Ezetimibe-SimvastatinSkip to the navigation
Common brand names:Vytorin
Summary of Interactions with Vitamins, Herbs, & Foods
Replenish Depleted Nutrients
In a group of patients beginning treatment with atorvastatin (a drug similar to simvastatin), the average concentration of coenzyme Q10 in blood plasma decreased within 14 days, and had fallen by approximately 50% after 30 days of treatment.1 In a preliminary study, supplementation with 100 mg of CoQ10 per day reduced the severity of muscle pain by 40% in people with muscle pain caused by a statin drug.2 A double-blind trial also found that CoQ10 (200 mg per day) significantly decreased drug-induced muscle symptoms in people taking statin drugs.3
However, in another double-blind trial, CoQ10 in the amount of 60 mg twice a day for one month was not more effective than a placebo for relieving muscle pain.4 Although the evidence is conflicting regarding whether supplementing with CoQ10 relieves statin-induced muscle symptoms, many doctors recommend CoQ10 supplementation to prevent the drug-induced decline in CoQ10 levels.
Reduce Side Effects
In a group of patients beginning treatment with atorvastatin (a drug similar to simvastatin), the average concentration of coenzyme Q10 in blood plasma decreased within 14 days, and had fallen by approximately 50% after 30 days of treatment.5 In a preliminary study, supplementation with 100 mg of CoQ10 per day reduced the severity of muscle pain by 40% in people with muscle pain caused by a statin drug.6 A double-blind trial also found that CoQ10 (200 mg per day) significantly decreased drug-induced muscle symptoms in people taking statin drugs.7
However, in another double-blind trial, CoQ10 in the amount of 60 mg twice a day for one month was not more effective than a placebo for relieving muscle pain.8 Although the evidence is conflicting regarding whether supplementing with CoQ10 relieves statin-induced muscle symptoms, many doctors recommend CoQ10 supplementation to prevent the drug-induced decline in CoQ10 levels.
In a preliminary study, ten patients who had to discontinue statin drugs because of muscle-related side effects were given creatine (as creatine monohydrate) in the amount of 5 grams twice a day for five days, then 5 grams per day. Eight of the ten patients experienced no muscle symptoms upon resuming the statin drug.9
In a preliminary trial, supplementation with vitamin D appeared to prevent muscle-related side effects in patients taking statin drugs.10 The amount of vitamin D used in this study was very large (up to 50,000 IU twice a week) and potentially toxic. People taking statin drugs should consult with their doctor regarding how much vitamin D can be taken.
In a preliminary trial, taking an HMG-CoA reductase inhibitor (“statin”) for about three years significantly lowered triglyceride levels and raised levels of HDL (“good”) cholesterol in people with high cholesterol who had also been supplementing with either 900 mg or 1,800 mg of EPA for three months.11 The authors of the study concluded that the combination of the statin and EPA may prevent coronary heart disease better than the drug alone. Since drugs in the statin family have similar mechanisms of action, people taking any statin drug may benefit from fish oil.
In one study, supplementation with 15 grams of psyllium per day for eight weeks enhanced the cholesterol-lowering effect of simvastatin.12
St. John’s Wort
In patients taking simvastatin, treatment with St. John's wort increased serum cholesterol levels, apparently because St. John's wort interfered with the effect of the medication.16
Potential Negative Interaction
Grapefruit contains substances that may inhibit the body’s ability to break down simvastatin; consuming grapefruit or grapefruit juice might therefore increase the potential toxicity of the drug. In a study of healthy volunteers, ingesting 200 ml of grapefruit juice along with simvastatin increased blood levels of the drug, compared with taking simvastatin with water.17 There is one case report of a woman developing severe muscle damage from simvastatin after she began eating one grapefruit per day.18 Although there have been no reports of a grapefruit–simvastatin interaction, to be on the safe side, people taking simvastatin should not eat grapefruit or drink grapefruit juice.
