While it is common for a large number of our patients to be taking medications, it is reassuring to know that as practitioners there are many supplements we can co-prescribe that may have a beneficial effect in reducing some of the side effects. An example of this is statin medications, myopathy associated with these medications and how co-prescription of co-enzyme Q10 (CoQ10) may assist in reducing the incidence of these side effects.

The Role of CoQ10

CoQ10 functions to assist in modulating inflammatory processes, apoptosis and gene expression and plays an essential role in mitochondrial energy production.^1,2 Found in the vast majority of all human tissues, CoQ10 is also an important molecule for cellular redox regulation, essential for maintaining cellular homeostasis.¹ Endogenously synthesized through a combination of the quinone and mevalonate pathways, synthesis in the mevalonate pathway is reliant on the enzyme 3-hydroxy-3-methylglutaryl coenzyme A (HMG-CoA) reductase, also necessary in the production of endogenous cholesterol.³ 

CoQ10 conversion and utilisation occurs at the inner mitochondrial membrane and functions to transfer electrons in the oxidative phosphorylation reaction from Mitochondrial Complex I and II to Complex III. Complex I and II donate electrons to ubiquinone (oxidised form of CoQ10), this transforms ubiquinone to ubiquinol (reduced form of CoQ10). The electrons are then transferred to Complex III, transforming ubiquinol back to ubiquinone, completing the redox reaction and allowing our cells to produce adenosine tri-phosphate (ATP) via the electron transport chain.³

Ubiquinol, the reduced form of CoQ10 has shown to have increased absorption and superior bioavailability and has shown to increase plasma CoQ10 levels by over 300% compared to those receiving ubiquinone.⁵ Due to this superior bioavailability and absorption, ubiquinol in practice may be more clinically effective than other forms. There are no known risks for the supplementation of CoQ10 with statin medications.⁶

Evidence has shown Ubiquinol to protect against oxidative stress, working both intracellularly and extracellularly to protect from free radical damage and assist with the regeneration of other antioxidants, such as vitamin E and C.^1,5

Statin Myopathy

Statin medications (HMG-CoA reductase inhibitors), work to inhibit the enzyme HMG-CoA reductase, this inhibition decreases the synthesis of mevalonate; an important compound in the synthesis of cholesterol. This results in inhibition of the intermediate farnesyl pyrophosphate, required in endogenous production of CoQ10.²

Common side effects experienced with statin medications include mild muscle complaints, muscle weakness and cramping.⁷ Myopathy complaints, ranging from mild myalgia to rhabdomyolysis (which can be fatal), are other potential side effects from statin medication use.²

While depletion of CoQ10 may be a contributing factor in myopathy, research has shown that supplementing with up to 300mg/day of ubiquinol improves plasma CoQ10 concentrations in patients taking statins.⁴

Summary

With well over 7 million prescriptions of statin medications in 2015, they are one of the most prescribed medications in Australia.⁶ The supplementation and co-prescription of ubiquinol is an important consideration for patients in reducing the risk of developing statin associated myopathy and improving serum CoQ10 levels.¹

 

Reference List

1.  Onur S, Niklowitz P, Jacobs G, Nothlings U, Lieb W, Menke T, et al. Ubiquinol reduces gamma glutamyltransferase as a marker of oxidative stress in humans. BMC Res Notes. 2014;7:427.
2. Marcoff L, Thompson PD. The role of coenzyme Q10 in statin-associated myopathy: a systematic review. J Am Coll Cardiol. 2007;49(23):2231-7.
3. De Frutos F, Gea A, Hernandez-Estefania R, Rabago G. Prophylactic treatment with coenzyme Q10 in patients undergoing cardiac surgery: could an antioxidant reduce complication? A systematic review and meta-analysis. Interact Cardiovasc Thorac Surg. 2015:20(2):254-9.
4. Mazirka P, Jones E, Strachan P, McNurlan M, Lawson W, Caso G. effect of Coenzyme Q10 Supplementtion in patients with Statin-related Myalgia. The FASEB Journal. 2015;29(1):LB334.
5. Evans M, Baisley J, Brass S, Guthrie N. A Randomized, double-blind trial on the bioavailability of two CoQ10 formulations. Journal of functional Foods. 2009;1(1):65-73.
6. Australian Government [Internet]. Australian Statistics on Medicines [updated 2016; cited 2017 December 14] Available from: https://www.pbs.gov.au/statistics/asm/2015/australian-statistics-on-medicines-2015.pdf
7. Parker BA, Thompson PD. Effect of statins on skeletal muscle: exercise, myopathy, and muscle outcomes. Exerc Sport Sci Rev. 2012;40(4):188-94.