Recent perspectives on the role of nutraceuticals as cholesterol-lowering agents

Biomedical role of L-carnitine in several organ systems, cellular tissues, and COVID-19

Carnitine is a conditionally necessary vitamin that aids in energy creation and fatty acid metabolism. Its bioavailability is higher in vegetarians than in meat-eaters. Deficits in carnitine transporters occur because of genetic mutations or in conjunction with other illnesses. Carnitine shortage can arise in health issues and diseases-including hypoglycaemia, heart disease, starvation, cirrhosis, and ageing-because of abnormalities in carnitine control. The physiologically active form of L-carnitine supports immunological function in diabetic patients. Carnitine has been demonstrated to be effective in the treatment of Alzheimer's disease, several painful neuropathies, and other conditions. It has been used as a dietary supplement for the treatment of heart disease, and it also aids in the treatment of obesity and reduces blood glucose levels. Therefore, L-carnitine shows the potential to eliminate the influences of fatigue in COVID-19, and its consumption is recommended in future clinical trials to estimate its efficacy and safety. This review focused on carnitine and its effect on tissues, covering the biosynthesis, metabolism, bioavailability, biological actions, and its effects on various body systems and COVID-19.

Nutritional Composition, Health Benefits, and Application Value of Edible Insects: A Review

For thousands of years, edible insects have been used as food to alleviate hunger and improve malnutrition. Some insects have also been used as medicines because of their therapeutic properties. This is not only due to the high nutritional value of edible insects, but more importantly, the active substances from edible insects have a variety of biofunctional activities. In this paper, we described and summarized the nutritional composition of edible insects and discussed the biological functions of edible insects and their potential benefits for human health. A summary analysis of the findings for each active function confirms that edible insects have the potential to develop functional foods and medicines that are beneficial to humans. In addition, we analyzed the issues that need to be considered in the application of edible insects and the current status of edible insects in food and pharmaceutical applications. We concluded with a discussion of regulations related to edible insects and an outlook on future research and applications of edible insects. By analyzing the current state of research on edible insects, we aim to raise awareness of the use of edible insects to improve human health and thus promote their better use and development.

Low-density lipoprotein-cholesterol lowering effect of a nutraceutical regimen with or without ezetimibe in hypercholesterolaemic patients with statin intolerance

Background

Statins are the most widely prescribed medication to lower low-density lipoprotein cholesterol (LDL-c). However, a significant portion of patients are unable to tolerate them due to side effects, most commonly muscle related. Nutraceuticals, natural plant derivatives with lipid-lowering properties, may provide an alternative to lower LDL-c in these patients.

Aims

To investigate whether a nutraceutical regimen, either alone or in combination with ezetimibe, can lower LDL-c in patients with hypercholesterolemia who are intolerant to statins.

Methods

Participants were recruited into a double-blind, randomized, placebo-controlled intervention study. Treatments were (i) placebo, (ii) nutraceutical (500 mg berberine, 200 mg red yeast rice (RYR), 2 g plant sterols)/daily, (iii) ezetimibe (10 mg)/daily, or (iv) the combination of nutraceutical and ezetimibe/daily. At baseline and week 8, all participants provide a fasting blood sample for assessment of lipid profile and safety bloods.

Results

Fifty participants were randomized, with 44 completing the treatment period. Following adjustment for baseline levels and compared with placebo, LDL-c was significantly reduced (all p < 0.0001) with ezetimibe (-1.02 mmol/L), nutraceutical (-1.15 mmol/L) and the nutraceutical and ezetimibe combination (-1.92 mmol/L). Non-HDL cholesterol was significantly reduced (all p < 0.0001) with ezetimibe (-1.29 mmol/L), nutraceutical (-1.37 mmol/L) and the nutraceutical and ezetimibe combination (-2.18 mmol/L). Remnant cholesterol and triglycerides was significantly reduced with the nutraceutical and ezetimibe combination (p = 0.018).

