Role of vitamin d and statin induced muscle pain

by James Ketterer, PharmD

Statins are a class of drugs used to lower cholesterol and decrease the risk of cardiovascular events. They work by inhibiting an enzyme from completing an early step in the body’s process of synthesizing cholesterol. Statins are among the most commonly prescribed medications in the country. Approximately 1-2% of patients on statins report experiencing muscle pain. This pain can present itself in a variety of ways but most often results in flu-like aches and pains. The muscles may feel stiff or sore like the feeling after working out. This usually effects the larger muscles of the body such as parts of the back or thighs. This side effect is often responsible for patients discontinuing the use of these drugs.

Does Vitamin D Play a Role in Statin-induced Muscle Pain?

Do statins cause muscle pain? The exact cause of this phenomenon is not completely understood, but many researchers have hypothesized that vitamin D levels may play a role. Vitamin D is mainly produced in the skin from sun exposure. However, this source is not active. The liver and kidneys are responsible for activating the vitamin D which then plays a role in facilitating intestinal absorption of essential nutrients as well as balancing bone health homeostasis. Vitamin D deficiencies often present with similar muscle pain as those found as a side effect in statins.

Some researchers have theorized that statins could reduce vitamin D levels because certain types of cholesterol carry vitamin D and when the cholesterol is reduced, less vitamin D could be transported. On the other hand, many have theorized that since both vitamin D and statins are metabolized by the same enzyme in the liver, the use of statins could delay metabolism of vitamin D, thus increasing levels in the blood.

Muscle Pain in Clinical Trials

Clinical trials and various other studies and reports have yielded mixed results on muscle pain in statin users with low compared to high levels of vitamin D. A large analysis of these trials showed that more studies resulted in statin users having higher levels of vitamin D on average. One retrospective study divided statin users into 4 groups, 1 being the lowest vitamin D levels and 4 being the highest. Group 1 was 1.21 times more likely to develop muscle pain than group 4. Another study showed statin users with vitamin D levels of less than 15 ng/mL were 1.9 times more likely to experience muscle pain compared with non-statin users. The statin users with higher levels of vitamin D did not have higher risk for muscle pain compared with non-statin users.

When a patient experiences what is believed to be the side effect of a drug, they are often taken off of the drug to see if the symptoms resolve. If they do resolve, sometimes the patient is started back on the drug to see if the symptoms return. This a referred to as a “rechallenge”. One chart review showed that returning vitamin D levels to a sufficient level before a rechallenge in statin users who had experienced muscle pain, increased their tolerability to statins.

Do Vitamin D Supplements Help Reduce Statin-induced Muscle Pain?

Some studies have given vitamin D supplements to statin users experiencing muscle pain. While these studies were uncontrolled, they did show improvement in muscle pain in nearly 90% of patients.

These are just a few of the examples of research looking at the correlation between stain use and vitamin D levels as a possible cause of muscle pain. While nothing is definitive at this point, patients on statins that are experiencing muscle pain may want to explore vitamin D supplementation as a possible resolution plan. The benefits of statins are well documented in patients with heart risks. Any side effects should be attempted to be overcome before giving up on the statin and assuming it is the cause.

References:

Gregory, Philip J. ” Vitamin D and Statin-Related Myalgia”. Medscape. 2017. Web. 10 Mar. 2017.

Simvastatin.  Micromedex Solutions.  Truven Health Analytics, Inc. Ann Arbor, MI.  Available at: http://www.micromedexsolutions.com.  Accessed March 20, 2017.


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photo ScriptSave WellRx vitamin supplements

by Sandra Leal, PharmD, MPH, CDE, FAPhA

The US supplement industry is a $30 billion dollar business.1 The Council for Responsible Nutrition estimates that almost 70% of US adults use dietary supplements.2 Before I continue, I must state that I do not have any conflicts of interest and rest assured, although I am a pharmacist, I do not support ‘Big Pharma’ when it comes patients unnecessarily being prescribed medication.

Personally, I use caution when it comes to dietary supplements for one simple reason – they are not regulated like prescription medications. The FDA is the administration that regulates the approval and use of prescription medication. What this means is that on a prescription bottle labeled with a specific amount of ingredients, you can be certain that the actual amount in a given tablet, capsule, cream, suppository, solution, etc. is between about 95% and 105% of what the label actually states. As an example, if you are prescribed to take a tablet that is 100mg in strength, then you can be certain that the amount is between 95mg and 105mg of that medication.

