statins have proven efficacy in reducing vascular disease , but statin - induced myalgia is relatively common in clinical practice , and can sometimes leave patients who are high risk for vascular disease unable to take these important preventative treatments . low or intermittent dose rosuvastatin has been shown to be useful in lowering cholesterol with fewer side - effects . a retrospective review of patients attending a tertiary referral lipid clinic with statin - induced myalgia was carried out . patients were counseled on commencing low - dose rosuvastatin , titrated at monthly intervals , and supplemented by co - enzyme q10 100 mg daily . total and ldl - cholesterol levels fell by a mean of 29.1% and 27.5% , respectively . in this retrospective review of clinical practice ,  low and slow  rosuvastatin supplemented by co - enzyme q10 led to clinically meaningful reductions in total and ldl - cholesterol in patients with statin - induced myalgia . their principal effect is to reduce serum low - density lipoprotein - cholesterol ( ldl - c ) through inhibition of cholesterol synthesis and increased hepatic low - density lipoprotein receptor activity . adverse effects of statins are usually mild , but can be problematic in a small proportion of patients . around 5 - 10% of patients report muscle symptoms whilst taking statins , although only around 1 - 3% of patients actually have muscle symptoms related to statins . several mechanisms for statin - associated muscle symptoms have been suggested , including mitochondrial dysfunction secondary to impaired endogenous synthesis of co - enzyme q10 ( also called ubiquinone ) . oral supplementation of co - enzyme q10 has been shown to be a safe intervention and can reverse the decline in plasma levels of the co - enzyme q10 seen with statin use . there is some suggestion that rosuvastatin may cause less myalgia compared to other statins by virtue of its hydrophilic nature . use of low or infrequent dose rosuvastatin in patients with statin - induced myalgia has been shown to be effective in lowering ldl - c levels and in improving tolerability . the aim of this study was to retrospectively review the effect of slowly titrated low - dose rosuvastatin , in addition to co - enzyme q10 supplementation , in patients with statin - induced myalgia referred to a single center tertiary referral lipid clinic . all patients referred to a lipid clinic with symptoms of statin - induced myalgia were included in the study . we defined statin - induced myalgia as per the national institute of health and clinical excellence ( nice ) guidelines , as any patient in whom statin therapy was deemed appropriate , but who was unable to tolerate the statin due to myalgic symptoms . patients were only defined as statin - intolerant if they had tried at least three different statins and developed myalgic symptoms with each . if tolerated , the dose was increased to twice weekly , for 4 weeks , and then titrated incrementally until the patient was on the maximum tolerated dose , to a maximum of 5 mg daily initially . if side - effects developed , patients were advised to go back one step . in addition , patients were asked to take co - enzyme q10 supplements at a dose of 100 mg daily starting at least 1 week before the first rosuvastatin tablet . patients were seen at 12 weekly intervals for at least a year , with fasting lipid profiles , creatine kinase , and liver biochemistry checked prior to each visit , and rosuvastatin dose was titrated according to total cholesterol target ( 5.0 mmol / l or 193 mg / dl in most , 4.0 mmol / l or 155 mg / dl in patients with diabetes or known ischemic heart disease ) . data was analyzed for adverse effects , discontinuation rates , and changes in lipid profiles . six discontinued therapy , all within the first 12 weeks of commencement of therapy , 5 due to recurrence of severe myalgic symptoms and 1 because of an increase in liver transaminases . iu / l ) were seen in any patients on this regime , including the patients with the severe myalgic symptoms . of the remaining 37 patients , the maximum tolerated rosuvastatin dose ranged from 5 mg every week to 20 mg daily . the mean reduction in total cholesterol was 29.1% , and in ldl - c was 27.5% . of these 37 patients , all achieved a total cholesterol of 7.0 mmol / l ( 271 mg / dl ) or less , 23 ( 62.2% ) achieved a total cholesterol of 5.0 mmol / l ( 193 mg / dl ) or less , and 16 ( 43.2% ) achieved a total cholesterol of 4.0 mmol / l ( 155 mg / dl ) or less . eight patients discontinued the co - enzyme q10 therapy , but continued rosuvastatin , without side - effects . we describe a small , single - center retrospective case series of patients with statin - induced myalgia treated with a low - dose , slowly titrated regime of rosuvastatin supplemented by co - enzyme q10 . within the limitations of the study , it is reasonable to suggest that this method of dealing with statin - induced myalgia may be clinically effective and worth a trial in patients who are genuinely statin - intolerant . some patients may develop mild myalgia with statin therapy , but are willing to continue therapy due to significant cardiovascular benefits . many patients , however , have to stop therapy due to adverse effects , and management can prove a significant therapeutic challenge . co - enzyme q10 has been suggested as having a possible role in the development of statin - induced myalgia . inhibition of hmg - coa reductase results in reduced synthesis of cholesterol and other products downstream of mevalonate . mevalonate itself is a precursor for co - enzyme q10 , and one postulated mechanism for statin - induced myalgia is through mitochondrial dysfunction , secondary to the depletion of co - enzyme q10 . low - dose potent statin therapy has been suggested as a useful method of obviating statin - induced myalgia . use of rosuvastatin 2.5 to 20 mg once a week has been shown to decrease ldl cholesterol by 25% and be tolerated by up to 70% of statin - intolerant patients . twice - weekly or alternate - day regimens of rosuvastatin or atorvastatin alone or in combination with ezetimibe have also been well tolerated in patients with statin - induced myalgia . one randomized trial has shown that use of extended release fluvastatin 80 mg daily in patients with statin intolerance may be effective in reducing myalgic symptoms . on the basis of our retrospective data of real clinical practice , and in the absence of hard outcomes data from randomized trials , we propose that a strategy of  low and slow rosuvastatin combined with co - enzyme q10 can lead to clinically meaningful reductions in serum cholesterol in patients previously affected by statin - induced myalgia . a randomized controlled trial of this regime is required to be undertaken to determine whether these results can be confirmed in the context of a clinical trial .
background : statins have proven efficacy in reducing vascular disease , but statin - induced myalgia is relatively common in clinical practice , and can sometimes leave patients who are high risk for vascular disease unable to take these important preventative treatments . 
 low or intermittent dose rosuvastatin has been shown to be useful in lowering cholesterol with fewer side - effects . 
 supplementation with co - enzyme q10 is suggested to reduce statin - induced myalgia.materials and methods : a retrospective review of patients attending a tertiary referral lipid clinic with statin - induced myalgia was carried out . 
 patients were counseled on commencing low - dose rosuvastatin , titrated at monthly intervals , and supplemented by co - enzyme q10 100 mg daily.results:forty three patients were reviewed . 
 six were unable to tolerate the regime at all . 
 the remaining 37 patients tolerated rosuvastatin between 5 mg weekly and 20 mg daily . 
 total and ldl - cholesterol levels fell by a mean of 29.1% and 27.5% , respectively . 
 62.2% of patients achieved total cholesterol under 5.0 mmol / l.conclusions : in this retrospective review of clinical practice ,  low and slow  rosuvastatin supplemented by co - enzyme q10 led to clinically meaningful reductions in total and ldl - cholesterol in patients with statin - induced myalgia .