Effects of Coenzyme Q10 on Statin-Induced Myopathy: An Updated Meta-Analysis of Randomized Controlled Trials

The Role of Mitochondria in Statin-Induced Myopathy

Statins represent the primary therapy for combatting hypercholesterolemia and reducing mortality from cardiovascular events. Despite their pleiotropic effects in lowering cholesterol synthesis, circulating cholesterol, as well as reducing the risk of other systemic diseases, statins have adverse events in a small, but significant, population of treated patients. The most prominent of these adverse effects is statin-induced myopathy, which lacks precise definition but is characterised by elevations in the muscle enzyme creatine kinase alongside musculoskeletal complaints, including pain, weakness and fatigue. The exact aetiology of statin-induced myopathy remains to be elucidated, although impaired mitochondrial function is thought to be an important underlying cause. This may result from or be the consequence of several factors including statin-induced inhibition of coenzyme Q10 (CoQ10) biosynthesis, impaired Ca2+ signalling and modified reactive oxygen species (ROS) generation. The purpose of this review article is to provide an update on the information available linking statin therapy with mitochondrial dysfunction and to outline any mechanistic insights, which may be beneficial in the future treatment of myopathic adverse events.

Effect of Coenzyme Q10 on Physical Performance in Older Adults with Statin-Associated Asthenia: A Double-Blind, Randomized, Placebo-Controlled Clinical Trial

Background: Available evidence from randomized clinical trials is contrasting and definitely inconclusive in determining whether or not CoQ10 dietary supplementation is advisable in patients with statin intolerance or poor statin tolerability. Methods: This randomized, double-blind, placebo-controlled clinical study aimed at investigating the effect of chronic dietary supplementation with coenzyme Q10 (CoQ10) phytosome on physical performance in older adults with a ≥3-month history of statin-associated asthenia. The study's participants were randomized to either a placebo or 300 mg daily CoQ10 phytosome (equivalent to 60 mg CoQ10; Ubiqsome®, Indena SpA, Milan, Italy). Asthenia, handgrip strength (HGs), 2-min step test (2MST), and 1-min sit-to-stand (STS) repetitions were assessed at baseline and at 8-week follow-up. Results: After the first 4 weeks of dietary supplementation, individuals taking CoQ10 phytosome showed a greater improvement in asthenia compared to the placebo group (p < 0.05). Even more significantly, at 8-week follow-up, participants receiving CoQ10 showed substantial improvements in asthenia (-30.0 ± 20.0%), HGS (+29.8 ± 3.6%), 2MST (+11.1 ± 1.8%), and 1-min STS repetitions (+36.4 ± 3.9%) compared to both baseline and placebo (p < 0.05). Conclusions: According to our findings, chronic dietary supplementation with CoQ10 phytosome significantly enhances physical performance in older adults with statin-associated asthenia. This could have relevant implications for improving the compliance of older adults with statin treatment.

Efficacy Assessment of Five Policosanol Brands and Damage to Vital Organs in Hyperlipidemic Zebrafish by Six-Week Supplementation: Highlighting the Toxicity of Red Yeast Rice and Safety of Cuban Policosanol (Raydel®)

Policosanol is a mixture of long-chain aliphatic alcohols (LCAAs) derived from various plant and insect origins that are marketed by various companies with distinct formulations and brand names. Policosanols offer several beneficial effects to treat dyslipidemia and hypertension; however, a comprehensive functionality comparison of various policosanol brands has yet to be thoroughly explored. In the present study five distinct policosanol brands from different origins and countries, Raydel-policosanol, Australia (PCO1), Solgar-policosanol, USA (PCO2), NutrioneLife-monacosanol, South Korea (PCO3), Mothernest-policosanol, Australia (PCO4), and Peter & John-policosanol, New Zealand (PCO5) were compared via dietary supplementation (1% in diet, final wt/wt) to zebrafish for six weeks to investigate their impact on survivability, blood lipid profile, and functionality of vital organs under the influence of a high-cholesterol diet (HCD, final 4%, wt/wt). The results revealed that policosanol brands (PCO1-PCO5) had a substantial preventive effect against HCD-induced zebrafish body weight elevation and hyperlipidemia by alleviating total cholesterol (TC) and triglycerides (TG) in blood. Other than PCO3, all the brands significantly reduced the HCD's elevated low-density lipoprotein cholesterol (LDL-C). On the contrary, only PCO1 displayed a significant elevation in high-density lipoprotein cholesterol (HDL-C) level against the consumption of HCD. The divergent effect of PCO1-PCO5 against HCD-induced hepatic damage biomarkers, aspartate aminotransferase (AST) and alanine aminotransferase (ALT), was observed. PCO1, PCO2, and PCO4 efficiently curtailed the AST and ALT levels; however, PCO3 and PCO5 potentially aggravated the HCD's elevated plasma AST and ALT levels. Consistently, the hepatic histology outcome revealed the least effectiveness of PCO3 and PCO5 against HCD-induced liver damage. On the contrary, PCO1 exhibited a substantial hepatoprotective role by curtailing HCD-induced fatty liver changes, cellular senescent, reactive oxygen species (ROS), and interleukin-6 (IL-6) production. Likewise, the histological outcome from the kidney, testis, and ovary revealed the significant curative effect of PCO1 against the HCD-induced adverse effects. PCO2-PCO5 showed diverse and unequal results, with the least effective being PCO3, followed by PCO5 towards HCD-induced kidney, testis, and ovary damage. The multivariate interpretation based on principal component analysis (PCA) and hierarchical cluster analysis (HCA) validated the superiority of PCO1 over other policosanol brands against the clinical manifestation associated with HCD. Conclusively, different brands displayed distinct impacts against HCD-induced adverse effects, signifying the importance of policosanol formulation and the presence of aliphatic alcohols on the functionality of policosanol products.

Use of Statins in Heart Failure with Preserved Ejection Fraction: Current Evidence and Perspectives

Systemic inflammation and coronary microvascular endothelial dysfunction are essential pathophysiological factors in heart failure (HF) with preserved ejection fraction (HFpEF) that support the use of statins. The pleiotropic properties of statins, such as anti-inflammatory, antihypertrophic, antifibrotic, and antioxidant effects, are generally accepted and may be beneficial in HF, especially in HFpEF. Numerous observational clinical trials have consistently shown a beneficial prognostic effect of statins in patients with HFpEF, while the results of two larger trials in patients with HFrEF have been controversial. Such differences may be related to a more pronounced impact of the pleiotropic properties of statins on the pathophysiology of HFpEF and pro-inflammatory comorbidities (arterial hypertension, diabetes mellitus, obesity, chronic kidney disease) that are more common in HFpEF. This review discusses the potential mechanisms of statin action that may be beneficial for patients with HFpEF, as well as clinical trials that have evaluated the statin effects on left ventricular diastolic function and clinical outcomes in patients with HFpEF.

Statins affect human iPSC-derived cardiomyocytes by interfering with mitochondrial function and intracellular acidification

Statins are effective drugs in reducing cardiovascular morbidity and mortality by inhibiting cholesterol synthesis. These effects are primarily beneficial for the patient's vascular system. A significant number of statin users suffer from muscle complaints probably due to mitochondrial dysfunction, a mechanism that has recently been elucidated. This has raised our interest in exploring the effects of statins on cardiac muscle cells in an era where the elderly and patients with poorer functioning hearts and less metabolic spare capacity start dominating our patient population. Here, we investigated the effects of statins on human-induced pluripotent stem cell-derived cardiomyocytes (hiPSC-derived CMs). hiPSC-derived CMs were exposed to simvastatin, atorvastatin, rosuvastatin, and cerivastatin at increasing concentrations. Metabolic assays and fluorescent microscopy were employed to evaluate cellular viability, metabolic capacity, respiration, intracellular acidity, and mitochondrial membrane potential and morphology. Over a concentration range of 0.3-100 µM, simvastatin lactone and atorvastatin acid showed a significant reduction in cellular viability by 42-64%. Simvastatin lactone was the most potent inhibitor of basal and maximal respiration by 56% and 73%, respectively, whereas simvastatin acid and cerivastatin acid only reduced maximal respiration by 50% and 42%, respectively. Simvastatin acid and lactone and atorvastatin acid significantly decreased mitochondrial membrane potential by 20%, 6% and 3%, respectively. The more hydrophilic atorvastatin acid did not seem to affect cardiomyocyte metabolism. This calls for further research on the translatability to the clinical setting, in which a more conscientious approach to statin prescribing might be considered, especially regarding the current shift in population toward older patients with poor cardiac function.

