Cardiologist Dr. Paul D. Thompson, MD, describes how his group verifies statin-related muscle pain before testing treatments, that coenzyme Q10 did not help in their study, and the sequence of steps he follows in his practice when a patient reports muscle symptoms.
Statin Muscle Pain: Confirming the Cause, Coenzyme Q10, and Other Cholesterol-Lowering Options
Jump To Section
- Confirming that the statin causes the pain
- What the coenzyme Q10 study found
- Why CoQ10 levels fall on a statin
- Stopping the statin and trying again
- Options beyond standard statin doses
- LDL apheresis for very high cholesterol
- Full Transcript
Confirming that the statin causes the pain
Statin muscle pain is hard to study unless its cause is confirmed first, according to cardiologist Dr. Paul D. Thompson, MD. Speaking with Dr. Anton Titov, MD, he says that many studies of statin muscle pain never established for sure that the patient's pain came from the statin.
His own studies begin with clinic patients who report statin pain. They take either a statin or a placebo for eight weeks and are then switched to the other. Only people who develop pain on the statin and not on the placebo enter his treatment studies. He says he cannot tell for sure, but a worry about statins can sometimes bring on discomfort, and he stresses that he is not blaming patients for it.
What the coenzyme Q10 study found
Coenzyme Q10, or CoQ10, was tested in patients whose statin pain had been confirmed in this placebo-controlled run-in. Dr. Thompson reports that CoQ10 did not make any difference in his group: patients had as many symptoms on the statin with CoQ10 as without it.
Why CoQ10 levels fall on a statin
Blood CoQ10 levels do go down during statin treatment, Dr. Thompson explains. CoQ10 is carried in the cholesterol particles, specifically the low-density lipoprotein particles, so he says the fall is no surprise.
He describes himself as not a big fan of CoQ10. He considers it expensive and does not think it worked in his study. He adds one qualification: a genetic study by his group, looking for genes that predict statin muscle problems (statin myopathy), found that one of those genes was related to CoQ10. For that reason, he thinks CoQ10 may affect and help some people.
Stopping the statin and trying again
Stopping the statin is the first step Dr. Thompson takes when a patient reports statin muscle symptoms. He wants to see whether the discomfort goes away. In his account, pain caused by the statin should ease quickly, usually within days rather than weeks or months. If it does not go away, he concludes it was not due to the statin.
Next, if the patient is willing, he tries another statin or a lower dose. He emphasizes that the choice belongs to the patient: "I do not own the body." One example he gives is rosuvastatin 5 mg taken on Monday and Thursday instead of daily. He may also combine a small statin dose with ezetimibe.
Options beyond standard statin doses
Bempedoic acid is his next option when a patient has trouble on low statin doses or does not want to try them. Dr. Thompson uses it alone, known as Nexletol, or combined with ezetimibe as Nexlizet.
He also lists injectable PCSK9 treatments, some given every two weeks, and inclisiran (Leqvio), given every three months at first and then every six months. A new oral pill and other medicines are further choices he mentions.
LDL apheresis for very high cholesterol
LDL apheresis is a program his group runs for patients whose cholesterol levels are still really high after all the medicines: people who, in his words, really did pick the wrong parents. They come in every two weeks. Their blood is taken out, the red blood cells are returned, and the plasma runs over a column with antibodies against ApoB that removes the bad cholesterol.
Dr. Thompson describes a patient arriving with an LDL cholesterol of 300 and going home at 20, with the level building back up over the following two weeks. His closing message is that there are many options, and the next step is to talk them over with your doctor.
Full Transcript
Dr. Anton Titov, MD: Treating muscle pain on a statin, coenzyme Q10 for statin muscle pain. You were senior author of a randomized clinical trial of coenzyme Q10 in confirmed statin muscle pain. Coenzyme Q10 did not reduce the pain. On your blog you described a step-by-step approach to muscle pain on a statin. Professor Thompson, how do you treat a patient who develops muscle pain on a statin? When should a doctor and patient decide to stop the statin permanently?
Dr. Paul D. Thompson, MD: Let me talk first of all about the study we did. We think the problem with many of the studies that have looked at statin muscle pain is that they have never really diagnosed for sure that the patient has the pain. So here is what I do in my statin studies.
