Statins drugs (with names such as atorvastatin, fluvastatin, pravastatin, rosuvastatin and simvastatin) reduce cholesterol production in your liver by inhibiting an enzyme (HMG-CoA reductase), which is needed to make cholesterol.
Large, early trials suggested that taking a statin for at least five years could reduce the risk of coronary heart disease (CHD) by around one third, and reduce overall mortality by approximately a quarter for those who had already experience a heart attack. Taking a statin also appeared to reduce the risk of non-haemorrhagic stroke by up to 29% in those with CHD. So, at first, statins were prescribed for people at high risk of coronary heart disease and stroke who also had a raised cholesterol level.
Then, in 2002, the Heart Protection Study, involving over 20,000 people, showed that statins appeared to reduce the risk of major cardiovascular events in everyone, even those with an ideal total cholesterol level that was not raised (less than 5.0 mmol/l). There did not seem to be a lower cut-off for cholesterol levels beneath which the benefits might end, so statins were recommended for anyone whose likelihood of developing CHD over the next 10 years is 20% or greater. New guidelines have now reduced this ten year risk-threshold for prescribing statins even further, to 10%, and is calculated from charts based on your gender, age, smoking status, blood pressure, cholesterol levels and whether or not you have diabetes. The decision to prescribe a statin is no longer based on your cholesterol level alone. This all sounds like good news, so where’s the problem?
Statin side effects Like all drugs, statins have the potential to cause side effects such as headache, nausea, and bowel disturbances. In particular, 1% to 5% of people taking a statin develop muscle problems such as muscle pain, inflammation and weakness. Out of every 100,000 people taking a statin for a year, one person will also develop a rare condition called rhabdomyolysis, in which muscle fibres break down. If this affects the heart, it is obviously serious, but muscle pigments (myoglobin) entering the circulation can also damage the kidneys.
As well as switching off cholesterol production in the liver, statins also switch off production of a vitamin-like substance called co-enzyme Q10 (or CoQ10 for short) and this is believed to be an underlying factor in the muscle problems associated with statin drugs.
Co-enzyme Q10 CoQ10 is needed for energy production in all body cells and is especially important in muscle cells, including those of the heart. Your cells make CoQ10 at maximum efficiency around the age of 20, then production starts to decrease so that, by the age of 40, the amount present in heart cells is only 68% of what it was in your 20s, falling to 43% by age 80 years. The age-related fall in the CoQ10 levels of heart muscle cells is associated with heart problems, especially heart pump failure.
When CoQ10 levels are low, cells cannot produce energy efficiently, so they function less well and are more likely to become diseased. Biopsies from people with various forms of heart disease have shown, for example, that between half and three-quarters are deficient in CoQ10.
Statins reduce both cholesterol and CoQ10 levels by up to 50%, and taking a statin can halve your circulating blood levels of CoQ10 within just two weeks. Although lowering CoQ10 levels may not cause problems for healthy volunteers, it can worsen heart problems in some people, especially those with heart failure. As a result, all statins sold in Canada are now required to carry a warning that they may seriously deplete CoQ10 levels in the body, which can lead to impaired cardiac functioning in people with congestive heart failure.
Taking co-enzyme Q10 supplements has been shown to maintain blood levels of CoQ10 without affecting the cholesterol-lowering effect of the statin, and would seem to be a sensible precaution for all those taking a statin drug – in fact, one of the first statin patents even suggested this to reduce CoQ10 suppression. As an added benefit, research shows that combining simvastatin with 60mg CoQ10 produces improved heart health benefits compared with taking simvastatin alone.
Unintended consequences A recent gold-standard analysis of 18 randomised controlled trials involving almost 57,000 people concluded that taking a statin could reduce the risk of death from any cause by around 14%, a heart attack by 25% and a stroke by 22% with no evidence of any serious harm caused by statin prescription.
However, a recent analysis of data from 90 studies identified 48 different unintended effects of statins, some of which were positive such as lower risks of dementia and cognitive impairment, venous thrombo-embolism, fractures and pneumonia, and also confirmed evidence of an increased risk of muscle problems (myopathy), raised liver enzymes and diabetes. Overall, it seems that the absolute excess risk of the observed harmful unintended effects of statins is small compared to the beneficial effects of statins on reducing major cardiovascular events.
Unfortunately, the unpleasant side effects, although often classed as unimportant, are unpleasant. One in 10 statin users experience muscle side effects such as aching or fatigue. As a result, they stop taking their medication. One study found that out of over 85,000 patients, 75% were no longer refilling their statin prescriptions after just two years. Yet, taking a CoQ10 supplement can decrease muscle pain in statin users by 40% within 30 days (compared with no significant change in pain severity with placebo) without affecting the statin cholesterol lowering action.
To help prevent these recognised side effects, it’s worth taking a co-enzyme Q10 supplement to maintain your circulating CoQ10 levels. The usual recommended dose is Ubiquinol (the active, body-ready form) 100mg or Ubiquinone (which the body must convert to ubiquinol to use) 200mg.
If you or anyone in your family is taking a statin drug, tell your doctor promptly if you develop unexplained muscle pain, tenderness or weakness. If muscle problems (myopathy) occur, treatment may need to be stopped if symptoms are severe, or your blood levels of a muscle enzyme, creatine kinase, are significantly raised.
Although less well-known, statins also lower blood levels of fat-soluble vitamin E by 17%. If you are taking a statin, it’s worth ensuring your dietary intake of vitamin E is good. The main food sources of vitamin E are wheatgerm oil, avocado, wholegrain cereals, nuts and seeds. If choosing to take a supplement, select one supplying natural source vitamin E (d-alpha tocopherol).