Statins (HMG-CoA-reductase inhibitors) are the most widely prescribed cholesterol-lowering drugs in the world. And they get a lot of attention, both good and bad. Some of it is deserved and some of it is ridiculous (kind of like celebrity gossip).
The next time you read an exposé and start thinking statins are overrated or part of some conspiracy to pad the pockets of “big pharma,” come over to my house (well, not really). I’ll tell you about how many coronary artery bypass surgeons and cardiologists are looking for extra work and how many cardiovascular procedures are no longer done (saving billions of dollars annually), all because these drugs are keeping most of your circulatory system free of cholesterol.
And most statins are now available as generics, so many of them cost less than dietary supplements! I (as well as many other researchers) have been investigating the benefits of lowering cholesterol and am convinced statins and low cholesterol prevent many other conditions from occurring as we age, from brain diseases to sexual dysfunction to some aggressive cancers.
One of the side effects of statin use is muscle pain, and this condition is called statin-induced myalgia (SIM). Supplements are a very good option for SIM but not the best one because there are so many contributing factors.
The best option (besides finding the specific cause) is to exercise more and make dietary changes to reduce cholesterol. Time and time again, I have seen patients make moderate changes to their lifestyles that dropped their statin dosage down to almost nothing or that allowed them to stop taking the drug altogether.
The second-best option for SIM is to lower your current statin dose or switch to one of the newer prescriptions—such as rosuvastatin (my favorite), atorvastatin, pitavastatin, or even ezetimibe (it blocks cholesterol absorption from food and you take it in addition to your statin)—which you may be able to take once or twice a week instead of daily.
The third option is to either switch to a red yeast rice supplement to lower cholesterol or take a dietary supplement to reduce the side effects of statins (such as CoQ10 and others).
What is Statin-Induced Myalgia?
Myalgia is muscle ache, pain, or weakness without any obvious underlying cause, such as muscular disease or damage, in which case you would see elevated creatine kinase (CK) in the blood. At least 10 to 20 percent of statin users complain of muscle problems, and it’s the primary reason people quit taking them.
Of course, as we get older, we tend to get more muscle aches and pains anyway, which can confuse the situation, but statin-induced myalgia will usually start within 6 months of taking a statin.
Research suggests that taking half the recommended dose (and making up the difference with better diet and exercise habits) appears to dramatically reduce or completely eliminate the risk of muscle problems for many people. Even if you’re not experiencing muscle pain, the higher your dose, the greater the risk of experiencing other side effects, such as reduced libido, memory loss, type 2 diabetes, and liver damage. So the goal should always be to take the smallest dose that will work.
Just a quick note about myositis, which is muscle pain accompanied by increased levels of CK, indicating there is injury or breakdown of the tissues: This is rare but can occur with statins, especially at higher doses. It’s also a medical emergency, so if you’re having muscle pain and you’re on a statin, ask your doctor for a CK test. If it’s high, a urine myoglobin test (to detect muscle- breakdown by-products in the urine) might also be ordered, or even a muscle biopsy in really rare cases.
You should never just deal with the pain or take a supplement to solve it first. Work with your doctor to figure out the true cause and try to resolve it without taking more pills. While statins can trigger pain, often it’s because of another underlying factor, and this is what frequently gets missed with SIM. Here’s the latest evidence-based list of factors that can increase the risk of SIM.
- Age (older than 70)
- Alcohol abuse
- Carnitine deficiency syndromes
- Exercise (excessive exercise can raise CK levels way above normal)
- Grapefruit/grapefruit juice (It and perhaps even pomegranate juice has the
- ability to reduce the metabolism or breakdown of statins, leading to higher blood levels over time, almost as if you had taken a higher dose, as well as cause muscle pain and liver damage. Grapefruit impacts atorvastatin, lovastatin, and simvastatin the most and does not appear to affect fluvastatin, pitavastatin, pravastatin, and rosuvastatin.)
- Hereditary muscle problems
- High blood potassium levels
- High statin dose
- High triglycerides
- Hypertension (Some medications can increase risk, such as amiodarone, verapamil, or diltiazem; you may need to switch to another drug.)
- Kidney problems (low glomerular filtration rate or high creatinine levels)
- Liver problems (fatty liver, hepatitis, high liver enzymes)
- Low thyroid levels (untreated hypothyroidism)
- Low vitamin B12
- Low vitamin D
- McArdle’s disease
- Muscle pain when taking statins previously
- Other cholesterol medications (It’s not uncommon to take two different
- types of cholesterol medications. However, some nonstatin meds, such as gemfibrozil, can increase the amount of statin active ingredients in your bloodstream, leading to toxicity.)
