What can be done about the muscle-related side-effects induced by statins?

Over recent weeks there has been a flurry of research that has challenged the notion that lower levels of cholesterol are always better. In particular, there is evidence linking lower cholesterol levels with an increased risk of cancer (see here, here and here for more on this). In the light of this, it seems reasonable to question the rampant practice in medicine of encouraging individuals to drive their cholesterol levels down to recommended levels (that get steadily lower over time).

Recently, the British Medical Journal contained a review that explored the issue of raised cholesterol and its management. Its publication was followed by a letter in the journal from a UK general practitioner, Mark Struthers, who highlighted the recent evidence from the SEAS trial (covered here) which has linked with the taking of two cholesterol-reducing agents (simvastatin and ezetimibe) and an increased risk of cancer. Dr Struthers suggests, quite reasonably I think, that we should be cautious about the ‘collateral damage’ suffered in the war on cholesterol.

This letter has been followed, this week, by another which refers to Dr Struthers’ letter, this one coming from a consultant rheumatologist. The author expresses his concern that the protocols for lipid management seem to have resulted in a completely uncritical prescribing phenomenon, largely driven by targets and without regard for common sense.

He then goes on to highlight potential problems associated with the use of cholesterol-reducing statin drugs, by initially sharing with his first hand experience with the capacity of these drugs to induce muscular symptoms including weakness. The author goes on to describe how he finds it difficult to suggest that his patients with similar side-effects might stop their treatment, on the basis that many of them seem to have been programmed that this will result in them having an immediate heart attack. He ends by calling for a full reassessment of statins not least because, in his opinion, their benefits do not appear to outweigh their risks.

Reading this letter reminded me of the fact the ability of statins to cause muscle-related side-effects, and how often it seems to me that these side effects can be missed. Part of the reason for this appears to be that the side-effects of statins can start months or even years after the medication is commenced. Another problem is that there is some evidence that even when patients bring up the possibility of side-effects with their doctor (and there exists scientific evidence to support such a link), the doctor will tend to dismiss the association. It occurs to me, therefore, that if someone is having side-effects such as fatigue, muscle pain and muscle weakness as a result of taking a statin, then they can’t necessarily rely on their doctor for help.

Previously, I have written about this problem, and have discussed the ability of statins to cause the depletion of the nutrient coenzyme Q10 in the body. Lower levels of this substance does seem to be a common causative factor in the common side-effects seen with statins. More importantly, though, is the fact that in practice coenzyme Q10 supplementation very often relieves what can be really quite debilitating symptoms. Not only that, but last year saw the publication of a study which supports the effectiveness of coenzyme Q10 for the reversal of statin-related symptoms. See here for information about this and the recommended dosage of coenzyme Q10.

References:

1. Struthers M. Reasons to be cautious about cholesterol lowering drugs. BMJ 2008;337: a1493-a1493

2. Bamji AN. More reasons for caution with statins and other such. BMJ 2008;337:a1782

21 Responses to What can be done about the muscle-related side-effects induced by statins?

  1. Brian Donovan 26 September 2008 at 11:57 am #

    I added a comment to one of your earlier blogs about the severe often excrutiating pain I suffered in my legs whilst on statins. I had numerous exhaustive tests at hospital to try and find the cause of the pain but no answer was found. It was only talking to a relative about the pain I was having who said thats strange because she knew of two other people on statins who were suffering with leg pains. When I checked this out I discovered that not only could these statins cause this severe pain they could actually cause the muscles to slowly disintegrate get into your blood stream and eventually even cause death. I went to my doctor who said slightly flippantly he did not think I was that far down the line yet albeit I could only walk 20-30 metres before the pain caused me to sit down. Even on sitting down the pain intensified for about 30 seconds then abated. My doctor agreed that I should come off statins and within a short time my legs apart from some residual low level pain were back to normal. It is 18 months to two years now that I have been off statins and can walk relatively normally.

  2. Anne 26 September 2008 at 12:45 pm #

    Dear Dr Briffa,

    Bit confused – are you saying therefore that as long as people are given coenzyme Q10 that it’s okay to have statins ?

    My endo is pressurising me to to take statins. My total cholesterol is 6.3, HDL 2.3, LDL 3.8 and triglycerides 0.4. I have no intention of taking statins even if I can have coenzyme Q10 until I can find compelling evidence that lowering cholesterol would be beneficial. I have diabetes but it is under very good control – HbA1c only 5.2%.