Dantrolene and coenzyme Q10 as a suggested combination therapy to statin-induced myopathy in high fat diet rats: A possible interference with ROS/ TGF-β / Smad4 signaling pathway

One of the major hitches for statins' utilization is the development of myotoxicity. Versatile studies reported that the underlining molecular mechanisms including coenzyme Q10 (CoQ10)/ubiquinone depletion, as well as the disturbance in the cytoplasmic Ca2+ homeostasis. Therefore, we investigated the consequences of supplementing CoQ10 and dantrolene, a cytoplasmic Ca2+ reducing agent, in combination with simvastatin. This adjuvant therapy normalized the simvastatin-mediated elevation in serum ALT, AST, CK-MM, as well as tissue Ca2+ content, in addition to suppressing the simvastatin-mediated oxidative stress in simvastatin-treated rats, while having no effect upon statin-induced antihyperlipidemic effect. Additionally, the combination inhibited the simvastatin-induced TGF-β/ Smad4 pathway activation. Collectively, the current study emphasizes on the potential utilization of dantrolene and CoQ10 as an adjuvant therapy to statins treatment for improving their side effect profile.

A scoping review on natural cholesterol lowering supplements sold in South African pharmacies

Background

Dyslipidaemia is defined as elevated total or low-density lipoprotein (LDL) levels or low levels of high-density lipoprotein (HDL). Patients may often make use of natural cholesterol lowering supplements (NCLSs) available at the pharmacy; however, limited information on these supplements is readily available. Pharmacists should be knowledgeable about NCLSs to ensure that the use of these supplements is supported by evidence and to provide appropriate advice to patients for desirable therapeutic outcomes.

Aim

This study aimed to identify the NCLSs being sold in South African pharmacies and review the scientific evidence for each of the ingredients in these NCLSs.

Methods

Seventeen NCLS products were identified, and the Joanna Briggs Institute (JBI) scoping review methodology was used to conduct a literature review of NCLSs.

Results

From the ingredients reviewed it is evident that co-enzyme Q10, probiotics and sterols have sufficient evidence supporting their use. However, there is still limited scientific evidence available to validate the remaining ingredients.

Conclusion

Further research on NCLSs will provide practising pharmacists and practitioners with a guide of the evidence available on the various ingredients in NCLSs.

Contribution

This study provides a review of the available literature on the NCLSs being sold in the pharmacies across South Africa to provide pharmacists with a collated document of the evidence behind these popular supplements to assist them in making evidence based informed decision regarding natural products for cholesterol.

Prostate Cancer and the Mevalonate Pathway

Antineoplastic therapies for prostate cancer (PCa) have traditionally centered around the androgen receptor (AR) pathway, which has demonstrated a significant role in oncogenesis. Nevertheless, it is becoming progressively apparent that therapeutic strategies must diversify their focus due to the emergence of resistance mechanisms that the tumor employs when subjected to monomolecular treatments. This review illustrates how the dysregulation of the lipid metabolic pathway constitutes a survival strategy adopted by tumors to evade eradication efforts. Integrating this aspect into oncological management could prove valuable in combating PCa.

Prospects of Intravenous Coenzyme Q10 Administration in Emergency Ischemic Conditions

Coenzyme CoQ10 (CoQ10) is an endogenous lipid-soluble antioxidant that effectively protects lipids, proteins, and DNA from oxidation due to its ability to undergo redox transitions between oxidized and reduced forms. Various oxidative stress-associated infectious and somatic diseases have been observed to disrupt the balance of CoQ10 concentration in tissues. As a high molecular weight polar lipophilic compound, CoQ10 exhibits very limited oral bioavailability, which restrains its therapeutic potential. Nevertheless, numerous studies have confirmed the clinical efficacy of CoQ10 therapy through oral administration of high doses over extended time periods. Experimental studies have demonstrated that in emergency situations, intravenous administration of both oxidized and reduced-form CoQ10 leads to a rapid increase in its concentration in organ tissues, offering protection for organ tissues in ischemic conditions. This suggests that the cardio- and neuroprotective efficacy of intravenously administered CoQ10 forms could present new opportunities in treating acute ischemic conditions. Based on these findings, the review provides reasoning supporting further research and implementation of CoQ10 dosage forms for intravenous administration in emergency situations into clinical practice.

Coenzyme Q10 for Enhancing Physical Activity and Extending the Human Life Cycle

BACKGROUND

Coenzyme Q (CoQ) is an enzyme family that plays a crucial role in maintaining the electron transport chain and antioxidant defense. CoQ10 is the most common form of CoQ in humans. A deficiency of CoQ10 occurs naturally with aging and may contribute to the development or progression of many diseases. Besides, certain drugs, in particular, statins and bisphosphonates, interfere with the enzymes responsible for CoQ10 biosynthesis and, thus, lead to CoQ10 deficiency.

OBJECTIVES

This article aims to evaluate the cumulative studies and insights on the topic of CoQ10 functions in human health, focusing on a potential role in maintaining physical activity and extending the life cycle.

RESULTS

Although supplementation with CoQ10 offers many benefits to patients with cardiovascular disease, it appears to add little value to patients suffering from statin-associated muscular symptoms. This may be attributed to substantial heterogeneity in doses and treatment regimens used.

CONCLUSION

Therefore, there is a need for further studies involving a greater number of patients to clarify the benefits of adjuvant therapy with CoQ10 in a range of health conditions and diseases.

Potential role of geranylgeraniol in managing statin-associated muscle symptoms: a COVID-19 related perspective

Myopathy is the most common side effect of statins, but it has not been addressed effectively. In anticipation of its wider use as a small molecule to complement the current COVID-19 management, a pharmacological solution to statin-associated muscle symptoms (SAMS) is warranted. Statins act by suppressing the mevalonate pathway, which in turn affects the downstream synthesis of isoprenoids required for normal physiological functions. CoQ10 and geranylgeraniol (GG) syntheses are reduced by statin use. However, CoQ10 supplementation has not been shown to reverse SAMS. GG is an obligatory substrate for CoQ10 synthesis, an endogenous nutrient critical for skeletal muscle protein synthesis. Multiple studies showed GG supplementation is effective in reversing SAMS. This opinion paper proposes employing GG to prevent SAMS in pleiotropic statin use, including usage in the post-COVID-19 pandemic era.

Prescribing statin therapy in physically (in)active individuals vs prescribing physical activity in statin-treated patients: A four-scenario practical approach

Statins are among the most commonly prescribed medications worldwide. Statin-associated muscle symptoms (SAMS) represent a frequent statin-related adverse effect associated with statin discontinuation and increased cardiovascular disease (CVD) events. Emerging evidence indicate that the majority of SAMS might not be actually caused by statins, and the nocebo/drucebo effect (i.e. adverse effects caused by negative expectations) might also explain SAMS. Physical activity (PA) is a cornerstone in the management of CVD risk. However, evidence of increased creatine-kinase levels in statin-treated athletes exposed to a marathon has been generalized, at least to some extent, to the general population and other types of PA. This generalization is likely inappropriate and might induce fear around PA in statin users. In addition, the guidelines for lipid management focus on aerobic PA while the potential of reducing sedentary behavior and undertaking resistance training have been overlooked. The aim of this report is to provide a novel proposal for the concurrent prescription of statin therapy and PA addressing the most common and clinically relevant scenarios by simultaneously considering the different stages of statin therapy and the history of PA. These scenarios include i) statin therapy initiation in physically inactive patients, ii) PA/exercise initiation in statin-treated patients, iii) statin therapy initiation in physically active patients, and iv) statin therapy in athletes and very active individuals performing SAMS-risky activities.

Effect of Some Risk Factors on Over-Anticoagulation Disorders and Bleeding in Patients Receiving Anticoagulant Therapy with Overdosage of Vitamin K Antagonist

Objective

Study on effect of risk factors on over-anticoagulation in patients taking anticoagulant drugs with VKAs (vitamin K antagonists).

Methods

Cross-sectional descriptive, prospective research. Study on 79 patients taking anticoagulant drugs with VKAs who had an INR (International Normalized Ratio) index of more than indicated anticoagulation dose with VKAs therapy.

Results

A total of 79 patients, mean age 65.65 ± 12.17 years [33:85], the elderly group is common (73.4%). Patients had hemorrhage disorders account for 22.8%. The INR index had an average value was 5.88 ± 3.0 [3.02-23.95]; The INR> 5 level group is a higher risk of bleeding than the INR ≤5 level group, it's the statistical significance (p < 0.001). The risk factors such as drugs to treat dyslipidemia, hyperthyroid, amiodarone, beta blocker, prednisone, NSAIDs (Non-steroidal anti-inflammatory), BMI (Body Mass Index), smoke and alcohol that the risk factors of increasing of bleeding when receiving anticoagulants but it's not statistically significant yet (OR >1, p > 0.05); These patients using coenzyme Q10 and green vegetable nutrition such as cruciferous vegetables (Brassicaceae, Asteraceae) are quite common (31.6% and 35.4%), its effect on coagulation with vitamin K and cause of the increased in risk of bleeding was statistical significantly with OR = 5.28 (CI: 1.72-16.17, p < 0.01), and OR = 2.99 (CI: 1.01-8.80, p < 0.05) respectively.

