liver, and kidneys.3-5 Although small amounts of the compound are available in certain foods such as meats and seafood, most CoQ10 is manufactured in the cells.

In addition to inhibiting HMG-CoA reductase, statins are believed to halt the production of mevalonate, a CoQ10 precursor. In this way, statins may also decrease CoQ10 levels in the body. Evidence suggests that low CoQ10 levels may cause mitochondrial dysfunction, which results in myopathy.6

Benefits are inconsistent
There is considerable evidence that patients who take statins have lower levels of endogenous CoQ10.7 However, a 2001 randomized crossover trial of 12 participants found no significant decrease in CoQ10 levels after initiation of selected statins.8Two other studies found that CoQ10 use reduced the effects of myopathy in patients taking statins, but this research was for an investigational cancer treatment using small numbers of participants who were taking very high dosages of statins. It is not known if the results would be the same for patients taking typical dosages of statin drugs.9 CoQ10 supplements may be effective for other conditions, such as heart failure and Parkinson's disease; however, evidence supporting these indications is inconsistent.

When taken as a supplement, CoQ10 appears to be well tolerated. Fewer than 1% of patients in clinical trials report GI distress. CoQ10 supplements could adversely interact with warfarin. Additionally, CoQ10 may have hypotensive and hypoglycemic effects, so patients with low blood pressure or diabetes should be monitored closely.4 CoQ10 does not affect the cholesterol- lowering effects of statins. The most common dosages are 50 to 200 mg daily in divided doses. Patients should not take more than 300 mg per day because higher dosages have been associated with elevated levels of liver enzymes.7

What patients must know
Patients should be counseled to contact their health care provider if they develop severe muscle aches, weakness, fever, or any other side effect while taking these drugs. Consider assessing baseline creatine phosphokinase and liver enzymes with any new statin prescription.

When patients ask about supplementing statins with CoQ10, explain that available evidence does not support this practice. However, when taken at the recommended doses, CoQ10 likely poses little health risk. Patients should also be reminded of the proven benefits of statins, as well as the importance of lifestyle changes such as eating a low-fat diet and exercising regularly.

John Bradford is a physician assistant in family practice with the National Health Service in Edinburgh, Scotland.