    My endo said that if he were diabetic he’d take a statin even though his total cholesterol is only 3…he said he’d take it for it’s other effects, presumably he means anti-inflammatory effects….but surely there are other things that have those anti-inflammatory effects, like fish oils ? Which I take. Are there other things ?

    Btw, I enjoyed that Sat Fat debate you took part in the other week. I wish we could contact Esther Rantzen and advise her to read Dr Malcom Kendrick’s book ‘The Great Cholesterol Con’…she wanted more information about cholesterol and statins. I couldn’t find any contact information for her or I would have emailed her myself.

    Anne

  3. Dr John Briffa 26 September 2008 at 12:55 pm #

    Anne

    “Bit confused – are you saying therefore that as long as people are given coenzyme Q10 that it’s okay to have statins ?”

    No, what I’m saying is that if you’re taking statins (and wish to continue them) then you may take coQ10 as a precaution, or if you have side-effects, take coQ10 in an effort to reverse them.

    Personally, I think the benefits of these drugs has been very overstated. Your idea about fish oils is a good one, I think. And well done on having a HbA1c of 5.2 as a diabetic!

  4. Anna 26 September 2008 at 5:05 pm #

    I definitely think too many people have taken leave of their senses when it comes to statins, both too many doctors as well as patients. They’ll continue to prescribe and take statins, despite muscle aches and pains (not to mention memory loss and dementia) and the knowledge that the statins cause this, because they are afraid of an imminent heart attack?

    Have they forgotten the most important muscle in their body? Their heart? Do they think that a drug that makes legs weak and miserable won’t somehow also affect their heart muscle, too? So they’d rather get congestive heart failure?

    I think also doctors who push statins on their patients fail to inform their patients of the true, unbiased risk factor data (or they don’t understand it themselves). If they told patients the truth, that about 100 people have to take statins to prevent only one of those 100 people from having a heart attack, I’ll bet far fewer people would agree to put up with the serious and debilitating side affects, the high financial cost (out side of universal health care systems), or think that taking statins is the only thing between them and a visit to the ER with a MI.

    And there is no conclusive data proving that statins are preventive for women, the elderly, and younger or middle aged men who do not have diagnosed CVD (haven’t had a heart attack).

  5. JOHN IVENS 26 September 2008 at 9:00 pm #

    It’s time it was made clear that high cholesterol is a so-called disease invented by the Pharmas to sell $ billions of drugs.
    Autopsies show that those with high cholesterol actually have a lower incidence of death by heart attack.
    It is well written up that lower cholesterol increases the risk of cancer and heart attacks, but in the Pharma-controlled media, this will never appear.
    Have you read that one Pharma is trying to encourage legislation for all babies of 7 months to be put on statins for the rest of their lives to maintain a level as low as 50!!
    All the Pharmas are wicked and evil, and have absolutely no interest in human welfare–only in feeding us ever increasing numbers of hugely profitable drugs, until the corpse is certified dead.
    Do they then sell the embalming fluid before signing the patient off?
    I’ll bet you some of them are working on a resurrection fluid, to have another bite at the cherry !!

  6. Janni Victor 27 September 2008 at 6:25 am #

    Dear John Ivens, You are right on the button. The pharma companies can go to any extent to churn out money. My mother was also put on Simvastatin. as usual began complaining muscular pain in both her arms. now I know the reason. I dont think it might be because of any other reason cos she hardly does any hard work. I have got an Indian Ayurvedic herbal supplement called Lomedus from my friend. She says its widely used in India to keep cholesterol levels under normalcy. Let me try that. Though I have heard that they are purely herbal and kinda mild drugs with slow action, but thats far better than giving an added benefit of arm pain by using statins to mom.

  7. Diana 1 27 September 2008 at 2:19 pm #

    I thought that the interpretation of cholesterol had moved on – rather than the total level the LDL/HDL ratio was more significant and a ratio of less than 3 was good. And elevated triglycerides were not good.
    However other considerations may come into play for people with diabetes.

  8. Cybertiger 27 September 2008 at 2:28 pm #

    Janni Victor said:

    “Dear John Ivens, You are right on the button …. I have got an Indian Ayurvedic herbal supplement called Lomedus from my friend. She says its widely used in India to keep cholesterol levels under normalcy Let me try that.”