Conclusion

Most patients in over-anticoagulation were the elderly group. Patients had hemorrhage disorders account for 22.8%. The INR> 5 level group was a higher risk of bleeding than the INR ≤5 level group with statistical significance. Patients using Coenzyme Q10 and green vegetable nutrition such as cruciferous vegetables (Brassicaceae, Asteraceae) are quite common, its effect on coagulation and cause of the increased risk of bleeding complication with statistical significance.

Ferroptosis, a new pathogenetic mechanism in cardiometabolic diseases and cancer: Is there a role for statin therapy?

One of the newly recognized types of cell death is ferroptosis which is related to the accumulation of iron and lipid-reactive oxygen species. Ferroptosis is considered a programmed cell death with a different mechanism from apoptosis, necrosis, and autophagy. Emerging evidence suggests that ferroptosis may occur in the context of cardiovascular disease (CVD), cancer, neurodegenerative diseases, and non-alcoholic fatty liver disease (NAFLD). Statins are the first-line therapy for dyslipidemia. The suppression of the HMG-CoA reductase by statins leads to decreased expression of glutathione peroxidase 4 (GPX4), a key regulator of lipid peroxidation, which in turn results in lipid ROS production and induction of ferroptosis. Experimental data suggest that statins may act as anti-cancer drugs by enhancing tumor cells' ferroptosis. In contrast, statins have also been reported to mitigate ferroptosis in animal models of myocardial ischemia-reperfusion and heart failure. This mini-review presents statin effects on the ferroptosis pathway, based on up-to-date in vivo and in vitro research. Furthermore, the potential impact of these effects on cardiometabolic diseases (e.g., CVD and NAFLD) and cancer is briefly discussed. Overall, there is a need for future studies focusing on statin-induced changes in ferroptosis as a therapeutic approach to such diseases.

Understanding the molecular mechanisms of statin pleiotropic effects

Statins represent the cornerstone of pharmacotherapy for the prevention of atherosclerotic cardiovascular disease. These medications not only reduce low-density lipoprotein cholesterol (LDL-C) via inhibition of 3-hydroxy-3-methylglutarate attached to CoA reductase, the key rate-limiting step in the cholesterol biosynthetic pathway, but also upregulate expression of the low-density lipoprotein receptor, improving serum clearance. Given LDL-C is a causal risk factor for the development of atherosclerosis, these complementary mechanisms largely explain why statin therapy leads to reductions in major adverse cardiovascular events. However, decades of basic and clinical research have suggested that statins may exert other effects independent of LDL-C lowering, termed pleiotropic effects, which have become a topic of debate among the scientific community. While some literature suggests statins may improve plaque stability, reduce inflammation and thrombosis, decrease oxidative stress, and improve endothelial function and vascular tone, other studies have suggested potential harmful pleiotropic effects related to increased risk of muscle-related side effects, diabetes, hemorrhagic stroke, and cognitive decline. Furthermore, the introduction of newer, non-statin LDL-C lowering therapies, including ezetimibe, proprotein convertase subtilisin/Kexin Type 9, and bempedoic acid, have challenged the statin pleiotropy theory. This review aims to provide a historical background on the development of statins, explore the mechanistic underpinnings of statin pleiotropy, review the available literature, and provide up to date examples that suggest statins may exert effects outside of LDL-C lowering and the cardiovascular system.

Efficacy and Safety of Coenzyme Q10 Supplementation in the Treatment of Polycystic Ovary Syndrome: a Systematic Review and Meta-analysis

The aim of this study is to evaluate the efficacy and safety of coenzyme Q10 supplementation in the treatment of polycystic ovary syndrome (PCOS). We first searched PubMed, Wanfang Data, CNKI, Embase, ClinicalTrial.gov, and other databases. The retrieval time from the establishment of the database to January 2021. We collected relevant randomized controlled trials (RCTs) about coenzyme Q10 in the treatment of PCOS. Risk of bias assessment and meta-analysis of RCTs were performed using RevMan 5.0 software. This systematic review and meta-analysis include a total of 9 RCTs involving 1021 patients. The results show that the addition of coenzyme Q10 may improve insulin resistance (HOMA-IR (WMD - 0.67 [- 0.87, - 0.48], P < 0.00001); fasting insulin (WMD - 1.75 [- 2.65, - 0.84], P = 0.0002); fasting plasma glucose (WMD - 5.20 [- 8.86, - 1.54], P = 0.005)), improve sex hormone levels (FSH (SMD - 0.45 [0.11, 0.78], P = 0.009); testosterone (SMD - 0.28 [- 0.49, - 0.06], P = 0.01)), and improve blood lipids (triglycerides (SMD - 0.49 [- 0.89, - 0.09], P = 0.02); total cholesterol (SMD - 0.35 [- 0.56, - 0.14], P = 0.001); LDL-C (SMD - 0.22 [- 0.43, - 0.01], P = 0.04); HDL-C (SMD 0.22 [0.01, 0.43], P = 0.04)). Only one RCT reported adverse events, and they found that patients had no adverse effects or symptoms following supplementation. Based on the current evidence, it could be considered that the addition of CoQ10 is a safe therapy to improve PCOS by improving insulin resistance (reduce HOMA-IR, FINS, FPG), increasing sex hormone levels (increase FSH, reduce testosterone), and improving blood lipids (reduce TG, TC, LDL-C, and increased HDL-C).

Statin Intolerance: a Review and Update

OBJECTIVE

To review evidence of existing literature on the management of statin intolerance.

METHODS

We searched for literature pertaining to statin intolerance and treatments in PubMed. We reviewed articles published between 2005 and 2022.

RESULTS

Statin-associated myalgia is the most common adverse effect of statin therapy and the most common reason for statin discontinuation. Risk factors for statin intolerance include unexplained muscle pain with other lipid-lowering therapy, unexplained cramps, history of elevated creatinine kinase levels, family history of muscle symptoms, and family history of muscle symptoms with lipid therapy. Vitamin D repletion and coenzyme Q supplementation may help alleviate the musculoskeletal effects of statins. Trials of different types of statins and different dosing regimens are recommended to improve tolerability. The use of statins in individuals who perform regular exercise requires closer attention to muscular symptoms and creatinine kinase levels, but it does not preclude the use of statins.

CONCLUSION

Management of the adverse effects of statin therapy and improving statin tolerability is key to achieving optimum cardiovascular benefits. Identifying statin-associated adverse effects and managing appropriately can reduce unnecessary statin discontinuation and subsequently provide longer cardiovascular protection.

Nutraceutical approaches to non-alcoholic fatty liver disease (NAFLD): A position paper from the International Lipid Expert Panel (ILEP)

Non-Alcoholic Fatty Liver Disease (NAFLD) is a common condition affecting around 10-25% of the general adult population, 15% of children, and even > 50% of individuals who have type 2 diabetes mellitus. It is a major cause of liver-related morbidity, and cardiovascular (CV) mortality is a common cause of death. In addition to being the initial step of irreversible alterations of the liver parenchyma causing cirrhosis, about 1/6 of those who develop NASH are at risk also developing CV disease (CVD). More recently the acronym MAFLD (Metabolic Associated Fatty Liver Disease) has been preferred by many European and US specialists, providing a clearer message on the metabolic etiology of the disease. The suggestions for the management of NAFLD are like those recommended by guidelines for CVD prevention. In this context, the general approach is to prescribe physical activity and dietary changes the effect weight loss. Lifestyle change in the NAFLD patient has been supplemented in some by the use of nutraceuticals, but the evidence based for these remains uncertain. The aim of this Position Paper was to summarize the clinical evidence relating to the effect of nutraceuticals on NAFLD-related parameters. Our reading of the data is that whilst many nutraceuticals have been studied in relation to NAFLD, none have sufficient evidence to recommend their routine use; robust trials are required to appropriately address efficacy and safety.

The Management of Hypercholesterolemia in Patients with Neuromuscular Disorder

PURPOSE OF REVIEW

We describe and discuss the safety of statins and non-statin drugs in neuromuscular disorders (NMDs). We also propose a pragmatic model of care for the management of such cases.

RECENT FINDINGS

Patients with both NMD and hypercholesterolemia may be particularly disadvantaged owing to the toxic effects of cholesterol-lowering therapy and the inability to take medication. Specifically, the management of hypercholesterolemia in patients with NMD is complicated by the increased risk of statin-related myotoxicity and concerns that statins may aggravate or possibly induce the onset of a specific NMD. The most severe form of statin-related myotoxicity is immune-mediated necrotizing myopathy. Management of hypercholesterolemia in patients with NMDs include treating modifiable factors, consideration of toxicity risk of statin, use of non-statin lipid lowering agents, noting possible drug interactions, and careful monitoring.