- Small body frame or low body mass index
- Substance abuse (amphetamines, cocaine, heroin)
What are the Best Supplements For Treating Statin-Induced Myalgia?
1. Red yeast rice 600 to 2,400 milligrams divided into two daily doses either in place of a prescription statin or with a lower- dose statin
The first prescription statin drugs may have been isolated from red yeast rice, which is a mixture of yeast and rice. The active cholesterol-lowering ingredient in red yeast rice (RYR) is known as monacolin K, a compound that blocks the same cholesterol-synthesizing enzyme in the liver that prescription statins do. (See the High Cholesterol section for more detailed information on red yeast rice.)
In studies, RYR has been found to lower LDL (bad cholesterol) by 10 to 30 percent at dosages as low as 600 milligrams (1 pill) and as high as 1,800 to 2,400 milligrams. (Monacolin K has a similar structure to the drug lovastatin, so take RYR with food and avoid all forms of grapefruit and pomegranate when taking this supplement.)
RYR has consistently been shown to help people lower their cholesterol without increasing the risk of SIM. RYR may have fewer muscle pain side effects because its active ingredient is more diluted than the active ingredient in statins, or it may be due to other compounds in RYR that haven’t yet been researched. Regardless, RYR has become a wonderful option for people with SIM who don’t want to continue on a prescription statin or who want to lower their dose.
Here’s the frustrating thing about RYR: Dietary supplement companies are not supposed to standardize it, meaning they can’t guarantee the amount of monacolin K in each product. Because RYR works too much like prescription statins, the companies can get in trouble for selling an over-the-counter product that acts too much like a drug.
This is one of the dumbest penalties against dietary supplement companies that I have ever witnessed. Either the supplement should be banned entirely from the United States or companies should be able to standardize the monacolin K amount in red yeast rice!
The bottom line: You have to test different brands to see which ones have enough of the active ingredient to make a difference in your cholesterol levels. Also, since RYR is a natural statin that works somewhat similar to synthetic drugs, it can also cause liver and muscle side effects in rare cases, so your doctor still needs to monitor you as if you were on a prescription statin.
2. CoQ10 (ubiquinone) 100 to 600 milligrams a day
This fat-soluble antioxidant is used in every cell of the human body. One of the building blocks of CoQ10 is created in the liver as part of the cholesterol- production process.
Statins block the ability of the liver to make cholesterol, so when you take them, the amount of CoQ10 produced by the body drops! Atorvastatin (Lipitor), for example, can cause a 50 percent reduction in CoQ10 levels in the blood in just 30 days. Since the mitochondria in every cell need CoQ10 to produce energy, a lack of it can impact muscle tissue, leading to pain.
Even the drug companies realize it has some potential benefit; some of them tried to obtain a patent on it for reducing SIM. CoQ10 has, by far, the most human research of any dietary supplement for lowering the risk of muscle problems with statins. But the results are mixed, with about half the studies showing some benefit and the other half showing no benefit. Again, since there are so many underlying causes that can increase the risk of SIM, there is no dietary supplement or drug that will ever prevent or reduce this condition in everyone.
That said, most studies have participants taking 100 to 600 milligrams of CoQ10 daily to prevent or reduce myalgia, with higher dosages showing more efficacy. One of the biggest side effects of CoQ10, however, is the cost! If it’s not working within 4 weeks, increase the dose, and if it’s not working at the maximum dosage (600 milligrams per day), then it’s time to give up. (Or you can continue to use it for its many other benefits, such as increasing muscle performance during exercise, boosting strength, or reducing muscle fatigue in statin users.)
Side effects are rare with CoQ10, but GI problems and allergic rash have been reported. Weirdly, it has both antiplatelet (blood-thinning) and proclotting effects, depending on what medications you’re taking it with, so always check with your doctor. Ideally, you should take CoQ10 with a meal that has some fat in it for better absorption (save your money and don’t buy brands that say they have better absorption; they’re not worth it, and most studies tested the cheaper ones). Let your doctor know you’re taking CoQ10 as she may want to monitor blood levels.
3. Creatine monohydrate powder 5 grams a day
Inside muscle tissue, creatine helps produce energy. In fact, many people take it to boost their workouts, especially weight lifters (it’s one of my recommended supplements for athletic enhancement; see this page). Some individuals experience a decrease in creatine when taking a statin or other drugs, which can lead to muscle pain.
Preliminary research published in the Annals of Internal Medicine indicates taking 5 to 10 grams of this powdered dietary supplement daily (with water) can reduce myalgia.
