Alternative answers to hyperlipidaemia

FIRST-LINE management of hyperlipidaemia must always include lifestyle changes, particularly weight loss when required.

Reducing saturated fatty acid intake to less than 7% of energy and cholesterol intake to less than 200mg per day reduces LDL-C by 9% to 12%. In conjunction with a 3–6kg weight loss, LDL-C can be reduced by 16% if necessary. Also exercise, added soluble fibre (e.g. β-glucan, pectin, guar gum, glucomannan and psyllium) and phytosterols (e.g. stanols and sterols) play a role. 

Vitamin B3 (niacin or nicotinic acid) has long been valued as playing a role in lowering LDL-cholesterol and triglyceride levels and raising HDL-cholesterol, even when combined with statins.

The main side effect of niacin includes flushing due to vasodilatation effects which wears off after two weeks of continued use, and there have been several case reports of hepatotoxicity associated with extended release forms.

Garlic extract or powder may reduce cholesterol although meta-analyses have found conflicting results with no significant benefits.

A meta-analysis of 26 studies demonstrated that garlic powder and aged garlic extract significantly lowered total cholesterol levels whilst garlic oil reduced serum triglyceride when compared with placebo.

Fish oils are well recognised in lowering triglyceride levels (not cholesterol) which is dose dependent. The recommended dose is 1–2 grams daily. Side-effects include gastrointestinal upset, reflux, burping, allergic reactions in people with seafood allergy, and blood thinning in very high doses (>9 gram daily). A meta-analysis found a marine source of omega-3 fatty acid not derived from fish (median dose of algal DHA 1.68g/d) may reduce serum triglycerides and increase HDL-cholesterol and LDL-cholesterol in persons without coronary heart disease. 

Van Horne, L., M. McCoin, et al. (2009). “The evidence for dietary prevention and treatment of cardiovascular disease.” J Am Diet Assoc 108(2): 287-

O’Connor PJ, Quiter ES, Rush WA, et. al. Relative effectiveness of niacin and lovastatin for treatment of dyslipidemias in a health maintenance organisation. J Family Pract 1997;44:462 – 7.

Illingworth D, Stein EA, Mitchel YB, et. al. Comparative effects of lovastatin and niacin in primary hypercholesterolemia: a prospective trial.Arch Intern Med 1994;154:1586 – 95.

Guyton JR, Blazing MA, Hagar J, et. al. Extended release niacin vs gemfibrozil for the treatment of low levels of high-density lipoprotein cholesterol. Niaspan-Gemfi brozil Study Group. Arch Intern Med 2000;160:1177 – 84.

Wolfe ML, Vartanian SF, Ross JL, et. al. Safety and effectiveness of Niaspan when added sequentially to a statin for treatment of dyslipidemia. Am J Cardiol 2001;87:476 – 9.

Wink J, Giacoppe G, King J. Effect of very-low dose naicin on high-density lipoprotein in patients undergoing long-term statin therapy. Am Heart J 2002;143:514 – 8.

Brown BG, Zhao XQ, Chait A. Simvastatin and niacin, antioxidant vitamins, or the combination for the prevention of coronary disease. N Engl J Med 2001;345:1583 – 93.

Kamanna VS, Kashyap ML. Nicotinic acid (niacin) receptor agonists: will they be useful therapeuticagents? Am J Cardiol. 2007;100:S53 – S61.

Robinson JG. Management of complex lipid abnormalities with a fixed dose combination of simvastatin and extended release niacin. Vasc Health Risk Manag. 2009;5:31 – 43.

Karas RH, Kashyap ML, Knopp RH. Long-term safety and efficacy of a combination of niacin extended release and simvastatin in patients with dyslipidemia: the OCEANS study. Am J Cardiovasc Drugs 2008;8:69 – 81.

Plaisance EP, Mestek L, Mahurin AJ, et. al. Postprandial triglyceride responses to aerobic exercise and extended-release niacin. American Journal of Clinical Nutrition 2008;88:30 – 37.

Kamanna VS, Ganji SH, Kashyap ML. Niacin: an old drug rejuvenated. Curr Atheroscler Rep 2009;11:45 – 51.

Insull W, Toth PP, Superko HR, Thakkar RB, Krause S, Jiang P, Parreno RA, Padley RJ. Combination of niacin extended-release and simvastatin results in a less atherogenic lipid profile than atorvastatin monotherapy; Vascular Health and Risk Management 6 1065-75 (2010)

The AIM-HIGH Investigators. Niacin in Patients with Low HDL Cholesterol Levels Receiving Intensive Statin Therapy. N Engl J Med 2011; 365:2255-2267

Warshafsky S, Kamer RS, Sivak SL. Effect of garlic on total serum cholesterol. A meta-analysis. Ann Intern Med 1993;119:599 – 605.