Evident lower blood levels of multiple nutritional compounds and highly prevalent malnutrition in sub-acute stroke patients with or without dysphagia

Introduction

Malnutrition is prevalent after stroke, particularly if post-stroke oropharyngeal dysphagia (OD) reduces nutritional intake. To further understand stroke-related malnutrition, a thorough nutritional assessment was performed in ischemic stroke patients with or without OD during sub-acute inpatient rehabilitation.

Methods

In this exploratory, observational, cross-sectional, multi-center study in Germany (NTR6802), ischemic stroke patients with (N = 36) or without (N = 49) OD were age- and sex-matched to healthy reference subjects. Presence of (risk of) malnutrition (MNA-SF), blood concentration of stroke-relevant nutritional compounds and metabolites, nutritional intake, quality of life (EQ-5D-5L), and activities of daily living (Barthel index) were assessed.

Results

More than half of the stroke patients displayed (risk of) malnutrition, with higher prevalence in patient with OD vs. without OD. Fasted blood concentrations of vitamins B1, B2, B6, A, D, and E, selenium, choline, coenzyme Q10, albumin, pre-albumin, transferrin, docosahexaenoic acid, and eicosapentaenoic acid were all lower in stroke patients compared to their matched healthy reference subjects, irrespective of OD status. Reported energy, macronutrient, and water intake were lower in stroke patients vs. healthy reference subjects. As expected, quality of life and activities of daily living scores were lower in stroke vs. healthy reference subjects, with OD scoring worse than non-OD patients.

Discussion

This study shows that malnutrition is highly prevalent in sub-acute stroke patients during rehabilitation. Even though patients with OD were more likely to be malnourished, blood levels of specific nutritional compounds were similarly lower in stroke patients with or without OD compared to healthy reference subjects. Furthermore, subgroup analysis showed similarly lower blood levels of specific nutritional compounds in patients that are normal nourished vs. patients with (risk of) malnutrition. This might imply disease-specific changes in blood levels on top of overall protein-energy malnutrition. The results of the current study underline that it is important to screen for nutritional impairments in every stroke patient, either with or without OD.

Assessment and management of statin-associated muscle symptoms (SAMS): A clinical perspective from the National Lipid Association

Statin-associated muscle symptoms (SAMS) are the most common form of statin intolerance and are associated with increased risk of cardiovascular events that manifest from statin underutilization and discontinuation. The reported frequencies of SAMS are divergent in the literature. The writing group estimates the prevalence of SAMS, namely all muscle symptoms temporally related to statin use but without regard to causality, to be about 10% (range 5% to 25%), and the prevalence of pharmacological SAMS, specifically muscle symptoms resulting from pharmacological properties of the statin, to be about 1-2% (range 0.5% to 4%). In clinical practice, SAMS are likely to result from a combination of pharmacological and nonpharmacological effects, however this does not make the symptoms any less clinically relevant. Regardless of the etiology, SAMS need to be addressed in accordance with patients' preferences and experiences. This clinical perspective reviews the epidemiology and underlying pathophysiology of SAMS, and the cardiovascular consequences resulting from statin discontinuation. We present patient-centered clinical and communication strategies to mitigate SAMS and improve medication adherence and outcomes among statin users. Treatment strategies include 1) optimizing lifestyle interventions, 2) modulating risk factors that may contribute to muscle symptoms, 3) optimizing statin tolerability by dose reduction, decreased dosing frequency, or use of an alternate statin with more favorable pharmacokinetic properties, and 4) use of non-statins, emphasizing those with evidence for atherosclerotic risk reduction, either in combination with or in place of statin therapy depending on the patient's circumstances. The focus of this clinical perspective is sustainable lipoprotein goal achievement, which is important for cardiovascular risk reduction.

Serum Cholesterol Differences Between Statin Users Who Take Dietary Supplements and Those Who Do Not: NHANES 2013-2018

Background

Cardiovascular disease (CVD) is the leading cause of mortality in the United States and statins are the most commonly prescribed medication. It is important to understand the potential impact supplements may have when taken in combination with statins on serum lipid outcomes.

Objectives

To evaluate the differences in the concentrations of cholesterol, triacylglycerol (TAG), and HbA1c between adults who use statins alone and those who combine statins and dietary supplements.

Methods

A cross-sectional analysis using data from US adults aged ≥20 years who participated in the NHANES (2013-2018). The serum concentrations of lipids and the HbA1c levels were compared using independent sample t-tests. All analyses were adjusted for the complex survey design and used appropriate sample weights.

Results

Of 16,327 participants included in this analysis, 13% reported the use of statins alone, and 8.8% used statins and dietary supplements. Statin users who used dietary supplements tended to be women (50.5%), aged 65.8 ± 0.4 years, and were more likely to be White (77.4%). Participants who used statins in combination with dietary supplements were less likely to have higher levels of total cholesterol (5.1% ± 1.4% vs. 15.6% ± 2.7%, P < 0.001), HbA1c (6.0% ± 0.1% vs. 6.3% ± 0.1%, P < 0.05), and HDL cholesterol (50 ± 1.3 vs. 47 ± 0.8 mg/dL, P < 0.05) than those who used statins alone. No significant differences were identified between the two groups for LDL cholesterol and TAG concentrations.

Conclusions

Statin users who coingested dietary supplements were less likely to have high levels of total cholesterol and HbA1c and greater HDL levels than statin users who did not take dietary supplements. Dietary intake, lifestyle choices, and other confounders may have influenced the observed outcome differences for those who took dietary supplements with statins and those who did not.

[Asthenic post-COVID syndrome]

OBJECTIVE

To evaluate the efficacy and safety of combination therapy for post-COVID asthenic syndrome with multicomponent bioregulatory drugs Traumeel S, Ubichinon compositum and Coenzyme compositum.

MATERIAL AND METHODS

The study included 104 patients (averaged age 39.5 [30.8; 48] years) after COVID-19, clinically recovered from an acute infectious process, with asthenic syndrome lasting from 2 weeks to 6 months; the severity of asthenic syndrome on the asthenia VAS scale was at least 30 points. Before the start of the study, in addition to a physical examination, the patient's condition was assessed using the following questionnaires and scales: VAS for asthenia, subjective scale for assessing asthenia (MFI-20), L.D. Malkova, a questionnaire for the quality of life (EQ-5D), a questionnaire for identifying signs of autonomic disorders (Vayne A.M.). The patient's condition was monitored during follow-up visits 2 weeks, 1 month after the start of treatment and 1 month after the end of treatment. Patients of the main group received combination therapy, which included Traumeel S 1 tablet x 3 times a day, Ubichinone compositum and Coenzyme compositum 2.2 ml intramuscularly, alternating every other day, for 1 month (15 injections of each drug per course of treatment). Patients of the comparison group received eleutherococcus extract 100 mg during 30 days, 2 tablets x 2 times a day before mealsand vitamins B. The effectiveness of therapy was assessed by analysis of the asthenia severity (VAS scale), quality of life (EQ-5D questionnaire), patient satisfaction with treatment on a 5-point scale, which was carried out 1 month after the end of the course of treatment.

RESULTS

As a result of the treatment was positive. The general asthenia severity, low activity and motivation significantly decreased in patients of both groups without significant differences. At the same time, in patients of the comparison group, there was no correlation between the quality of life and physical and mental asthenia, while in the main group there was an inverse correlation with the asthenia severity, which indicates an increase in the quality of life with a decrease in the severity of asthenia. One of the significant differences was the regression of headache and musculoskeletal pain in patients of the main group.

CONCLUSION

The advantage of combined therapy of post-COVID asthenic syndrome with bioregulation therapy Traumeel S, Ubichinone compositum and Coenzyme compositum was shown in comparison with one of the common treatment regimens, including eleutherococcus extract and combined preparations of B vitamins.

Combined Therapy with Simvastatin- and Coenzyme-Q10-Loaded Nanoparticles Upregulates the Akt-eNOS Pathway in Experimental Metabolic Syndrome

In addition to their LDL-cholesterol-lowering effect, statins have pleiotropic beneficial effects on the cardiovascular system. However, long-term treatment with statins may be associated with serious side effects. With the aim to make statin therapy more effective, we studied the effects of simvastatin- and coenzyme-Q10-loaded polymeric nanoparticles on the lipid profile and nitric oxide (NO)/reactive oxygen species (ROS) balance in the heart and aorta of adult male obese Zucker rats. The rats were divided into an untreated group, a group treated with empty nanoparticles, and groups treated with simvastatin-, coenzyme Q10 (CoQ10)-, or a combination of simvastatin- and CoQ10-loaded nanoparticles (SIMV+CoQ10). After 6 weeks, the lipid profile in the plasma and the concentration of conjugated dienes in the liver were determined. Nitric oxide synthase (NOS) activity, Akt, endothelial NOS (eNOS), phosphorylated eNOS (p-eNOS), nicotinamide adenine dinucleotide phosphate (NADPH) oxidase, and nuclear factor kappaB (NF-kappaB) protein expressions were measured in the heart and aorta. All simvastatin, CoQ10, and SIMV+CoQ10 treatments decreased plasma LDL levels, but only the combined SIMV+CoQ10 treatment increased NOS activity and the expression of Akt, eNOS, and p-eNOS in both the heart and the aorta. Interestingly, NADPH oxidase in the heart and NF-kappaB protein expression in the aorta were decreased by all treatments, including nanoparticles alone. In conclusion, only combined therapy with SIMV- and CoQ10-loaded nanoparticles increased NOS activity and upregulated the Akt-eNOS pathway in obese Zucker rats, which may represent a promising tool for the treatment of cardiometabolic diseases.