In another study, daily supplementation with a combination of antioxidants (800 IU of vitamin E, 1,000 mg of vitamin C, 25 mg of beta-carotene, and 100 mcg of selenium) blocked the beneficial effect of simvastatin-plus-niacin on HDL cholesterol levels. 19 Although there is evidence that some or all of these nutrients may help prevent heart disease, individuals taking simvastatin who wish to take antioxidants should discuss the use of these supplements with their doctor.The interaction is supported by preliminary, weak, fragmentary, and/or contradictory scientific evidence.
Pomegranate juice has been shown to inhibit the same enzyme that is inhibited by grapefruit juice.20 , 21 The degree of inhibition is about the same for each of these juices. Therefore, it would be reasonable to expect that pomegranate juice might interact with simvastatin in the same way that grapefruit juice does.The interaction is supported by preliminary, weak, fragmentary, and/or contradictory scientific evidence.
Red Yeast Rice
A supplement containing red yeast rice (Cholestin) has been shown to effectively lower cholesterol and triglycerides in people with moderately elevated levels of these blood lipids.22 This extract contains small amounts of naturally occurring HMG-CoA reductase inhibitors such as lovastatin and should not be used if you are currently taking a statin medication.The interaction is supported by preliminary, weak, fragmentary, and/or contradictory scientific evidence.
Vitamin B3 (Niacin)
Niacin is the form of vitamin B3 used to lower cholesterol. Taking large amounts of niacin along with HMG-CoA reductase inhibitors may cause muscle disorders (myopathy) that can become serious (rhabdomyolysis).23 , 24 Such problems appear to be uncommon.25 , 26 Moreover, concurrent use of niacin has been reported to enhance the cholesterol-lowering effect of HMG-CoA reductase inhibitors.27 , 28 Individuals taking simvastatin should consult a doctor before taking niacin.
A study of 37 people with high cholesterol treated with diet and HMG-CoA reductase inhibitors found blood vitamin A levels increased over two years of therapy.29 Until more is known, people taking HMG-CoA reductase inhibitors, including simvastatin, should have blood levels of vitamin A monitored if they intend to supplement vitamin A.
In a study of seven patients with hypercholesterolemia, eight weeks of simvastatin plus vitamin E 300 IU improved markers of blood vessel elasticity more than simvastatin alone.30
1. Rundek T, Naini A, Sacco R, et al. Atorvastatin decreases the coenzyme Q10 level in the blood of patients at risk for cardiovascular disease and stroke. Arch Neurol 2004;61:889-92.
2. Caso G, Kelly P, McNurlan MA, Lawson WE. Effect of coenzyme Q10 on myopathic symptoms in patients treated with statins. Am J Cardiol 2007;99:1409-12.
3. Fedacko J, Pella D, Fedackova P, et al. Coenzyme Q10 and selenium in statin-associated myopathy treatment. Can J Physiol Pharmacol2013;91:165–70.
4. Bookstaver DA, Burkhalter NA, Hatzigeorgiou C. Effect of coenzyme Q10 supplementation on statin-induced myalgias. Am J Cardiol 2012;110:526-9.
5. Rundek T, Naini A, Sacco R, et al. Atorvastatin decreases the coenzyme Q10 level in the blood of patients at risk for cardiovascular disease and stroke. Arch Neurol 2004;61:889-92.
6. Caso G, Kelly P, McNurlan MA, Lawson WE. Effect of coenzyme Q10 on myopathic symptoms in patients treated with statins. Am J Cardiol 2007;99:1409-12.
7. Fedacko J, Pella D, Fedackova P, et al. Coenzyme Q10 and selenium in statin-associated myopathy treatment. Can J Physiol Pharmacol2013;91:165–70.
8. Bookstaver DA, Burkhalter NA, Hatzigeorgiou C. Effect of coenzyme Q10 supplementation on statin-induced myalgias. Am J Cardiol 2012;110:526-9.
9. Shewmon DA, Craig JM. Creatine supplementation prevents statin-induced muscle toxicity. Ann Intern Med 2010;153:690-2.
10. Glueck CJ, Budhani SB, Masineni SS, et al. Vitamin D deficiency, myositis-myalgia, and reversible statin intolerance. Curr Med Res Opin 2011;27:1683-90.