But here’s how you have to do it: Take a “loading dose” of 10 grams for the first 5 days with no statin drug and then 5 grams a day after that with reintroduction of the statin. It can help some individuals reduce or eliminate myalgia after 2 to 3 months. (Use creatine powder please, not the pills; otherwise, you have to take too many.)
4. Carnitine 1,000 to 2,000 milligrams a day
Some people, whether they’re taking statins or not, have a difficult time metabolizing carnitine, an amino acid that is crucial for energy production.
Researchers are not certain why this is, but it’s not uncommon for people with carnitinemetabolizing abnormalities to suffer from SIM. Dosages of 1,000 to 2,000 milligrams per day (with or without food) of a type of carnitine called L- carnitine (acetyl-L-carnitine, for example) should help.
The research on this is just getting started, but in my experience—and based on the high number of carnitine problems in people with SIM—it’s smart to give this a try, especially since the benefit outweighs the risk; just work with your doctor.
5. Vitamin D at least 1,000 IU a day
Vitamin D has many functions within muscles, including reducing inflammation, preventing injury, and simply improving function. Being deficient in D (less than or equal to 20 ng/mL on the 25-OH vitamin D blood test) can cause pain.
Your doctor will look at your blood levels to determine how much D you need to correct an insufficiency.
Some doctors want to correct these big deficiencies right away and will give something like 50,000 IU of vitamin D as a prescription twice a week for 3 weeks and then continue or discontinue it based on the lab results, eventually introducing the statin again. I’m concerned that radically normalizing any deficiency with megadoses comes with its own toxicity, especially since vitamin D acts more like a hormone than a vitamin.
6. Phytosterols (plant sterols and stanols) 2,000 milligrams a day
Phytosterols block the uptake of cholesterol from dietary and bile sources in the intestinal tract. They reduce “bad” (LDL) cholesterol but don’t really impact HDL (good cholesterol) and triglycerides.
Phytosterol supplements are really just less potent copycats of the drug ezetimibe (Zetia), which can reduce LDLs by approximately 20 percent (at a 10-milligram dose).
These supplements can help reduce your statin dose, which can help minimize SIM. At 2,000 milligrams per day, they’ve been shown to lower LDL by an average of 10 to 11 percent. Phytosterols may also reduce the absorption of some fat-soluble vitamins, so you need to take a multivitamin daily as well.
Finally, always take this supplement before every meal (or just before large meals with lots of cholesterol) to block cholesterol absorption. (Phytosterols are now FDA approved to be used in food products, such as margarine and orange juice; I like the margarine option best.)
What Supplements Are Useless For Treating Statin-Induced Myalgia?
Omega-3 fatty acids
Taking omega-3s to reduce cholesterol levels is perhaps one of the biggest mistakes people make. Fish oil can increase LDL cholesterol as you increase the dosage! Some experts discount the rise and say it’s not a big deal, but it is a big deal! Fish oil (or the active ingredients EPA and DHA) is FDA approved to lower triglycerides, not LDL! Do not take fish oil to lower LDL cholesterol or for SIM. (See the High Cholesterol section.)
Niacin or no-flush niacin
Niacin dietary supplements, which cause facial flushing, can only add to the toxicity of a statin by increasing the risk of liver injury. The no-flush niacin (inositol hexaniaci-nate), so named because it doesn’t cause the telltale flushing that regular niacin does, also doesn’t work to lower cholesterol levels or for SIM. No flush = no work!
Vitamin E and selenium
Experts used to believe these popular antioxidants reduced SIM by preventing muscle injury, but neither of them reduced SIM in clinical studies with people taking statins.
What Lifestyle Changes Can Help With Statin-Induced Myalgia?
Change your diet
Low-fat diets have a profound impact on reducing LDL, and low-carbohydrate diets have a profound impact on reducing triglycerides and LDL.
Research has also shown that higher daily intakes of plant sterols (1,000 to 2,000 milligrams), soy protein (11 to 15 grams), soluble fiber (5 to 10 grams), nuts and seeds, and veggies and lower intakes of beef, poultry, fish, and eggs reduced LDL by 10 to 15 percent on average. The better your diet, the less you have to rely on a statin.
Reduce your statin dose slightly and add 5 to 15 grams of psyllium fiber powder or another soluble fiber product to your diet.
An older study from the Robert Wood Johnson Medical School in New Jersey found that 10 milligrams of simvastatin along with 15 grams of fiber lowered LDL just as much as taking 20 milligrams of simvastatin with no fiber! Nice! Fiber blocks the absorption of cholesterol and helps bacteria in the intestines create compounds that lower the production of cholesterol.