Is a PCSK9 Inhibitor Right for Your Patient? A Review of Treatment Data for Individualized Therapy

INTRODUCTION

In the United States, a significant amount of the population is affected by hyperlipidemia, which is associated with increased levels of serum low-density lipoprotein (LDL-C) and risk of cardiovascular disease. As of 2019, the guidelines set by the American College of Cardiology/American Heart Association advocate for the use of statins as the major contributor to lowering serum LDL-C. While proven to be effective, side effects, including muscle-related symptoms and new-onset diabetes mellitus, can make patients unable to tolerate statin therapy. Additionally, there is a subset of the population which does not approach a recommended LDL-C goal on statin treatment. Due to these findings, it was deemed necessary to review the literature of current statin-alternative lipid-lowering therapies.

METHODS

A systematic review of preclinical and clinical papers, and a current meta-analysis, was performed using PubMed and Google Scholar. Following the literature review, a meta-analysis was conducted using ProMeta 3.

RESULTS

Through systematic review and meta-analysis of the current literature, it is suggested that newer lipid-lowering therapies such as proprotein convertase subtilsin-kixen type 9 (PCSK9) inhibitors are a safe and effective statin alternative for the population with statin intolerance. PCSK9 inhibitors were shown to have no significant effect in causing myalgia in patients and showed no increase in adverse cardiovascular outcomes compared to a control of a current antilipemic medication regimen.

DISCUSSION

There are many statin-alternative therapies that should be investigated further as a potential replacement for patients with statin intolerance or as an addition for patients with statin resistance.

Statins for Smith-Lemli-Opitz syndrome

BACKGROUND

Smith-Lemli-Opitz syndrome (SLOS) is a multiple congenital malformations syndrome caused by defective cholesterol biosynthesis. Affected individuals show cholesterol deficiency and accumulation of various precursor molecules, mainly 7-dehydrocholesterol and 8-dehydrocholesterol. There is currently no cure for SLOS, with cholesterol supplementation being primarily a biochemical therapy of limited evidence. However, several anecdotal reports and preclinical studies have highlighted statins as a potential therapy for SLOS.

OBJECTIVES

To evaluate the effects of statins, either alone or in combination with other non-statin therapies (e.g. cholesterol, bile acid, or vitamin co-supplementation), compared to cholesterol supplementation alone or in combination with other non-statin therapies (e.g. bile acid or vitamin supplementation) on several important outcomes including overall survival, neurobehavioral features, and adverse effects in individuals with SLOS.

SEARCH METHODS

We searched CENTRAL, MEDLINE, Embase, five other databases and three trials registers on 15 February 2022, together with reference checking, citation searching and contact with study authors to identify additional studies.

SELECTION CRITERIA

Randomized controlled trials (RCTs) and quasi-RCTs with parallel or cross-over designs, and non-randomized studies of interventions (NRSIs) including non-randomized trials, cohort studies, and controlled before-and-after studies, were eligible for inclusion in this review if they met our prespecified inclusion criteria, i.e. involved human participants with biochemically or genetically diagnosed SLOS receiving statin therapy or cholesterol supplementation, or both.

DATA COLLECTION AND ANALYSIS

Two authors screened titles and abstracts and subsequently full-texts for all potentially-relevant references. Both authors independently extracted relevant data from included studies and assessed the risks of bias. We analyzed the data extracted from the included NRSIs and cohort studies separately from the data extracted from the single included RCT. We used a random-effects model to account for the inherent heterogeneity and methodological variation between these different study designs. We used GRADE to assess the certainty of evidence.

MAIN RESULTS

We included six studies (61 participants with SLOS); one RCT (N = 18), three prospective NRSIs (N = 20), and two retrospective NRSIs (N = 22). Five studies included only children, and two limited their participant inclusion by disease severity. Overall, there were nearly twice as many males as females. All six studies compared add-on statin therapy to cholesterol supplementation alone. However, the dosages, formulations, and durations of treatment were highly variable across studies. We judged the RCT as having a high risk of bias due to missing data and selective reporting. All included NRSIs had a serious or critical overall risk of bias assessed by the Risk Of Bias In Non-randomized Studies of Interventions tool (ROBINS-I). None of the included studies evaluated survival or reported quality of life (QoL). Only the included RCT formally assessed changes in the neurobehavioral manifestations of SLOS, and we are uncertain whether statin therapy improves this outcome (very low-certainty evidence). We are also uncertain whether the adverse events reported in the RCT were statin-related (very low-certainty evidence). In contrast, the adverse events reported in the NRSIs seem to be possibly due to statin therapy (risk ratio 13.00, 95% confidence interval 1.85 to 91.49; P = 0.01; low-certainty evidence), with only one of the NRSIs retrospectively mentioning changes in the irritability of two of their participants. We are uncertain whether statins affect growth based on the RCT or NRSI results (very low-certainty evidence). The RCT showed that statins may make little or no difference to plasma biomarker levels (low-certainty evidence), while we are uncertain of their effects on such parameters in the NRSIs (very low-certainty evidence).

AUTHORS' CONCLUSIONS

Currently, there is no evidence on the potential effects of statin therapy in people with SLOS regarding survival or QoL, and very limited evidence on the effects on neurobehavioral manifestations. Likewise, current evidence is insufficient and of very low certainty regarding the effects of statins on growth parameters in children with SLOS and plasma or cerebrospinal fluid (CSF) levels of various disease biomarkers. Despite these limitations, current evidence seemingly suggests that statins may increase the risk of adverse reactions in individuals with SLOS receiving statins compared to those who are not. Given the insufficient evidence on potential benefits of statins in individuals with SLOS, and their potential for causing adverse reactions, anyone considering this therapy should take these findings into consideration. Future studies should address the highlighted gaps in evidence on the use of statins in individuals with SLOS by collecting prospective data on survival and performing serial standardized assessments of neurobehavioral features, QoL, anthropometric measures, and plasma and CSF biomarker levels after statin introduction. Future studies should also attempt to use consistent dosages, formulations and durations of cholesterol and statin therapy.

Statins Induce Locomotion and Muscular Phenotypes in Drosophila melanogaster That Are Reminiscent of Human Myopathy: Evidence for the Role of the Chloride Channel Inhibition in the Muscular Phenotypes

The underlying mechanisms for statin-induced myopathy (SIM) are still equivocal. In this study, we employ Drosophila melanogaster to dissect possible underlying mechanisms for SIM. We observe that chronic fluvastatin treatment causes reduced general locomotion activity and climbing ability. In addition, transmission microscopy of dissected skeletal muscles of fluvastatin-treated flies reveals strong myofibrillar damage, including increased sarcomere lengths and Z-line streaming, which are reminiscent of myopathy, along with fragmented mitochondria of larger sizes, most of which are round-like shapes. Furthermore, chronic fluvastatin treatment is associated with impaired lipid metabolism and insulin signalling. Mechanistically, knockdown of the statin-target Hmgcr in the skeletal muscles recapitulates fluvastatin-induced mitochondrial phenotypes and lowered general locomotion activity; however, it was not sufficient to alter sarcomere length or elicit myofibrillar damage compared to controls or fluvastatin treatment. Moreover, we found that fluvastatin treatment was associated with reduced expression of the skeletal muscle chloride channel, ClC-a (Drosophila homolog of CLCN1), while selective knockdown of skeletal muscle ClC-a also recapitulated fluvastatin-induced myofibril damage and increased sarcomere lengths. Surprisingly, exercising fluvastatin-treated flies restored ClC-a expression and normalized sarcomere lengths, suggesting that fluvastatin-induced myofibrillar phenotypes could be linked to lowered ClC-a expression. Taken together, these results may indicate the potential role of ClC-a inhibition in statin-associated muscular phenotypes. This study underlines the importance of Drosophila melanogaster as a powerful model system for elucidating the locomotion and muscular phenotypes, promoting a better understanding of the molecular mechanisms underlying SIM.