Dr. Paul D. Thompson, MD: I take people from my clinic who complain about statin pain, and we put them either on a statin or a placebo for eight weeks. After eight weeks we see who developed pain. The people who are on the placebo we turn over to the statin.
Dr. Paul D. Thompson, MD: The people who are on the statin we turn over to placebo. Only if the patients get pain on the statin and not on the placebo, only then do we put them into our studies to see how to treat statin pain, because you have got to document that it is really due to the statins.
Dr. Paul D. Thompson, MD: People get a lot of discomfort on statins. A lot of it is here. Now, I am not blaming them.
Dr. Paul D. Thompson, MD: You do not know, and I cannot tell for sure, but the head bone is connected to the muscle bone, and so if people have a worry about the statins, they can sometimes get it. So we document that they got the discomfort in a placebo-controlled run-in. If they only got the pain during the statin treatment, not during placebo, then we put them in the CoQ10 study.
Dr. Paul D. Thompson, MD: So we put them in the CoQ10 study, and we found that CoQ10 did not make any difference. The patients had as many symptoms on the statin with or without the CoQ10, so it did not seem to function in our group. Now, when you are treated with a statin, your blood CoQ10 level goes down.
Dr. Paul D. Thompson, MD: Why is that? Because CoQ10 is actually carried in the cholesterol particle. It is carried in the low-density lipoprotein particles, so it is no surprise that it goes down, because statins lower your CoQ10 level.
Dr. Paul D. Thompson, MD: Now, one other thing. I am not a big fan of CoQ10. I think it is expensive.
Dr. Paul D. Thompson, MD: I do not think, in our study, that it works. But I will point out that in one of the studies we did, we found one of the things that might predict who is going to get it. When we did a genetic study to see if there were genes predicting who was going to get statin myopathy, one of the genes was related to CoQ10. So I think it may affect and help some people.
Dr. Paul D. Thompson, MD: So what do I do if someone complains of statin muscle symptoms? First of all, I stop the statin. I want to see: does the discomfort go away?
Dr. Paul D. Thompson, MD: If it does not go away, then it was not due to the statin, because the discomfort should go away very quickly. It does not take weeks, years, or months.
Dr. Paul D. Thompson, MD: It usually takes a matter of days for people to feel better. Then I try them on another statin or a lower dose of the statin, if they are willing to do it. I do not own the body.
Dr. Paul D. Thompson, MD: It is not my body being treated. It is the patient's body, so they have to be willing to do it. But I will frequently do the low dose of statin.
Dr. Paul D. Thompson, MD: For example, the daily dose of rosuvastatin, 5 mg, not daily, Monday and Thursday. Or what I will do is the small dose with ezetimibe, as we have talked about before. Then I use bempedoic acid if the patient gets trouble on low doses of statins or does not want to try a low dose.
Dr. Paul D. Thompson, MD: I do bempedoic acid alone. It is also known as Nexletol, or Nexletol with ezetimibe, which is known as Nexlizet. So I will do the bempedoic acid.
Dr. Paul D. Thompson, MD: Then we have the injectable PCSK9. Some are given every two weeks. One called Leqvio, or inclisiran, is given every three months at first and then every six months.
Dr. Paul D. Thompson, MD: There is now a new oral pill, and we try up other medicines. We do also run what is called an LDL apheresis program. I have some patients whose cholesterol levels are still really high after all the medicines.
Dr. Paul D. Thompson, MD: These are people who really did pick the wrong parents. What we do is we bring them in every two weeks. We hook them up to a machine that actually filters their blood.
Dr. Paul D. Thompson, MD: We take out their blood, separate the red blood cells, and give those back. We run the plasma, the fluid, over a column that has antibodies against ApoB. It sucks out the bad cholesterol and takes it in.
Dr. Paul D. Thompson, MD: So we will have a person who comes in with an LDL cholesterol of 300. They go home with a cholesterol level of 20. Over the next two weeks, it builds back up.
Dr. Paul D. Thompson, MD: So there are lots of things to do. It is just a matter of talking it over with your doctor and getting it done.