On the contrary, dietary supplements are regulated by the Dietary Supplement Health and Education Act of 1994. Since they are not regulated like drugs, companies that manufacture and produce dietary supplements are able to put whatever claims they want on their bottles. It is possible and highly likely that what is stated on the supplement label is not what is in the actual tablet or capsule. In fact, the New York Attorney General and the Federal Trade Commission have recently filed suit against Prevagen for their claims of memory boosting.

Moreover, many weight loss dietary supplements contain botanicals and plant-derived ingredients that can cause and make health problems worse. Sometimes, these supplements can interact with prescription medicines that you are prescribed. St. John’s wort, in particular, can negatively interact with a number of medications, including Statins (Crestor, Simvastatin), Warfarin (Coumadin), and Tricyclic antidepressants, like Elavil or Pamelor.

I believe there are great health benefits and medicinal properties of nutraceuticals, however there is a great need for credible research and evidence before I would be comfortable recommending these products to my patients. Throughout my years of practice, I have found that many patients do not consider dietary supplements, OTC products, and vitamins as medications. I would recommend that the next time you have an appointment with your doctor, inform him/her of everything you take, even those that you purchase in a store or online, just to ensure that they are safe for you and do not interact with your prescription medications.

The next time you think of taking a supplement, remember that right now you have no way of knowing for sure what’s really in your supplement bottle. And despite the promising on the labels, the pills probably won’t make you any healthier (unless you have a medically diagnosed deficiency), and they might even be hurting you.

 

References:

  1. http://www.vox.com/2016/3/10/11179842/dietary-supplements-medical-evidence
  2. http://www.crnusa.org/CRNPR14-CRNCCSurvey103014.html
  3. http://annals.org/article.aspx?articleid=1789253
  4. http://www.iflscience.com/health-and-medicine/23000-people-us-end-er-annually-because-supplements

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Folic acid info for expectant mothers

The truth about folic acid

Folic acid supplementation has always been regarded as the key to natal wellness. However, recent studies have linked high levels of this vitamin to autism. So this may have you wondering what is a sufficient amount and where can I obtain it? First, you should be aware of the difference between folate and folic acid. Folate is the naturally occurring form of the vitamin which is found in foods such as dark leafy greens and legumes. On the other hand, folic acid is the synthetic form of the vitamin that you will find in over the counter supplements and fortified foods. There are many sources of folic acid which you may not have thought contained this pertinent vitamin (See Table 1). Depending on your diet, you may be able to obtain the daily requirements of folic acid from everyday foods. The daily requirement for adults is 400 mcg per day, for pregnant women it is 600 mcg per day and for breastfeeding women it is 500 mcg per day.

Folic acid containing foods

●     Dark leafy greens- spinach (1 cup raw = 110 mcg folate)

●     Asparagus- (1 cup raw = 122 mcg folate)

●     Broccoli- (½ cup cooked = 50 mcg folate)

●     Citrus Fruits- oranges (1 medium = 40 mcg folic acid)

●     Strawberries- (8 medium = 80 mcg folate)

 

●     Okra- (½ cup cooked = 135 mcg folate)

●     Beans-(black, kidney, pinto), ½ cup = 115-145 mcg folate

●     Peanuts- (¼ cup dry roasted, unsalted = 166 mcg folate)

●     Avocado- (1 cup = 386 mcg folate)

●     Banana Pepper- (1 cup raw = 443 mcg folate)

●     Salmon- (1 filet = 881 mcg folate)

Folic acid dietary intake is important because it aids in the development of the brain and spinal cord of the developing infant. Therefore, it is crucial that you are getting the correct amount either from the foods you eat or through supplementation. A recent study by ConsumerLab tested multivitamins and discovered that many vitamins did not match label claims, so you may be getting too much or too little of the desired vitamin. As always, it is important to discuss supplementation with your doctor and also consider blood work to determine your current levels of folic acid prior to adjusting your daily intake.

Although the prevalence of autism is at an all-time high, with careful monitoring of your daily folic acid intake you can avoid getting too much of this vitamin.

References:

  1. USDA.gov/food-sources
  2. Wiens D, DeWitt A, Kosar M, et al. Influence of Folic Acid on Neural Connectivity during Dorsal Root Ganglion Neurogenesis. Cells Tissues Organs 2016:1-12.

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