A Pilot Study on the Effect of Virgin Coconut Oil On Serum Lipid Profile and HS CRP Level Among Post Acute Coronary Syndrome Patients: A Randomized Controlled Trial

ABSTRACT Introduction: Acute coronary syndrome (ACS) is a leading cause of death in Malaysia and worldwide. Besides, teh current treatment which involves teh prescription of statins is found to TEMPhas several side TEMPeffects on ACS patients. Those side TEMPeffects TEMPhas guided teh author to introduce virgin coconut oil (VCO) as supplemental management of ACS. However, its benefits TEMPhas not been widely tested on humans. Methodology: dis study examines teh use of VCO among ACS patients via a crossover trial. It seeks to ascertain teh TEMPeffect of VCO on serum lipid profile and hs-CRP level among ACS patients. Result: VCO was found to be statistically significant in reducing serum lipid level and hs-CRP level (p&lt;0.001). These findings measured from small to moderate Cohen’s d TEMPeffect size, thus proving teh results from dis study as statistically and clinically significant. Conclusion: These findings suggest dat dietary intake wif saturated fatty acid (C6 to C12) can improve health condition. Keywords: virgin coconut oil, acute coronary syndrome, saturated fatty acid, medium-chain triglycerides

Combined Supplementation of Coenzyme Q10 and Other Nutrients in Specific Medical Conditions

Coenzyme Q₁₀ (CoQ₁₀) is a compound with a crucial role in mitochondrial bioenergetics and membrane antioxidant protection. Despite the ubiquitous endogenous biosynthesis, specific medical conditions are associated with low circulating CoQ₁₀ levels. However, previous studies of oral CoQ₁₀ supplementation yielded inconsistent outcomes. In this article, we reviewed previous CoQ₁₀ trials, either single or in combination with other nutrients, and stratified the study participants according to their metabolic statuses and medical conditions. The CoQ₁₀ supplementation trials in elders reported many favorable outcomes. However, the single intervention was less promising when the host metabolic statuses were worsening with the likelihood of multiple nutrient insufficiencies, as in patients with an established diagnosis of metabolic or immune-related disorders. On the contrary, the mixed CoQ₁₀ supplementation with other interacting nutrients created more promising impacts in hosts with compromised nutrient reserves. Furthermore, the results of either single or combined intervention will be less promising in far-advanced conditions with established damage, such as neurodegenerative disorders or cancers. With the limited high-level evidence studies on each host metabolic category, we could only conclude that the considerations of whether to take supplementation varied by the individuals' metabolic status and their nutrient reserves. Further studies are warranted.

Proximal myopathy: causes and associated conditions

Proximal myopathy presents as generalized muscle weakness commonly involving the muscles of upper and/or lower limbs. Toxins, long-term use of statins, corticosteroids, alcohol, SGLT2 inhibitors, COVID-19 vaccination, and antimalarials have been attributed to its development. In endocrine and metabolic disorders, adrenal dysfunction including both overproduction and insufficiency of the adrenal gland hormones has been reported to cause myopathy. Moreover, parathyroid and thyroid disorders along with pituitary gland disorders can also directly or indirectly contribute to this condition. In idiopathic inflammatory myopathies including polymyositis, dermatomyositis, inclusion body myositis (IBM), and Systemic Lupus Erythematosus (SLE), Sjögren's Syndrome, and overlap syndromes, moderate to severe muscle weakness has been observed. IBM has been reported to be the most prevalent acquired myopathy above the age of 50. Hereditary or congenital myopathies include limb girdle muscular dystrophies, facioscapulohumeral muscular dystrophy, Duchenne and Becker muscular dystrophy, and proximal myotonic myopathy. In addition to these, glycogen storage diseases such as the McArdle disease can also cause fast exhaustion, myalgia, and cramping in working muscles. It is pertinent to mention here that a class of hereditary metabolic myopathies, referred to as "lipid deposition myopathy" causes lipids to accumulate in skeletal muscle fibers, leading to lesions and degeneration. Among viral causes, HIV, dengue virus, influenza virus, hepatitis B virus, hepatitis C virus, SARS-CoV2 are also associated with muscle weakness. Sarcoidosis, an inflammatory disease, can also manifest as muscle weakness and myalgia. Owing to this complicated pathophysiology of proximal myopathy, this review aims to summarize the existing literature on conditions associated with this phenomenon and other recent developments that have been made regarding events leading to development of generalized muscle weakness. To the authors' knowledge this is the first narrative review that discusses causes and conditions associated with proximal myopathy in thorough detail.

Production of Coenzyme Q10 by microbes: an update

Coenzyme Q₁₀ (CoQ₁₀) is the main CoQ species in human and is used extensively in food, cosmetic and medicine industries because of its antioxidant properties and its benefit in prophylactic medicine and therapy for a variety of diseases. Among various approaches to increase the production of CoQ₁₀, microbial fermentation is the most effective. As knowledge of the biosynthetic enzymes and regulatory mechanisms modulating CoQ₁₀ production increases, opportunities arise for metabolic engineering of CoQ₁₀ in microbial hosts. In this review, we present various strategies used up to date to improve CoQ₁₀ production and focus on metabolic engineering of CoQ₁₀ overproduction in microbes. General strategies of metabolic engineering include providing sufficient precursors for CoQ₁₀, increasing metabolic fluxes, and expanding storage capacity for CoQ₁₀. Based on these strategies, CoQ₁₀ production has been significantly improved in natural CoQ₁₀ producers, as well as in heterologous hosts.

Mitochondrial Dysfunction and Cardiovascular Disease: Pathophysiology and Emerging Therapies

Mitochondria ensure the supply of cellular energy through the production of ATP via oxidative phosphorylation. The alteration of this process, called mitochondrial dysfunction, leads to a reduction in ATP and an increase in the production of reactive oxygen species (ROS). Mitochondrial dysfunction can be caused by mitochondrial/nuclear DNA mutations, or it can be secondary to pathological conditions such as cardiovascular disease, aging, and environmental stress. The use of therapies aimed at the prevention/correction of mitochondrial dysfunction, in the context of the specific treatment of cardiovascular diseases, is a topic of growing interest. In this context, the data are conflicting since preclinical studies are numerous, but there are no large randomized studies.

SAMSON and the Nocebo Effect: Management of Statin Intolerance

PURPOSE OF REVIEW

Statins are essential medications in the treatment of atherosclerotic cardiovascular disease; however, remain widely underutilized in large part due to concerns regarding adverse side effects. We describe the role of the nocebo effect in the perception of statin intolerance and provide management recommendations utilizing both statin and non-statin lipid-lowering therapies.

RECENT FINDINGS

The recent Self-Assessment Method for Statin side-effects Or Nocebo (SAMSON) trial demonstrated that 90% of adverse symptoms related to statins were also elicited by placebo, a powerful demonstration of the nocebo effect. Importantly, 50% of the study patients were able to successfully reinitiate statin therapy. Statin intolerance is common and can often be managed with expectation setting and adjustment of doses and/or dosing regimens. In those who remain unable to tolerate statins, numerous alternative lipid-lowering therapies exist with strong safety and efficacy profiles.

Coenzyme Q10 supplementation for the treatment of statin-associated muscle symptoms

Aim: To determine the association of coenzyme Q10 (CoQ10) use with the resolution of statin-associated muscle symptoms (SAMS). Patients & methods: Retrospective analysis of a large, multicenter survey study of SAMS (total n = 511; n = 64 CoQ10 users). Univariate and multivariate logistic regression models assessed the association between CoQ10 use and the resolution of SAMS. Results: The frequency of SAMS resolution was similar between CoQ10 users and non-users (25% vs 31%, respectively; unadjusted odds ratio [OR]: 0.75 [95% CI: 0.41-1.38]; p = 0.357). Similarly, CoQ10 use was not significantly associated with the resolution of SAMS in multivariable models adjusted for SAMS risk factors (OR: 0.84 [95% CI: 0.45-1.55]; p = 0.568) or adjusted for significant differences among CoQ10 users and non-users (OR: 0.82 [95% CI: 0.45-1.51]; p = 0.522). Conclusion: CoQ10 was not significantly associated with the resolution of SAMS.

The Use of Medications and Dietary Supplements by Masters Athletes - a Review

PURPOSE OF REVIEW

Masters athletes (MA) are generally considered healthier than their sedentary peers. However, the prevalence of chronic conditions in any population increases with age. Treatments involve pharmacological and non-pharmacological interventions. A substantial proportion of the general population also use dietary supplements (DS). This raises questions about the potential for drug-nutrient interactions which may lead to adverse effects. We sought to determine the potential for drug-nutrient interactions MA may be exposed to by examining the prevalence of chronic conditions treated with medications and their DS use.

RECENT FINDINGS

Common conditions in MA include hypertension, hyperlipidemia, asthma, osteoarthritis, depression and anxiety. Treatments may involve prescribed medications. Few recent studies were identified on DS use; however, indications are for around 60% prevalence of supplement usage. The higher prevalence of DS use by MA may result in drug-nutrient interactions that impact the effectiveness and safety of prescribed medications for chronic conditions.