    Why?

    Dear Janni

    You’re on the button with John Ivens but did you really read what he said? What is the point of ‘normalizing’ cholesterol? Personally, I think the ‘cholesterol level’ is meaningless. The very modest benefits of statins to some people are probably due to some other property of the drugs apart from their undoubted cholesterol lowering efficacy. In my view, it is highly simplistic to think that a lowered cholesterol will enhance your health and longevity.

    So, how do we avoid that heart attack, fatal or otherwise?

    Avoiding dodgy genes, diabetes, excessive fatness, smoking, a stressful job, wife and mother-in-law, will all help in my opinion.

    Avoiding silly and expensive wars like those on terror, Iraq and cholesterol will also help big-time.

    PS. I believe stockbrokers, Wall Street wallahs and Threadneedle Street mullahs should all be given a one way ticket to the sunshine of Guantanamo Bay ” for the ultimate health of the nation.

    Love, Cybertiger (aka Dr Mark Struthers)

  9. Dennis Mangan 27 September 2008 at 7:40 pm #

    Regarding the link between low cholesterol levels and cancer, might it not be the case that early, undetected malignancies are manifested in the form of low cholesterol levels? Cancer typically takes many years from start to detection; and low cholesterol levels are also associated with wasting, which is in turn associated with cancer. It seems to me that to make the case one would have to follow subjects for decades. But perhaps I’m wrong. What would a possible mechanism linking cholesterol to cancer look like?

  10. helen 28 September 2008 at 9:27 pm #

    Dear Anne, you might try reminding your doctor that statins have absolutely no health benefit for women at all & that comes from the drug company testing results too not the anti statin side of the debate. You might also try asking your doctor to supply you with some scientific double blind studies that support his or her belief that cholesterol causes heart disease & or statins have any health benefits whatsoever. Don’t think it will happen though.

  11. Rita Schembri 29 September 2008 at 4:46 pm #

    Dear Dr Briffa, I am a bit confused about what I should do after reading this article. I take statins as i have high cholesterol. I too have weak legs and am not able to walk or exercise as i used to. i am now 50, overweight and did have a fall 4 mths ago and my leg isn’t getting better. is it just because of my age and wieght or a combination of all of the above including the statins that i am taking for the last 5 yrs. is there something else i can take to keep my cholesterol down. i have trouble getting my wieght down as i have a very slow metabolism and have to eat very little to try and loose weight as i cant excerise hardly at all as i cant stand on my legs for long (no more than an hour) I cant even walk for half hour straight. I hope I can get some sure answers, please!!

  12. Dr John Briffa 29 September 2008 at 7:38 pm #

    Dennis

    In the following study, individuals were followed for 20 years:
    Schatz IJ, et al. Cholesterol and all-cause mortality in elderly people from the Honolulu Heart Program: a cohort study. Lancet. 2001;358(9279):351-5

    in reference to their findings, the authors wrote:
    “Our data suggest that those with low serum cholesterol maintained over a 20-year period will have the worst outlook for all-cause mortality.”

    And in reference to the hypothesis you allude to (that people who are sick may have low cholesterol as a result) the authors wrote:

    “Our present analysis suggest that this hypothesis is implausible and is unlikely to account for the adverse effects of low cholesterol levels over 20 years.”

    There’s nothing definite about this, of course, but there is at least some evidence to refute the hypothesis you allude to.

    With regard to

  13. Sue 30 September 2008 at 12:22 am #

    Rita,
    I think you will benefit with supplementing with CoEnzymeQ10. Get some and see if you get relief. You can then tell your doctor you want to go off the meds. Fish oils will lower cholesterol. What are your cholesterol numbers?

  14. Jane Trobridge 1 October 2008 at 4:24 pm #

    hello,

    I’m 37, female, healthy and active. I was put on Simvastatin last year, and, after complaining about the tremors, pins and needles and muscle pain I was experiencing, my GP (unwillingly) switched me to Ezetimibe. This has lessened the effect but they are still quite bad, particularly in my arms.

    This is very difficult for me as I have a physically demanding job. Also, I’m really not liking the excessive flatulence much.

    I have been sent for an MRI and nerve conduction studies because of my arm, but they have been inconclusive, and personally, I think it might be the medication.

