In a group of patients beginning treatment with atorvastatin, 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 However, in a 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.3 Although there is no clear evidence that supplementing with CoQ10 relieves statin-induced muscle symptoms, many doctors recommend CoQ10 supplementation to prevent the drug-induced decline in CoQ10 levels.
A synthetic molecule related to beta-sitosterol, sitostanol, is available in a special margarine and has been shown to lower cholesterol levels. In one study, supplementing with 1.8 grams of sitostanol per day for six weeks enhanced the cholesterol-lowering effect of various statin drugs.6
Grapefruit contains substances that may inhibit the body’s ability to break down atorvastatin; consuming grapefruit or grapefruit juice might therefore increase the potential toxicity of the drug. There is one case report of a woman developing severe muscle damage from simvastatin (a drug similar to atorvastatin) after she began eating one grapefruit per day.8 Although there have been no reports of a grapefruit–atorvastatin interaction, to be on the safe side, people taking atorvastatin should not eat grapefruit or drink grapefruit juice.
A supplement containing red yeast rice (Monascus purpureas) (Cholestin) has been shown to effectively lower cholesterol and triglycerides in people with moderately elevated levels of these blood lipids.9 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.
Pomegranate juice has been shown to inhibit the same enzyme that is inhibited by grapefruit juice.10 , 11 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 atorvastatin in the same way that grapefruit juice does.
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.12 Until more is known, people taking HMG-CoA reductase inhibitors, including atorvastatin, should have blood levels of vitamin A monitored if they intend to supplement vitamin A.
Amlodipine has been shown to raise blood levels of DHEA-sulfate in insulin-resistant, obese men with high blood pressure.13
Ingestion of grapefruit juice has been shown to increase the absorption of felodipine (a drug similar in structure and action to that of amlodipine) and to increase the adverse effects of the medication in patients with hypertension. Until more is known, it seems that grapefruit juice should not be ingested by people taking amlodipine or similar drugs.14 The same effects might be seen from eating grapefruit as from drinking its juice.
A magnesium- and aluminum-containing antacid was reported to interfere with atorvastatin absorption.15 People can avoid this interaction by taking atorvastatin two hours before or after any aluminum/magnesium-containing antacids. Some magnesium supplements such as magnesium hydroxide are also antacids.
Niacin is the form of vitamin B3 used to lower cholesterol. Ingestion of large amounts of niacin along with lovastatin (a drug closely related to atorvastatin) or with atorvastatin itself may cause muscle disorders (myopathy) that can become serious (rhabdomyolysis).16 , 17 Such problems appear to be uncommon when HMG-CoA reductase inhibitors are combined with niacin.18 , 19 Moreover, concurrent use of niacin with HMG-CoA reductase inhibitors has been reported to enhance the cholesterol-lowering effect of the drugs.20 , 21 Individuals taking atorvastatin should consult their physician before taking niacin.
As pleurisy root and other plants in the Aesclepius genus contain cardiac glycosides, it is best to avoid use of pleurisy root with heart medications such as calcium channel blockers.22
Pomegranate juice has been shown to inhibit the same enzyme that is inhibited by grapefruit juice.23 , 24 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 amlodipine in the same way that grapefruit juice does.
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. Bookstaver DA, Burkhalter NA, Hatzigeorgiou C. Effect of coenzyme Q10 supplementation on statin-induced myalgias. Am J Cardiol 2012;110:526–9.
4. Shewmon DA, Craig JM. Creatine supplementation prevents statin-induced muscle toxicity. Ann Intern Med 2010;153:690–2.
5. 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.
6. 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.
7. Roby CA, Anderson GD, Kantor E, et al. St John's Wort: effect on CYP3A4 activity. Clin Pharmacol Ther 2000;67:451–7.
8. Dreier JP, Endres M. Statin-associated rhabdomyolysis triggered by grapefruit consumption. Neurology 2004;62:670 [Letter].
9. 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.
10. Sorokin AV, Duncan B, Panetta R, Thompson PD. Rhabdomyolysis associated with pomegranate juice consumption. Am J Cardiol 2006;98:705–6.
11. Summers KM. Potential drug-food interactions with pomegranate juice. Ann Pharmacother 2006;40:1472–3.
12. Muggeo M, Zenti MG, Travia D, et al. Serum retinol levels throughout 2 years of cholesterol-lowering therapy. Metabolism 1995;44:398–403.
13. Beer NA, Jakubowicz DJ, Beer RM, Nestler JE. The calcium channel blocker amlodipine raises serum dehydroepiandrosterone sulfate and androstenedione, but lowers serum cortisol, in insulin-resistant obese and hypertensive men. J Clin Endocrinol Metab 1993;76:1464–9.
14. Bailey DG, Arnold MO, Strong HA, Munoz C, Spence JD, et al. Effect of grapefruit juice and naringin on nisoldipine pharmacokinetics. Clin Pharmacol Ther 1993;54:589–94.
15. Threlkeld DS, ed. Diuretics and Cardiovasculars, Antihyperlipidemic Agents, HMG-CoA Reductase Inhibitors. In Facts and Comparisons Drug Information. St. Louis, MO: Facts and Comparisons, Sep 1998, 172a.
16. Garnett WR. Interactions with hydroxymethylglutaryl-coenzyme A reductase inhibitors. Am J Health Syst Pharm 1995;52:1639–45.
17. Yee HS, Fong NT. Atorvastatin in the treatment of primary hypercholesterolemia and mixed dyslipidemias. Ann Pharmacother 1998;32:1030–43.
18. Jacobson TA, Amorosa LF. Combination therapy with fluvastatin and niacin in hypercholesterolemia: a preliminary report on safety. Am J Cardiol 1994;73:25D–9D.
19. Jokubaitis LA. Fluvastatin in combination with other lipid-lowering agents. Br J Clin Pract Suppl 1996;77A:28–32.
20. 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.
21. Jacobson TA, Jokubaitis LA, Amorosa LF. Fluvistatin and niacin in hypercholesterolemia: a preliminary report on gender differences in efficacy. Am J Med 1994;96(suppl 6A):64S–8S.
22. Newall CA, Anderson LA, Phillipson JD. Herbal Medicines: A Guide for Health-Care Professionals. London: Pharmaceutical Press, 1996, 213–4.
23. Sorokin AV, Duncan B, Panetta R, Thompson PD. Rhabdomyolysis associated with pomegranate juice consumption. Am J Cardiol 2006;98:705–6.
24. Summers KM. Potential drug-food interactions with pomegranate juice. Ann Pharmacother 2006;40:1472–3.
Last Review: 05-01-2013
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