Statin holiday

An article written by Dr Edward Leatham, Consultant Cardiologist

Tags: Cholesterol, Coronary heart disease, LDL, NH1  search website using Tags to find related stories.

Statins are a cornerstone of modern cardiovascular health management, prescribed to millions of people worldwide to lower cholesterol and reduce the risk of heart attack and stroke. Yet, as with any medication, statins can cause side effects in some individuals, ranging from muscle cramps and joint pain (arthralgia) to other discomforts that may affect quality of life. If you’ve recently started statins or had your dosage increased, you might notice these symptoms becoming more pronounced. However, many of the symptoms associated with statin use can also occur at a time in life when people are becoming more health-conscious and might, for example, be increasing exercise or other activities linked to similar symptoms. Add in the “witch doctor effect”—the power of suggestion—and it’s no wonder why so many patients starting statins wonder whether the drug is causing side effects, and if so, whether these are likely to be harmful in the long term.

One possible strategy for managing these issues is taking a “statin holiday” or temporarily stopping the medication to evaluate whether your symptoms are linked to the statin. While this approach may not be suitable for everyone, it’s worth exploring under the guidance of a healthcare provider. In this article, we’ll discuss how to monitor symptoms systematically, how tools like a symptom diary can help, and what research says about strategies such as coenzyme Q10 supplementation and n-of-1 trials.

Understanding Statin Side Effects

Statins work by reducing cholesterol levels in the blood, primarily by inhibiting an enzyme involved in cholesterol production in the liver, which increases LDL receptor activity removing LDL from the blood. However, the same enzyme inhibition also occurs on other tissues including the pancreas and muscles, thus in some people statins can interfere with processes in muscle cells, potentially leading to:

• Muscle pain or cramps: A common side effect that can range from mild to debilitating.
• Arthralgia: Pain in one or more joints, which can be exacerbated by statins in some individuals.
• Fatigue or weakness: Some people report a general sense of reduced energy.
• Impaired glucose tolerance:
• Small changes in production of hormones such as testosterone in some people.

While these symptoms and effects may be concerning, it’s important to weigh the benefits of statins in preventing cardiovascular events against their potential downsides. If you’re experiencing significant discomfort or any of the listed potential side effects, a structured approach to identifying the cause and assessing solutions is crucial.

The Role of a “Statin Holiday”

A “statin holiday” involves temporarily discontinuing your statin medication—typically for four to six weeks—to observe whether your symptoms improve. This break can provide valuable insights into whether statins are the culprit or if other factors, such as unrelated medical conditions or lifestyle changes, are contributing to your symptoms.

However, it’s essential to discuss this approach with your healthcare provider before making any changes. Stopping statins abruptly without a plan may increase your cardiovascular risk, especially if you have a history of heart disease or other high-risk factors.

Using a Symptom Diary: Visualising Patterns with a Year-at-a-Glance Tool

A key component of evaluating statin-related symptoms is tracking them systematically. A symptom diary can help you visualise the severity and frequency of side effects over time. A “year-at-a-glance” dot plot is particularly useful. Here’s how it works:

1. Create a Calendar Grid: Print or draw a year-long calendar on one page, with each day represented by a small square or box.
2. Record Symptoms Daily: At the end of each day, evaluate the severity of your symptoms (e.g., muscle cramps, joint pain) and represent them with a dot. The larger the dot, the more severe the symptom.
3. Add Notes: Include brief notes about any significant changes, such as starting or stopping statins, altering the dose, or introducing supplements like coenzyme Q10.
4. An example can be downloaded here.

Over time, you’ll have a visual representation of your symptoms that can reveal patterns. For example:

• Do symptoms decrease during a statin holiday?
• Are they more pronounced after increasing the dosage?
• Do symptoms fluctuate independently of your statin use?

This dot plot not only helps you identify trends but also provides a clear and objective record to share with your healthcare provider.

The N-of-1 Trial: Personalising Your Experience

An N-of-1 trial is a scientific method tailored to the individual, where you act as both the subject and control. This approach is especially valuable for assessing side effects like those potentially caused by statins. Here’s how you can apply it:

1. Baseline Assessment: Begin by recording your symptoms for a few weeks while continuing your statin at the current dose.
2. Intervention Period: Take a statin holiday for four to six weeks (with your doctor’s approval) and continue recording symptoms.
3. Reintroduction Period: Restart the statin and monitor symptoms again, using the same recording method.