    I had a cholesterol of 6.1 18 months ago at my annual health screen, hence the medication. it’s now down to 4.6. I would really like to stop taking the drugs now and use diet to control my cholesterol instead, especially since I am now living with a vegetarian rather than a high metabolism carnivore (as I was prior to my initial check).

    But my GP will not agree to this. I believe this to be due to targets that he has been set.

    Just thought I would add my experience into the whole,

    cheers,

    Jane

  15. Cybertiger 5 October 2008 at 10:27 am #

    Jane Trobridge said,

    “I had a cholesterol of 6.1 18 months ago at my annual health screen, hence the medication. it’s now down to 4.6. I would really like to stop taking the drugs now … But my GP will not agree to this. I believe this to be due to targets that he has been set.”

    Uffe Ravnskov has again brillianty highlighted (as a BMJ rapid response) that things are just not that simple when it comes to the cholesterol level and the incidence of coronary heart disease – as evidenced by those with familial hypercholesterolaemia (FH). He also speculates that the raised level may actally be linked to a protective effect … in cancer. Read and enjoy …

    http://www.bmj.com/cgi/eletters/337/aug27_2/a1095#202758

    Uffe also posted this rapid response on which was subsequently printed in the paper journal (subscription control barriers).

    http://www.bmj.com/cgi/eletters/337/aug21_1/a993#201600

    PS. Jane, your posting made me weep … and then I wept some more …

    http://www.bmj.com/cgi/content/full/334/7601/983

    “Statins currently represent the single greatest drug expenditure in the National Health Service. In 2006, the cost in England was £625m (918m; $1.2bn). Statin prescribing is increasing by 30% each year, which means that in 2007 the cost of statins could well reach £1bn. However, this is only the direct drug cost. Combining additional expenditure resulting from activities such as blood tests, dispensing costs, and increased general practice consultations, this figure could easily double to around £2bn.”

  16. Lindy 7 October 2008 at 7:52 pm #

    Jane your doctor cannot make you take the drugs!

  17. Cybertiger 8 October 2008 at 7:20 am #

    “Jane your doctor cannot make you take the drugs!”

    Brainwash the doctor and you can get the patient to do almost anything – the drug companies certainly understand the power of brainwashing. And then there is bribery …

  18. Andrew Bamji 21 October 2008 at 5:12 pm #

    I was fascinated to find your dialogue while testing Google for the URL to my letter in the BMJ (so I could give it to a patient with possible statin myalgia). I had an acute episode of muscle breakdown on ezetimibe (and fenofibrate, so it’s not certain which was the real culprit). I have my doubts as to whether the oral administration of coenzyme Q10 will result in much effect, because most protein structures are destroyed in the stomach. However, if people have a reason to be concerned about their cholesterol (or LDL) then taking a substance that binds bile salts in the gut may work. The old-fashioned one is called cholestyramine, but is not easy to take; a newer one is colesevalam (sold as Cholestagel). I am only a series of one, but so far have had no significant side-effects and my cholesterol comes down from an alarming 9.1 to a slightly less alarming 7.

    I recommend Ravnskov’s analysis. There is poor evidence for benefits of cholesterol lowering in women, particularly in the older age group. Also if you reduce the risk of a heart attack by 100%, but the initial risk is only 1 in 200,000, then the absolute risk is still very small.

  19. John 28 October 2008 at 2:32 am #

    So here i am with my very high saturated fat diet with a cholesterol reading of 4.2 thanks to Dr. Ravnskov’s book “The Cholesterol Myths”

    It was over 7 when i foolishly consumed trans fats/hydrogonated fats which i cut out altogther.
    The body does not know how to cope with trans fats that do not exist in nature, it designed to handle saturated fats very well.
    I too think there is something in higher Cholesterol readings acting as a protective measure did my body produce more to help protect me against my bad diet before?

  20. rob clark 30 October 2008 at 5:29 pm #

    Dr Briffa,
    I’ve been on Simvastatin for 17 years (Type I diabetic plus other problems) but about a year ago I began to experience muscle aches and fatigues.

    Started taking CoQ10, muscle pain vanished. Doctors have poo-poohed any cause and effect, but there seemed to be a pretty clear correlation to me.

    So there you have it, not a very scientific study, I’ll admit, but good enough for me personally. Please keep up your work on statins.

    Regards

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