Conclusion

A nutraceutical regimen (berberine, RYR and plant sterols) and ezetimibe independently and additively lower LDL-c in patients with hypercholesterolemia who are intolerant to statins.

Effects of hawthorn seed oil on plasma cholesterol and gut microbiota

Background

Hypercholesterolemia and gut microbiota dysbiosis are associated with the risk of cardiovascular diseases. Hawthorn fruits has shown to be cardioprotective and hypocholesterolemic. However, no studies to date have studied the biological activity of hawthorn seed oil (HSO). The present study was to investigate if HSO could favourably reduce plasma cholesterol and modulate gut microbiota in hypercholesterolemia hamsters.

Methods

Golden Syrian hamsters (age, 8 weeks) were randomly divided into five groups (n = 8, each) and fed one of the following five diets, namely a non-cholesterol diet, a high cholesterol diet containing 0.15% cholesterol (HCD); a HCD diet with addition of 4.75% HSO (LHSO), a HCD diet with addition of 9.5% HSO (HHSO), a HCD diet with addition of 0.50% cholestyramine as positive control diet. After 6-week dietary intervention, plasma lipids, inflammatory markers, atherosclerosis plaque, hepatic and fecal lipids were quantified. Microbiota in fresh feces were analysed by sequencing 16S rRNA genes, while RT-PCR and Western blot analyses were employed to quantify the expression of genes involved in cholesterol homeostasis.

Results

HSO at a dose of 9.5% HSO could decrease plasma cholesterol and non-HDL-cholesterol by 15%. Additionally, both HSO experimental groups also suppressed mRNA of 3-Hydroxy-3-Methylglutaryl-CoA Reductase (HMG-CoA-R). Supplementation of HSO at 4.75% could significantly increase the excretion of fecal acidic sterols, accompanied by elevation of short-chain fatty acid levels in feces. The analyses of gut microbiome indicated that HSO supplementation could selectively alter the genera abundance of gut bacteria that were correlated with cholesterol metabolism including unclassified_f__Christensenellaceae, Ruminococcaceae_NK4A214_ group, norank_o_Gastranaerophilales, Faecalibaculum, Peptococcus, norank_f__Clostridiales_vadinBB60_group and Ruminococcus_2.

Conclusions

HSO supplementation was able to decrease plasma cholesterol by favourably modulating gut microbiota composition and gut-derived metabolites associated with cholesterol regulation.

Graphical Abstract

Biological and pharmacological effects and nutritional impact of phytosterols: A comprehensive review

Phytosterols (PSs), classified into plant sterols and stanols, are bioactive compounds found in foods of plant origin. PSs have been proposed to exert a wide number of pharmacological properties, including the potential to reduce total and low-density lipoprotein (LDL) cholesterol levels and thereby decreasing the risk of cardiovascular diseases. Other health-promoting effects of PSs include anti-obesity, anti-diabetic, anti-microbial, anti-inflammatory, and immunomodulatory effects. Also, anticancer effects have been strongly suggested, as phytosterol-rich diets may reduce the risk of cancer by 20%. The aim of this review is to provide a general overview of the available evidence regarding the beneficial physiological and pharmacological activities of PSs, with special emphasis on their therapeutic potential for human health and safety. Also, we will explore the factors that influence the physiologic response to PSs.

Statin-Induced Myopathy: Translational Studies from Preclinical to Clinical Evidence

Statins are the most prescribed and effective drugs to treat cardiovascular diseases (CVD). Nevertheless, these drugs can be responsible for skeletal muscle toxicity which leads to reduced compliance. The discontinuation of therapy increases the incidence of CVD. Thus, it is essential to assess the risk. In fact, many studies have been performed at preclinical and clinical level to investigate pathophysiological mechanisms and clinical implications of statin myotoxicity. Consequently, new toxicological aspects and new biomarkers have arisen. Indeed, these drugs may affect gene transcription and ion transport and contribute to muscle function impairment. Identifying a marker of toxicity is important to prevent or to cure statin induced myopathy while assuring the right therapy for hypercholesterolemia and counteracting CVD. In this review we focused on the mechanisms of muscle damage discovered in preclinical and clinical studies and highlighted the pathological situations in which statin therapy should be avoided. In this context, preventive or substitutive therapies should also be evaluated.