By comparing your dot plots during these phases, you can determine whether your symptoms align with statin use. This data-driven approach empowers you and your healthcare provider to make informed decisions about your treatment plan.

Exploring Coenzyme Q10 and Other Supplements

Coenzyme Q10 (CoQ10) is a naturally occurring compound in the body that plays a key role in energy production. Some researchers believe that statins may reduce CoQ10 levels, contributing to muscle-related side effects. While evidence is mixed, some patients report symptom relief with CoQ10 supplementation.

• How to Use CoQ10: If you’re considering CoQ10, consult your doctor about appropriate dosing, which typically ranges from 100 to 200 mg daily.
• Tracking Effects: Use your symptom diary to monitor changes after introducing CoQ10. Are muscle cramps or joint pain less severe? Does your overall energy improve?

Other potential supplements include vitamin D and magnesium, which may address muscle-related symptoms, especially if deficiencies are present. However, the benefits of these supplements are not universally proven, so it’s important to discuss them with your healthcare provider.

Balancing Benefits and Risks

While managing side effects is important, it’s equally crucial to consider the benefits of statins. These medications have been shown to:

• Reduce LDL (“bad”) cholesterol levels significantly.
• Lower the risk of heart attack and stroke by up to 30–40% in high-risk individuals.
• Stabilise plaque in the arteries, reducing the likelihood of rupture and clot formation.

If a statin holiday reveals that your symptoms are indeed linked to the medication, you and your doctor can explore alternatives, such as:

• Switching Statins: Some statins are less likely to cause muscle-related side effects.
• Lowering the Dose: A reduced dose may still offer cardiovascular protection with fewer side effects.
• Non-Statin Options: Medications like ezetimibe or PCSK9 inhibitors can lower cholesterol without affecting muscle cells.

A Collaborative Approach

Ultimately, managing statin side effects requires a partnership between you and your healthcare provider. By using tools like a symptom diary and considering strategies like a statin holiday or supplements, you can take an active role in your treatment while minimising discomfort.

Remember, the goal is not just to alleviate side effects but to maintain the long-term health of your heart and blood vessels. By approaching the issue systematically and thoughtfully, you can find a balance that works for you.

Key messages

1. When it comes to coronary heart disease, LDL Cholesterol is considered to be the main determinant of the build up in coronary plaque that occurs in about 50% of our population by the age of 60. Coronary plaque is the first of  four processes that lead to a heart attack, each featured in stories over the next few months.
2. If you have raised LDL, dietary changes alone are unlikely to lower LDL sufficiently to prevent the build up of coronary plaque, causing atherosclerosis, therefore a statin is likely to be prescribed.
3. Each human is unique, so no one can predict who will develop side effects. In general, most patients do not notice any side effects, a very small proportion have serious side effects and perhaps 10% notice ‘something’, but cannot be sure the effect is statin-related.  This is where a ‘statin holiday’ may be a good idea.
4. Use a diary or visual chart to track whether the statin holiday or supplement help the potential side effects.
5. Once you have completed your trial, discuss your N-of-1-trial with your healthcare provider to decide on options. In some cases where cardiovascular risk is high, it may be best to accept minor and non-serious side effects in exchange for the immense benefits of treatment. In other low risk cases, it may be best to come off statins, switch to another form of LDL lowering drug or see what natural cardioprotective protective strategies you can adopt instead – such as increase exercise and or lower carbohydrate intake. .

For other stories related to cholesterol, coronary heart disease, and LDL, explore the archives by entering a tag under the search function above.

Other related articles♦

1. statin holiday GP notebook
2. Coenzyme Q10 Supplementation Decreases Statin-Related Mild-to-Moderate Muscle Symptoms: A Randomized Clinical Study
3. https://www.healthline.com/health/coq10-and-statins
4. Does curcumin reduce inflammation and possibly lower raised LP (a)?
5. Effects of Coenzyme Q10 on Statin‐Induced Myopathy: An Updated Meta‐Analysis of Randomized Controlled Trials 2018
6. LDL: the lower the better
7. Cholesterol measuring 2024 guidance 
8. Gain of function mutations in PCSK9 regulators
9. The latest ESC and locally developed guidelines on LDL targets

The Naked Heart is an educational project owned and operated by Dr Edward Leatham. It comprises a series of blog articles, videos and reels distributed on Tiktok, Youtube and Instagram  aimed to help educate both patients and healthcare professionals about cardiology related issues.

If you would like to receive email notification each week from the Naked Heart, follow me on social media or please feel free to subscribe to the Naked Heart email notifications here