Why people take coenzyme Q10 supplements for statin-induced muscle symptoms

People purchase and take coenzyme Q10 supplements for a variety of reasons.

Some people who take statins are interested in taking them to manage or prevent statin-induced muscle symptoms.

As muscle pain can limit the dose of statin that people can tolerate, it is thought that coenzyme Q10 supplements may improve their adherence to statin therapy by preventing statin-induced muscle symptoms or reducing the symptoms.

Role of coenzyme Q10 in statin-induced muscle symptoms

The mechanism by which statin-induced muscle symptoms occur is unclear but there are several theories. One theory is that statins can induce coenzyme Q10 deficiency and the low levels could lead to myopathy, rhabdomyolysis, myoglobinuria, impaired mitochondrial energy and metabolism.

It is believed that coenzyme Q10 supplementation can improve this deficiency and help with managing or preventing statin-induced muscle symptoms.

Clinical guidance and evidence

Statin-induced muscle symptoms

European Atherosclerosis Society

The European Atherosclerosis Society 2015 consensus statement on statin-associated muscle symptoms recommends that coenzyme Q10 supplements should not be used for the treatment or prevention of statin-induced muscle symptoms as the evidence supporting its efficacy in reducing statin-associated muscle symptoms is lacking.

Clinical evidence

Evidence to support the use of coenzyme Q10 supplements alongside statins to manage or prevent statin-induced muscle symptoms is insufficient and inconclusive.

Evidence is limited to a small number of published randomised controlled trials (RCTs). These are small, single-centre trials following participants for a relatively short period of time (28- 90 days). Furthermore, there is no consensus on the dose of coenzyme Q10 used or the standardisation of preparations.

• A meta-analysis of seven small RCTs (n=321) shows no benefit of taking coenzyme Q10 supplements to improve statin-related muscle pain compared to placebo when used for 1-3 months. These findings are supported by another meta-analysis of eight small RCTs (n= 472; 215 on coenzyme Q10 supplementation and 215 on placebo). The study finds that coenzyme Q10 supplementation has no significant impact on creatinine kinase activity (p=0.84) and no significant improvement in muscle pain (p=0.22) when used for 1-3 months.

• However, one meta-analysis did show some benefit. A meta-analysis of 12 small RCTs (n= 575; 294 on coenzyme Q10 supplementation and 281 on placebo) concludes that coenzyme Q10 supplementation over 1 to 3 months significantly improves muscle symptoms (pain (p<0.001), weakness (p=0.006), cramp (p<0.001) and tiredness (p<0.001)) compared with placebo in people experiencing muscle pain with statins.

Adherence to statins

NICE

NICE guidance on cardiovascular disease: risk assessment and reduction, including lipid modification, does not support the use of coenzyme Q10 supplements as a strategy to improve adherence to statin therapy due to insufficient evidence. The guideline development group concluded that the use of coenzyme Q10 supplements for statin-induced muscle symptoms is not cost-effective as there is no clinical evidence in favour of benefit from its use.

Clinical evidence

There are no studies that directly assess the clinical and economic impact of coenzyme Q10 supplementation on adherence to statin treatment as a primary outcome measure. The available evidence is of low or very low quality with short study periods (1-3 months), small participant numbers (n=≤76) and inadequate power to show detect statistical significance.

• An analysis of three studies (n=157) within a meta-analysis (n=321) shows that taking coenzyme Q10 supplements does not increase the likelihood of remaining on statin therapy.

Advice for managing statin-induced muscle symptoms

Do not recommend coenzyme Q10 supplements for the management and prevention of statin-induced muscle symptoms.

NICE advises exploring and addressing the problems people are having with taking their statins. Refer to the NICE Clinical Knowledge Summary on statins for general advice to give to people taking statins.

Measures to manage statin-induced muscle symptoms include:

• Using the minimum effective dose of statin for the therapeutic indication (in people who have experienced muscle symptoms related to statins).
• Switching to an alternative statin may be helpful for some individuals.
• Adhering to the recommendations in the summaries of product characteristics of statins such as measuring baseline creatinine kinase levels before starting treatment in individuals with predisposing risk factors for muscle symptoms (e.g. older age, female, Asian ethnicity, low body weight, existing joint or muscle pain, severe renal or hepatic disease).
• Avoiding medicines that interact with statins where feasible.
• Educating people to recognise and act on the early signs of muscle symptoms.