Stevinson C, Pittler MH, Ernst E. Garlic for treating hypercholesterolemia. A meta-analysis of randomised clinical trials. Ann Intern Med 2001;135:65 – 66.

Stevinson C, Pittler MH, Ernst E. Garlic for treating hypercholesterolemia. A meta-analysis of randomized clinical trials. 2000 Sep 19;133(6):420-9. 

Khoo YSK, Azis Z. Garlic supplementation and serum cholesterol: a meta-analysis. J Clin Pharm Ther 2009;34:133 – 45. 

Zeng T, Guo FF, Zhang CL, Song FY, Zhao XL, Xie KQ. A meta-analysis of randomized, double-blind, placebo-controlled trials for the effects of garlic on serum lipid profiles. J Sci Food Agric. 2012 Jan 10. doi: 10.1002/jsfa.5557. [Epub ahead of print]

Mary R Dicklin; Andrea Lawless; Matthew S Reeves, Kevin C Maki. Omega-3 Fatty Acids for the Treatment of Elevated Triglycerides; Clin Lipidology. 2009;4(4):425-437.

Eslick GD, Howe PRC, Smith C, Priest R and Bensoussan A. Benefits of fish oil supplementation in hyperlipidemia: a systematic review and meta-analysis. Int J Cardiol 2009; doi:10.1016/j.ijcard.2008.03.092.

Bernstein AM, Ding EL, Willett WC, Rimm EB. A meta-analysis shows that docosahexaenoic acid from algal oil reduces serum triglycerides and increases HDL-cholesterol and LDL-cholesterol in persons without coronary heart disease. J Nutr. 2012 Jan;142(1):99-104. Epub 2011 Nov 23.

Pittler MH, Ernst E. Artichoke leaf extract for treating hypercholesterolaemia. Cochrane Database of Systematic Reviews, 2002; Art. No.: CD003335.doi: 10.1002/14651858.CD003335.8CBBD9B8A633.d01t04

Wider, B., M. H. Pittler, et al. (2009). “Artichoke leaf extract for treating hypercholesterolaemia.”Cochrane Database Syst Rev(4): CD003335.

Heber D, Yip I, Ashley JM, et. al. Cholesterol lowering effects of a proprietary Chinese red yeast-rice dietary supplement. Am J Clin Nutr1999;69:231 – 6.

Wang J, Lu A, Chi J. Multicenter clinical trial of the serum lipid-lowering effects of a monascus purpureus (red yeast) rice preparation from traditional Chinese medicine. Cur Ther Res 1997;58:964 – 78.

Blisnakov EG. More on the Chinese red-yeast-rice supplement and its cholesterol-lowering effect. Am JClin Nutr 2000;71:152 – 7.

Becker DJ, Gordon RY, Halbert SC, et. al. Red yeast rice for dyslipidemia in statin-intolerant patients:a randomised trial. Annals of Internal Medicine 2009;150:830 – 9.

Prasad GV, Wong T, Meliton G, et. al. Rhabdomyolysis due to red yeast rice (Monascuspurpureus) in a renal transplant recipient. Transplantation 2002;74:1200 – 1.

Mueller PS. Symptomatic myopathy due to red yeast rice. Ann Intern Med 2006;145:474 – 5.

Roselle H, Ekatan A, Tzeng J, et. al. Symptomatic hepatitis associated with the use of herbal red yeastrice. Ann Intern Med 2008;149:516 – 7.

Huang CF, Li TC, Lin CC, et. al. Efficacy of Monascus purpureus Went rice on lowering lipidratios in hypercholesterolemic patients. Eur J Cardiovasc Prev Rehabil 2007;14:438 – 40.

Lin CC, Li TC, Lai MM. Effi cacy and safety of Monascus purpureus Went rice in subjects withhyperlipidemia. Eur J Endocrinol 2005;153:679 – 86.

Gheith O, Sheashaa H, Abdelsalam M, et. al. Efficacy and safety of Monascus purpureus Went rice insubjects with secondary hyperlipidemia. Clin Exp Nephrol 2008;12:189 – 94.

Gordon, R. Y. and D. J. Becker (2011). “The role of red yeast rice for the physician.” Curr Atheroscler Rep 13(1): 73-80.

Liu J, Zhang J, Shi Y, et. al. Chinese red yeast rice (Monascus purpureus) for primary hyperlipidemia:ta-analysis of randomised controlled trials. Chin Med 2006;1:4.