Heart Failure—Do We Need New Drugs or Have Them Already? A Case of Coenzyme Q10

Heart failure (HF) is a global epidemic that contributes to the deterioration of quality of life and its shortening in 1–3% of adult people in the world. Pharmacotherapy of HF should rely on highly effective drugs that improve prognosis and prolong life. Currently, the ESC guidelines from 2021 indicate that ACEI, ARNI, BB, and SGLT2 inhibitors are the first-line drugs in HF. It is also worth remembering that the use of coenzyme Q10 brought many benefits in patients with HF. Coenzyme Q10 is a very important compound that performs many functions in the human body. The most important function of coenzyme Q10 is participation in the production of energy in the mitochondria, which determines the proper functioning of all cells, tissues, and organs. The highest concentration of coenzyme Q10 is found in the tissue of the heart muscle. As the body ages, the concentration of coenzyme Q10 in the tissue of the heart muscle decreases, which makes it more susceptible to damage by free radicals. It has been shown that in patients with HF, the aggravation of disease symptoms is inversely related to the concentration of coenzyme Q10. Importantly, the concentration of coenzyme Q10 in patients with HF was an important predictor of the risk of death. Long-term coenzyme Q10 supplementation at a dose of 300 mg/day (Q-SYMBIO study) has been shown to significantly improve heart function and prognosis in patients with HF. This article summarizes the latest and most important data on CoQ10 in pathogenesis.

Drug-Drug Interaction of the Sodium Glucose Co-Transporter 2 Inhibitors with Statins and Myopathy: A Disproportionality Analysis Using Adverse Events Reporting Data

INTRODUCTION

An increased risk of myopathy due to a potential interaction between sodium glucose co-transporter-2 inhibitors (SGLT-2i) and HMG-CoA reductase inhibitors (statins) has been suggested by case reports.

OBJECTIVE

We aimed to assess if the reporting of myopathy is disproportionally higher among people using both SGLT-2i and statins compared to using either SGLT-2i or statins alone.

METHODS

We conducted a disproportionality analysis using data from the US Food and Drug Administration Adverse Event Reporting System (FAERS). We included reports with at least one antihyperglycemic agent. We compared the proportion of myopathy cases to non-cases between those not using SGLT-2i or statins, using SGLT-2i only, statins only, or both. We calculated the reporting odds ratio and 95% confidence interval. We further stratified by individual SGLT-2i and selected statins (rosuvastatin or atorvastatin).

RESULTS

We included 688,388 reports with at least one antihyperglycemic agent recorded, of which 9.80% had at least one SGLT-2i agent. Among all included reports, there were a total of 2202 myopathy cases with the majority, 61.26%, occurring among those using statins alone and only 2.72% of myopathy cases were among those using both SGLT-2i and statins together. Reporting of myopathy was not disproportionally higher among those reporting the use of SGLT-2i with statins (reporting odds ratio 2.95, 95% confidence interval 2.27-3.85) compared to statins alone (reporting odds ratio 6.41, 95% confidence interval 5.86-7.02).

CONCLUSIONS

Reports of myopathy were not disproportionally higher among those using SGLT-2i with statins compared to SGLT-2i or statins alone at the class level. Further observational studies may be needed to better assess this interaction at the agent level.

Molecular targets of statins and their potential side effects: Not all the glitter is gold

Statins are a class of drugs widely used worldwide to manage hypercholesterolemia and the prevention of secondary heart attacks. Currently, available statins vary in terms of their pharmacokinetic and pharmacodynamic profiles. Although the primary target of statins is the inhibition of HMG-CoA reductase (HMGR), the rate-limiting enzyme in cholesterol biosynthesis, statins exhibit many pleiotropic effects downstream of the mevalonate pathway. These pleiotropic effects include the ability to reduce myocardial fibrosis, pathologic cardiac disease states, hypertension, promote bone differentiation, anti-inflammatory, and antitumor effects through multiple mechanisms. Although these pleiotropic effects of statins may be a cause for enthusiasm, there are many adverse effects that, for the most part, are unappreciated and need to be highlighted. These adverse effects include myopathy, new-onset type 2 diabetes, renal and hepatic dysfunction. Although these adverse effects may be relatively uncommon, considering the number of people worldwide who use statins daily, the actual number of people affected becomes quite large. Also, co-administration of statins with several other medications, herbal agents, and foods, which interact through common enzymatic pathways, can have untoward clinical consequences. In this review, we address these concerns.

The Single-dose Absorption and Steady-state Bioavailability of Different Coenzyme Q10 Formulations

Context

The results for the absorption and bioavailability of different product formulations of Coenzyme Q10 (CoQ10) that are found in the literature are highly variable and confusing to CoQ10 researchers and consumers.

Objective

The study intended to measure and compare the single-dose absorption and steady-state bioavailability of three types of Crystal Free (CF) CoQ10 formulations-CF CoQ10, crystalline CQ10, and dry-powder CoQ10.

Design

The researcher designed a randomized double-blind laboratory study for the three formulations that was conducted by the same laboratory and investigators and used the same protocol, the same analytical laboratory, and the same methods of analysis.

Participants

Participants were matched groups of normal males and females.

Outcome Measures

Single-dose absorption and steady-state bioavailability was determined for nine CoQ10 formulations: (1) three formulations of CF CoQ10 in lipid-based softgels, (2) three formulations of crystalline CoQ10 in lipid-based softgels, and (3) three formulations of dry-powder CoQ10 in two-piece, hard gelatin capsules. Plasma profiles were constructed and used to calculate the plasma level at Cmax and the percentage of the dose. From the steady-state bioavailability profiles, the plasma concentrations and the area under the curve (AUC) were determined. From that data, the relationship between the single-dose absorption and the steady-state bioavailability was derived using a linear regression analysis.

Results

The single-dose absorption was significantly greater for the CF group compared to that for the crystalline and dry-powder groups (P ≤ .001). The absorption and bioavailability of the crystalline group was significantly greater than that for the dry-powder group (P ≤ .001). For the CF group, the Δ Cmax was 1.83 ± 0.58 ug/ml, the % absorption was 7.03 ± 2.03, the steady-state CoQ10 level was 3.28 ±0.92 ug/ml, and the AUC was 32.80 ± 10.05 ug/ml x days. For the crystalline group, the Δ Cmax was 1.40 ±0.24, the % absorption 3.08 ± 0.53, the steady-state plasma level was 2.50 ± 0.54 ug/ml, and the AUC was 7.55 ± 1.87 ug/ml x days. For the dry powder group, the Δ Cmax was 0.33 ± 0.05 ug/ml, the % absorption was 1.28 ± 0.96 %, the steady-state plasma CoQ10 level was 1.55 ± 0.43 ug/ml, and the AUC was 5.34 ± 1.10 ug/ml x days. The CF formulation's absorption and bioavailability were superior to that of the crystalline and the dry powder formulations. The relationship between the single-dose absorption and the steady-state bioavailability was described by the linear equation y = 1.26 x 1.60.

Conclusions

The CF formulation was superior in absorption and steady-state bioavailability compared to the crystalline and dry powder formulations. The linear relationship between the single-dose absorption and the steady-state bioavailability gives an estimate of the steady-state bioavailability in a 24-hour study compared to a longer and more expensive 30-day study.

How Well Do Current Laboratory Biomarkers Inform Clinical Decision-Making in Chronic Pain Management?

OBJECTIVE

Decision-making in chronic pain patients involves a combination of subjective and objective criteria, including patient history, physical examination, imaging, and patient response to prior treatments, clinical experience, probabilities, and recognition of patterns. However, there is a distinct lack of objective laboratory biomarkers in use in routine clinical care. The objective was to review the literature to identify and describe specific biomarkers in chronic pain management.

METHODS

This is a narrative review of the literature regarding the use of laboratory biomarkers in chronic pain. A librarian-assisted literature search of the PubMed, Science Direct, and Google Scholar databases was performed and resulted in 304 possible manuscripts. We included manuscripts assessing laboratory collected biomarkers from urine, serum, cerebrospinal fluid, and saliva. After screening and review of the initial literature search results, a total of 75 manuscripts were included in the narrative review.

CONCLUSION

The studies reviewed suggested that specific biomarkers may help identify those patients at risk of disease development and function as a prognostic indicator for disease progression and treatment response. However, additional research is necessary before specific recommendations can be made, and current clinical decision-making is modified.

