Cardiologist explains the role ‘nutraceuticals’ can play in lipid management

Nutraceuticals are products from food sources with health benefits beyond their nutritional value –and there are three with good evidence for managing lipids.

Dr Jason Kaplan, a specialist adult cardiologist and accredited specialist in cardiac imaging, says nutraceuticals can play a role in lipid management for the right patients – and when used alongside other lifestyle strategies.

“They work best when used in conjunction with healthy dietary and lifestyle choices,” Dr Kaplan says.

Who can benefit from nutraceuticals?

• Lower-risk patients with high cholesterol levels who want to lower their LDL levels
• Individuals with statin intolerance and high cholesterol levels with intermediate CV risk who have not reached LDL-C targets
• High-risk or very-high-risk patients with partial statin intolerance who have not reached LDL-C targets with tolerable statin therapy and/or non-statin therapy

Which nutraceuticals have the best evidence for lipid management?

Three nutraceuticals have high-level clinical evidence based on data from multiple randomised clinical trials:

Berberine

A bioactive compound that can be extracted from several plants, including a group of shrubs called Berberis. It can reduce levels of total cholesterol and LDL in the plasma. Berberine can potentially be used as a cholesterol-lowering nutraceutical to prevent the development of atherosclerosis or in combination with statins to enhance LDL-lowering capability. Dr Kaplan says it is “currently underutilised in the clinical setting.”

Polyunsaturated omega-3 fatty acids

Commonly found in fish oil supplements, there is strong evidence for its use as first-line therapy to lower triglycerides. Dietary intake of polyunsaturated omega-3 fatty acids is essential as it cannot be synthesised in vivo. Dr Kaplan says most primary healthcare professionals do not use high enough doses of polyunsaturated omega-3 fatty acids. He added, “It is crucial to ensure that the product being used has high doses of EPA and DHA, which are the active ingredients. The product should have about 2000 mg (or 2g) of each active ingredient.”

Red yeast rice

Although there have been challenges with formulations, Dr Kaplan says “a good formulation can achieve the same clinical efficacy as a low-dose statin. It is important to use a trusted brand, who uses high quality source ingredients.” This is because red yeast rice contains monacolin K – the same active ingredient in some statins. However, this also means that creatine kinase levels and liver function should be monitored in patients taking red yeast rice. The recommended daily dose is 1,200–4,800 mg (3–10 mg of monacolin K).

How should nutraceuticals be used?

Nutraceuticals can be used as either monotherapy, in combination, or as an add-on therapy to statins. However, for best results, Dr Kaplan recommends using them in combination as opposed to monotherapy.

He suggests combining nutraceuticals that have complementary mechanisms of action. For instance, berberine seems to work in hepatocytes. When used in concert with plant sterols, psyllium husks, or fibre supplements that work within the small intestine, it is more effective at lowering LDL cholesterol.

There is also good evidence that the following combination therapies improve LDL-C Levels and cardiovascular risk: red yeast rice and policosanols; red yeast rice, policosanols, and berberine.

Armolipid Plus combines red yeast rice 200 mg (equivalent to monacolin K 3 mg), policosanol 10 mg, berberine 500 mg folic acid (0.2 mg), astaxanthin (0.5 mg), and coenzyme Q10 (2 mg). Treatment with Armolipid Plus leads to clinically meaningful improvements in serum lipids, glucose, and high-sensitivity C-reactive protein. It also improves vascular stiffness, an independent predictor of cardiovascular events.

Nutraceuticals can also be used in combination with statins. Nutraceuticals that work in the gut, such as plant sterols, psyllium husks, and fibre supplements, work in a complementary manner to statins. This enables the reduction of statin doses without diminishing the total cholesterol and LDL-C results and significantly limiting adverse effects. Thus, most patients may achieve the recommended goals safely and tolerably.

Key points

• Thoroughly assess the patient’s lipid profile, overall health, and potential interactions with other medications before recommending nutraceuticals.
• Due to the complexities around regulating nutraceuticals, it’s important to use established brands with good source materials and to adhere to recommended dose.
• Nutraceuticals should not replace lifestyle modifications, such as maintaining a balanced diet, exercising, getting enough sleep, and managing stress.
• Nutraceuticals work best in combination
• Ideally, a standard lipid panel blood test should be done every six months to assess the effectiveness of nutraceuticals
• Monitor liver health and creatine kinase levels in patients taking red yeast rice due to possible adverse events.

Further reading:

1. Moss JW, et al. Nutraceutical therapies for atherosclerosis. Nat Rev Cardiol. 2016;13(9):513–32. doi: 10.1038/nrcardio.2016.103.
2. Moss JWE, et al. Nutraceuticals as therapeutic agents for atherosclerosis. Biochim Biophys Acta Mol Basis Dis. 2018;1864(5 Pt A):1562–1572. doi: 10.1016/j.bbadis.2018.02.006.
3. Banach M, et al. The role of nutraceuticals in statin-intolerant patients. J Am Coll Cardiol. 2018;72(1):96–118. doi: 10.1016/j.jacc.2018.04.040.