11. Nakamura N, Hamazaki T, Ohta M, et al. Joint effects of HMG-CoA reductase inhibitors and eicosapentaenoic acids on serum lipid profile and plasma fatty acid concentrations in patients with hyperlipidemia. Int J Clin Lab Res 1999;29:22-5.
12. Moreyra AE, Wilson AC, Koraym A. Effect of combining psyllium fiber with simvastatin in lowering cholesterol. Arch Intern Med 2005;165:1161-6.
13. Hallikainen MA, Uusitupa MI. Effects of 2 low-fat stanol ester-containing margarines on serum cholesterol concentrations as part of a low-fat diet in hypercholesterolemic subjects. Am J Clin Nutr 1999;69:403-10.
14. Law M. Plant sterol and stanol margarines and health. BMJ 2000;320:861-4.
15. Goldberg AC, Ostlund RE Jr, Bateman JH, et al. Effect of plant stanol tablets on low-density lipoprotein cholesterol lowering in patients on statin drugs. Am J Cardiol 2006;97:376-9.
16. Eggertsen R, Andreasson A, Andren L. Effects of treatment with a commercially available St John's Wort product (Movina) on cholesterol levels in patients with hypercholesterolemia treated with simvastatin. Scand J Prim Health Care 207;25:154-9.
17. Lilja JJ, Neuvonen M, Neuvonen PJ. Effects of regular consumption of grapefruit juice on the pharmacokinetics of simvastatin. Br J Clin Pharmacol 2004;58:56-60.
18. Dreier JP, Endres M. Statin-associated rhabdomyolysis triggered by grapefruit consumption. Neurology 2004;62:670 [Letter].
19. Cheung MC, Zhao XQ, Chait A, et al. Antioxidant supplements block the response of HDL to simvastatin-niacin therapy in patients with coronary artery disease and low HDL. Arterioscler Thromb Vasc Biol 2001;21:1320-6.
20. Sorokin AV, Duncan B, Panetta R, Thompson PD. Rhabdomyolysis associated with pomegranate juice consumption. Am J Cardiol 2006;98:705-6.
21. Summers KM. Potential drug-food interactions with pomegranate juice. Ann Pharmacother 2006;40:1472-3.
22. Heber D, Yip I, Ashley JM, et al. Cholesterol-lowering effects of a proprietary Chinese red-yeast-rice dietary supplement. Am J Clin Nutr 1999;69:231-6.
23. Garnett WR. Interactions with hydroxymethylglutaryl-coenzyme A reductase inhibitors. Am J Health Syst Pharm 1995;52:1639-45.
24. Yee HS, Fong NT. Atorvastatin in the treatment of primary hypercholesterolemia and mixed dyslipidemias. Ann Pharmacother 1998;32:1030-43.
25. Jacobson TA, Amorosa LF. Combination therapy with fluvastatin and niacin in hypercholesterolemia: a preliminary report on safety. Am J Cardiol 1994;73:25D-9D.
26. Jokubaitis LA. Fluvastatin in combination with other lipid-lowering agents. Br J Clin Pract Suppl 1996;77A:28-32.
27. Davignon J, Roederer G, Montigny M, et al. Comparative efficacy and safety of pravastatin, Nicotinic acid and the two combined in patients with hypercholesterolemia. Am J Cardiol 1994;73:339-45.
28. Jacobson TA, Jokubaitis LA, Amorosa LF. Fluvastatin and niacin in hypercholesterolemia: a preliminary report on gender differences in efficacy. Am J Med 1994;96(suppl 6A):64S-8S.
29. Muggeo M, Zenti MG, Travia D, et al. Serum retinol levels throughout 2 years of cholesterol-lowering therapy. Metabolism 1995;44:398-403.
30. Neunteufl T, Kostner K, Katzenschlager R, et al. Additional benefit of vitamin E supplementation to simvastatin therapy on vasoreactivity of the brachial artery of hypercholesterolemic men. J Am Coll Cardiol 1998;32:711-6.
Last Review: 04-29-2014
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