Statin-Associated Myopathy: Emphasis on Mechanisms and Targeted Therapy

Hyperlipidemia is a major risk factor for cardiovascular morbidity and mortality. Statins are the first-choice therapy for dyslipidemias and are considered the cornerstone of atherosclerotic cardiovascular disease (ASCVD) in both primary and secondary prevention. Despite the statin-therapy-mediated positive effects on cardiovascular events, patient compliance is often poor. Statin-associated muscle symptoms (SAMS) are the most common side effect associated with treatment discontinuation. SAMS, which range from mild-to-moderate muscle pain, weakness, or fatigue to potentially life-threatening rhabdomyolysis, are reported by 10% to 25% of patients receiving statin therapy. There are many risk factors associated with patient features and hypolipidemic agents that seem to increase the risk of developing SAMS. Due to the lack of a "gold standard", the diagnostic test for SAMS is based on a clinical criteria score, which is independent of creatine kinase (CK) elevation. Mechanisms that underlie the pathogenesis of SAMS remain almost unclear, though a high number of risk factors may increase the probability of myotoxicity induced by statin therapy. Some of these, related to pharmacokinetic properties of statins and to concomitant therapies or patient characteristics, may affect statin bioavailability and increase vulnerability to high-dose statins.

Do medicines commonly used by older adults impact their nutrient status?

Background

Chronic health conditions and polypharmacy are common among the older population and associated with increased risks of adverse events, medicine-interactions, geriatric syndromes, falls and mortality. Poor nutrition is also common in older people. Causal associations between medication use and older people's nutrient status is seldom discussed.

Objectives

The objectives of this review were to summarise the literature reporting associations between medicines commonly prescribed to older adults and nutrient deficiencies, and to discuss the clinical implications and management.

Methods

Medicine information resources (n = 5) were searched for information about nutrient deficiencies associated with common medicines used by older people and listed within the top 50 medicines prescribed by volume on the Australian Pharmaceutical Benefits Scheme. This was followed by a search for clinical studies published on PubMed from inception to April 2020. Data was extracted, tabulated and summarised with clinical information relevant to pharmacists and clinicians involved in the care of older people taking medicines.

Results

A total of 23 clinical studies were identified reporting medicine-induced nutrient deficiencies in older adults. Vitamin B12, sodium, magnesium were identified as the 3 main nutrients susceptible to deficiency by medicines used to treat cardiovascular disease, neurological conditions, gastrointestinal conditions, and diabetes. The coenzyme CoQ10 was depleted by statins.

Conclusion: Certain medicines commonly prescribed to older adults are associated with nutrient deficiencies that may be clinically significant. Given the high prevalence of comorbidities and polypharmacy it is possible that some of these individual drug-induced nutrient deficiencies are compounded, warranting both clinical and research attention.

Identification of drugs associated with reduced severity of COVID-19 - a case-control study in a large population

Background

Until coronavirus disease 2019 (COVID-19) drugs specifically developed to treat COVID-19 become more widely accessible, it is crucial to identify whether existing medications have a protective effect against severe disease. Toward this objective, we conducted a large population study in Clalit Health Services (CHS), the largest healthcare provider in Israel, insuring over 4.7 million members.

Methods

Two case-control matched cohorts were assembled to assess which medications, acquired in the last month, decreased the risk of COVID-19 hospitalization. Case patients were adults aged 18 to 95 hospitalized for COVID-19. In the first cohort, five control patients, from the general population, were matched to each case (n=6202); in the second cohort, two non-hospitalized SARS-CoV-2 positive control patients were matched to each case (n=6919). The outcome measures for a medication were: odds ratio (OR) for hospitalization, 95% confidence interval (CI), and the p-value, using Fisher's exact test. False discovery rate was used to adjust for multiple testing.

Results

Medications associated with most significantly reduced odds for COVID-19 hospitalization include: ubiquinone (OR=0.185, 95% CI [0.058 to 0.458], p<0.001), ezetimibe (OR=0.488, 95% CI [0.377 to 0.622], p<0.001), rosuvastatin (OR=0.673, 95% CI [0.596 to 0.758], p<0.001), flecainide (OR=0.301, 95% CI [0.118 to 0.641], p<0.001), and vitamin D (OR=0.869, 95% CI [0.792 to 0.954], p<0.003). Remarkably, acquisition of artificial tears, eye care wipes, and several ophthalmological products were also associated with decreased risk for hospitalization.

Conclusions

Ubiquinone, ezetimibe, and rosuvastatin, all related to the cholesterol synthesis pathway were associated with reduced hospitalization risk. These findings point to a promising protective effect which should be further investigated in controlled, prospective studies.

Funding

This research was supported in part by the Intramural Research Program of the National Institutes of Health, NCI.

Altered cholesterol homeostasis in critical illness-induced muscle weakness: effect of exogenous 3-hydroxybutyrate

Background

Muscle weakness is a complication of critical illness which hampers recovery. In critically ill mice, supplementation with the ketone body 3-hydroxybutyrate has been shown to improve muscle force and to normalize illness-induced hypocholesterolemia. We hypothesized that altered cholesterol homeostasis is involved in development of critical illness-induced muscle weakness and that this pathway can be affected by 3-hydroxybutyrate.

Methods

In both human critically ill patients and septic mice, the association between circulating cholesterol concentrations and muscle weakness was assessed. In septic mice, the impact of 3-hydroxybutyrate supplementation on cholesterol homeostasis was evaluated with use of tracer technology and through analysis of markers of cholesterol metabolism and downstream pathways.

Results

Serum cholesterol concentrations were lower in weak than in non-weak critically ill patients, and in multivariable analysis adjusting for baseline risk factors, serum cholesterol was inversely correlated with weakness. In septic mice, plasma cholesterol correlated positively with muscle force. In septic mice, exogenous 3-hydroxybutyrate increased plasma cholesterol and altered cholesterol homeostasis, by normalization of plasma mevalonate and elevation of muscular, but not hepatic, expression of cholesterol synthesis genes. In septic mice, tracer technology revealed that 3-hydroxybutyrate was preferentially taken up by muscle and metabolized into cholesterol precursor mevalonate, rather than TCA metabolites. The 3-hydroxybutyrate protection against weakness was not related to ubiquinone or downstream myofiber mitochondrial function, whereas cholesterol content in myofibers was increased.

Conclusions

These findings point to a role for low cholesterol in critical illness-induced muscle weakness and to a protective mechanism-of-action for 3-hydroxybutyrate supplementation.

Supplementary Information

The online version contains supplementary material available at 10.1186/s13054-021-03688-1.

[Diagnostics and treatment of statin-associated muscle symptoms]

Statins are among the most frequently prescribed drugs in Germany. Their benefits in lowering cardiovascular risk are beyond dispute. Nevertheless, many patients complain of side effects from statin therapy, including statin-associated muscle symptoms (SAMS) in particular. Despite their relative frequency, it is difficult to objectively diagnose them, as the time until appearance of first symptoms, the nature of the complaints and the severity of muscle problems vary widely. This narrative review summarizes the causes of SAMS as well as new possibilities regarding their diagnosis and therapy.

Polypharmacy and Malnutrition Management of Elderly Perioperative Patients with Cancer: A Systematic Review

Malnutrition, which commonly occurs in perioperative patients with cancer, leads to decreased muscle mass, hypoalbuminemia, and edema, thereby increasing the patient's risk of various complications. Thus, the nutritional management of perioperative patients with cancer should be focused on to ensure that surgical treatment is safe and effective, postoperative complications are prevented, and mortality is reduced. Pathophysiological and drug-induced factors in elderly patients with cancer are associated with the risk of developing malnutrition. Pathophysiological factors include the effects of tumors, cachexia, and anorexia of aging. Metabolic changes, such as inflammation, excess catabolism, and anabolic resistance in patients with tumor-induced cancer alter the body's ability to use essential nutrients. Drug-induced factors include the side effects of anticancer drugs and polypharmacy. Drug-drug, drug-disease, drug-nutrient, and drug-food interactions can significantly affect the patient's nutritional status. Furthermore, malnutrition may affect pharmacokinetics and pharmacodynamics, potentiate drug effects, and cause side effects. This review outlines polypharmacy and malnutrition, the impact of malnutrition on drug efficacy, drug-nutrient and drug-food interactions, and intervention effects on polypharmacy or cancer cachexia in elderly perioperative patients with cancer.

A Rare Case of Statin-Induced Diplopia: An Often-Overlooked but Reported Side Effect

Statins are a class of medications indicated for atherosclerotic cardiovascular diseases and dyslipidemia. Ever since their introduction, various side effects have been reported with their use. Statin-induced myopathy is a well-established side effect of the medication, ranging in severity from mild myotoxicity to fatal rhabdomyolysis, with or without an increase in creatine kinase levels. Statin-induced diplopia, ptosis, or ophthalmoplegia are very rare, but they have been reported as adverse events in a handful of cases. These adverse events typically result from the progressive weakening of the external ocular musculature or the levator palpebrae superioris muscle. In this report, we present a rare case of statin-induced diplopia in a patient who had been on atorvastatin therapy for years. We believe this report will increase awareness among physicians about such an adverse event related to statins.