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Pravastatin

Also indexed as: Pravachol®

Pravastatin is a member of the HMG-CoA reductase inhibitor family of drugs, also called “statins,” such as lovastatin and simvastatin. Pravastatin blocks a key step in the body’s production of cholesterol and is used to lower cholesterol levels in people with hypercholesterolemia (high cholesterol).

Interactions with Dietary Supplements

Coenzyme Q10
In double-blind trials, treatment with pravastatin and other HMG-CoA reductase inhibitors has resulted in depleted blood levels of coenzyme Q10 (CoQ10).1 2 Supplementation with 90–100 mg CoQ10 per day has been shown to prevent reductions in blood levels of CoQ10 due to simvastatin, another drug in the same category as pravastatin.3 4 However, some investigators have questioned whether it is worthwhile or necessary for individuals taking HMG-CoA reductase inhibitors to supplement with CoQ10.5 Until more is known, people taking pravastatin should ask a doctor about supplementation with 30–100 mg CoQ10 per day.

Fish oil
The omega-3 fatty acid EPA present in fish oil may improve the cholesterol and triglyceride-lowering effect of pravastatin. In a preliminary trial, people with high cholesterol who had been taking pravastatin for about three years were able to significantly lower their triglyceride levels and raise their levels of HDL (“good”) cholesterol by supplementing with either 900 mg or 1,800 mg of EPA for three months in addition to pravastatin.6 The authors of the study concluded that the combination of pravastatin and EPA may prevent coronary heart disease better than pravastatin alone.

Niacin (Vitamin B3, Nicotinic acid)
Niacin is a vitamin used to lower cholesterol. Sixteen people with diabetes and high cholesterol were given pravastatin plus niacin to lower cholesterol.7 Niacin was added over a two week period, to a maximum amount of 500 mg three times per day. The combination of pravastatin plus niacin continued for four weeks. Compared with pravastatin, niacin plus pravastatin resulted in significantly reduced cholesterol levels. Others have also shown that the combination of pravastatin and niacin is more effective in lowering cholesterol levels than is pravastatin alone.8 However, large amounts of niacin taken with pravastatin might cause serious muscle disorders (myopathy or rhabdomyolysis).9

Red yeast rice  (Monascus purpureas)
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.10 This extract contains small amounts of naturally occurring HMG-CoA reductase inhibitors such as lovastatin and should not be used by people who are currently taking lovastatin or pravastatin.

Vitamin A
A study of 37 people with high cholesterol treated with diet and HMG-CoA reductase inhibitors found serum vitamin A levels increased over two years of therapy.11 It remains unclear whether this moderate increase suggests that people taking lovastatin have a particular need to restrict vitamin A supplementation.

Interactions with Herbs

Milk thistle  (Silybum marianum)
One of the possible side effects of pravastatin is liver toxicity. Although no clinical studies substantiate its use with pravastatin, a milk thistle extract standardized to 70–80% silymarin may reduce the potential liver toxicity of pravastatin. The suggested use is 200 mg of the extract three times daily.

Interactions with Foods and Other Compounds

Food
Pravastatin may be taken with or without food.12

Grapefruit juice
A study of grapefruit juice and lovastatin (a drug closely related to pravastatin) reported significantly increased lovastatin levels in people who drank grapefruit juice compared with water.13 This interaction has not yet been reported with pravastatin. Until more is known, it is prudent to avoid grapefruit juice during pravastatin therapy or discuss grapefruit juice intake (before consuming any) with the prescribing doctor. Although grapefruit could, in theory, be used to reduce the effective dose of the drug, current knowledge is not sufficient to guarantee against potentially harmful fluctuations in the levels of the drug in the body. Anyone taking pravastatin and drinking grapefruit juice would require very careful monitoring. The same effects might be seen from eating grapefruit as from drinking its juice.

Summary of Interactions for Pravastatin

Depletion or interference Coenzyme Q10
Adverse interaction Niacin*
Red yeast rice*
Side effect reduction/prevention Milk thistle*
Supportive interaction Fish oil (EPA)
Niacin
Reduced drug absorption/bioavailability None known
Other (see text) Grapefruit juice
Vitamin A

For the convenience of the reader, the information in the summary is categorized as follows: “Depletion or interference” indicates the drug may deplete or interfere with the absorption or function of the supplement or herb. “Adverse interaction” indicates that the supplement or herb used together with the drug may result in undesirable effects. “Side effect reduction/prevention” indicates the supplement or herb may reduce the likelihood and/or severity of a potential side effect caused by the drug. “Supportive interaction” indicates the supplement or herb may support or aid the function of the drug. “Reduced drug absorption/bioavailability” indicates that the supplement or herb may decrease the absorption and/or activity of the drug in the body. An asterisk (*) next to an item in the summary indicates that the interaction is supported only by weak, fragmentary, and/or contradictory scientific evidence.

References:

1. Mortensen SA, Leth A, Agner E, Rohde M. Dose-related decrease of serum coenzyme Q10 during treatment with HMG-CoA reductase inhibitors. Mol Aspects Med 1997;18(suppl):S137–44.

2. Ghirlanda G, Oradei A, Manto A, et al. Evidence of plasma CoQ10-lowering effect by HMG-CoA reductase inhibitors: a double-blind, placebo-controlled study. J Clin Pharmacol 1993;33:226–9.

3. Bargossi AM, Grossi G, Fiorella PL, et al. Exogenous CoQ10 supplementation prevents plasma ubiquinone reduction induced by HMG-CoA reductase inhibitors. Molec Aspects Med 1994;15(suppl):s187–93.

4. Miyake Y, Shouzu A, Nishikawa M, et al. Effect of treatment with 3-hydroxy-3-methylglutaryl coenzyme A reductase inhibitors on serum coenzyme Q10 in diabetic patients. Arzneimittelforschung 1999;49:324–9.

5. Paloma’ki A, Malminiemi K, Solakivi T, Malminiemi O. Ubiquinone supplementation during lovastatin treatment: Effect of LDL oxidation ex vivo. J Lipid Res 1998;39:1430–7.

6. 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.

7. Gardner SF, Marx MA, White LM, et al. Combination of low-dose niacin and pravastatin improves the lipid profile in diabetic patients without compromising glycemic control. Ann Pharmacother 1997;31:677–82.

8. O’Keefe JH Jr, Harris WS, Nelson J, Windsor SL. Effects of pravastatin with niacin or magnesium on lipid levels and postprandial lipemia. Am J Cardiol 1995;76:480–4.

9. Garnett WR. Interactions with hydroxymethylglutaryl-coenzyme A reductase inhibitors. Am J Health Syst Pharm 1995;52:1639–45.

10. 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.

11. Muggeo M, Zenti MG, Travia D, et al. Serum retinol levels throughout two years of cholesterol-lowering therapy. Metabolism 1995;44:398–403.

12. 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, 172.

13. Kantola T, Kivisto KT, Neuvonen PJ. Grapefruit juice greatly increases serum concentrations of lovastatin and lovastatin acid. Clin Pharmacol Ther 1998;63:397–402.