Statins and coenzyme Q10: should you take it, and can you take both at the same time?

Statins block an enzyme, HMG-CoA reductase, which opens the pathway that makes cholesterol. Coenzyme Q10 is produced by this same pathway, the mevalonate pathway, so a fall in its blood level on statins was to be expected^1,2.

A meta-analysis published in 2015 pooled the placebo-controlled trials that had measured plasma coenzyme Q10. Across 8 treatment arms, the average fall reached 0.44 µmol/L (95% confidence interval: 0.37 to 0.52). It was seen with all four statins studied (atorvastatin, simvastatin, rosuvastatin and pravastatin), whether the molecule was lipophilic or hydrophilic, and whether the trial lasted less or more than 12 weeks³.

The authors themselves conclude that the clinical relevance of this fall remains to be established. Coenzyme Q10 measured in the blood does not directly reflect levels in muscle, and the European Atherosclerosis Society panel notes that a decrease has also been reported in people on statins who had no symptoms at all¹.

No official guideline recommends it. In 2015, the European Atherosclerosis Society consensus panel wrote that it did not recommend coenzyme Q10 to treat or prevent statin-associated muscle symptoms, based on a double-blind randomised trial and a meta-analysis, both negative¹.

That position did not end the debate. The same year, a US team described coenzyme Q10 as the most widespread approach to pain attributed to statins, among patients and doctors alike, despite evidence that is limited and conflicting⁴. Small trials have reported a benefit, and a 2018 meta-analysis came to the same conclusion⁵.

Whether to take it is a decision to discuss with your doctor or pharmacist, who knows your treatment as a whole. A statin should not be stopped, nor its dose changed, without medical advice, even when it is blamed for discomfort.

They contradict each other: of four meta-analyses of randomised trials published between 2015 and 2022, only one concludes that coenzyme Q10 reduces statin-associated muscle pain.

• Banach et al., 2015: 6 trials, 302 patients. Pain tended to decrease, but the difference was not significant (standardised mean difference −0.53; 95% CI −1.33 to 0.28). Creatine kinase (CK) did not change⁶.
• Qu et al., 2018: 12 trials, 575 patients. The authors report a reduction in pain (weighted mean difference −1.60; 95% CI −1.75 to −1.44), muscle weakness, cramps and muscle tiredness, with no effect on CK⁵.
• Kennedy et al., 2020: 7 trials, 321 patients with myalgia. No benefit on pain (−0.42; 95% CI −1.47 to 0.62) or on continuing the statin (relative risk 0.99)⁷.
• Wei et al., 2022: 8 trials, 472 patients, including 4 trials and 220 participants for pain. No significant benefit (−0.59; 95% CI −1.54 to 0.36)⁸.

The pooled trials are small, with 37 to 76 participants each according to the 2020 review, and they measure pain on different scales⁷. The 2018 meta-analysis itself reports high heterogeneity between studies (I² of 89.6% for pain), which weakens any single estimate⁵. The choice of trials included also weighs on the result.

One last point complicates the picture. In the trial by Taylor et al., 120 people who attributed pain to their statin first took, blinded, simvastatin and then a placebo: only 36% had symptoms on the statin and not on placebo⁴. Some of the patients included in the coenzyme Q10 trials may therefore not have had myalgia caused by the drug, which blurs the measured effect.

Trials tested 100 to 600 mg a day, for 30 days to 3 months, and no link was found between the dose and the effect on pain^5,6. Three trials illustrate this range.

• 100 mg a day for 30 days: in 18 patients, pain intensity fell by 40%, while it did not change in the control group, who received vitamin E (14 patients)⁹.
• 200 mg a day for 12 weeks: in 44 patients, the myalgia score and simvastatin tolerance did not differ from those of the placebo group¹⁰.
• 600 mg a day of ubiquinol for 8 weeks: in 41 patients with confirmed myalgia, pain increased on simvastatin, with or without coenzyme Q10⁴.

No dose has therefore been validated for this use. The BfR, Germany’s Federal Institute for Risk Assessment, notes occasional side effects, mainly digestive (nausea, heartburn, diarrhoea), at doses of up to 300 mg a day. It also stresses that data in healthy people remain scarce².

In the trials cited, coenzyme Q10 was taken every day during statin treatment, throughout the study; none compared different times of intake^4,10.

So trial data offer no answer on timing. Published studies give no reason to space the two doses several hours apart, and none shows any advantage in taking them together. There is no official recommendation on this point either.

Caution applies more to other medicines. According to the BfR, possible interactions between coenzyme Q10 and coumarin anticoagulants (warfarin, acenocoumarol), as well as with blood pressure medicines, have not been sufficiently studied. The institute advises people taking these treatments to seek medical advice before using more than 100 mg a day². A pharmacist can check these combinations from the prescription.

The two names refer to the same molecule: ubiquinone is its oxidised form, ubiquinol its reduced form. The available trials do not compare them directly on muscle symptoms in people taking statins.

As for blood levels, a small study compared the two forms in 12 healthy volunteers, at 200 mg a day for 4 weeks each, in identical capsules. Plasma coenzyme Q10 rose from 0.9 to 2.5 µg/mL with ubiquinone, and from 0.9 to 4.3 µg/mL with ubiquinol¹¹. The study is modest: it involved 12 people who were not taking a statin, and the two forms were given in a fixed order, ubiquinone first, without randomisation.

A higher blood level does not, however, guarantee an effect on muscle. The trial by Taylor et al. used ubiquinol, at 600 mg a day: serum coenzyme Q10 increased fourfold (from 1.3 to 5.2 µg/mL), with no reduction in pain at all⁴. Ubiquinol raises blood levels more in the available study, but it has not shown any specific benefit on symptoms.

Three points lack solid evidence: that the fall in blood coenzyme Q10 explains the muscle pain attributed to statins, that supplementation relieves it, and that it helps people stay on treatment.

The 2015, 2018 and 2022 meta-analyses show no effect of coenzyme Q10 on creatine kinase, the blood marker of muscle damage^5,6,8. The proportion of patients who stayed on their statin, measured in the 2020 review, is the same with and without the supplement⁷. In Europe, EFSA reviewed several health claims for coenzyme Q10 in 2010, including its contribution to energy metabolism, and found no cause-and-effect relationship for any of them: none has therefore been authorised¹².

Trials remain few, short and small, so a modest benefit in some patients cannot be ruled out. The available figures invite caution with every promise made about coenzyme Q10, and keep the statin, whose cardiovascular benefit is established, at the centre of the decision.