The effects of L-carnitine supplementation on lipid concentrations inpatients with type 2 diabetes: A systematic review and meta-analysis of randomized clinical trials

This meta-analysis was performed to assess the effect of L-carnitine supplementation on lipid profile. A systematic search were conducted in PubMed and Scopus to identify randomized clinical trials (RCTs) which evaluated the effects of L-carnitine on lipid profile. Pooled effect sizes were measured using random-effect model (Dersimonian-Laird). Meta-analysis showed that L-carnitine supplementation significantly reduced total cholesterol (TC) (weighted mean difference [WMD]: -8.17 mg/dL; 95% CI,-14.68 to -1.65, I²=52.2%, P = 0.041). Baseline level of TC was a source of heterogeneity, with a greater effect in studies with a baseline level of more than 200 mg/d (WMD: -11.93 mg/dL; 95% CI, -20.80 to-3.05). L-carnitine also significantly decreased low-density lipoprotein-cholesterol (LDL-C) (WMD:-5.22 mg/dL; 95% CI, -9.54 to -0.91, I²=66.7%, P = 0.010), and LDL-C level <100 mg/dL), trial duration,and L-carnitine dosage were potential sources of heterogeneity. L-carnitine supplementation appeared to have no significant effect on high-density lipoprotein-cholesterol (HDL-C) (WMD: -0.51 mg/dL;95% CI, -2.45 to 1.44) and triglyceride (TG) (WMD: 2.80 mg/dL; 95% CI, -8.09 to 13.69). This meta-analysisrevealed that L-carnitine may have favorable effects on lipid profile, especially LDL-C and TC. However, further RCTs are needed to confirm the veracity of these results, particularly among hyperlipidemic patients.

The Effects of Curcumin on Diabetes Mellitus: A Systematic Review

Diabetes mellitus (DM) is an ensemble of metabolic conditions that have reached pandemic proportions worldwide. Pathology's multifactorial nature makes patient management, including lifelong drug therapy and lifestyle modification, extremely challenging. Currently, there is growing evidence about the effectiveness of using herbal supplements in preventing and controlling DM. Curcumin is a bioactive component found Curcuma longa, which exhibits several physiological and pharmacological properties such as antioxidant, anti-inflammatory, anticancer, neuroprotective, and anti-diabetic activities. For these reasons, our objective is to systematically review the effects of Curcuma longa or curcumin on DM. Databases such as PUBMED and EMBASE were searched, and the final selection included sixteen studies that fulfilled the inclusion criteria. The results showed that curcumin's anti-diabetic activity might be due to its capacity to suppress oxidative stress and inflammatory process. Also, it significantly reduces fasting blood glucose, glycated hemoglobin, and body mass index. Nanocurcumin is also associated with a significant reduction in triglycerides, VLDL-c, total cholesterol, LDL-c, HDL-c, serum C reactive protein, and plasma malonaldehyde. Therefore, it can be considered in the therapeutic approach of patients with DM.

Natural compounds as anti-atherogenic agents: Clinical evidence for improved cardiovascular outcomes

Atherosclerosis, a chronic progressive inflammatory condition characterized by the formation of lipid-laden lesions in arterial walls, is associated with substantial morbidity (including ischaemic stroke and myocardial infarction) and mortality. Risk factors for atherosclerosis are well understood and can be ameliorated by evidence-based and guideline-directed pharmaceutical agents (e.g. the reduction of circulating concentrations of low-density lipoprotein cholesterol by statins). Additionally, many natural products (usually food derivatives) and 'nutraceuticals' (pharmaceutical formulations prepared from components of foods) have been shown to have favourable effects on risk factors for atherosclerotic cardiovascular disease. This literature review summarises the evidence for anti-atherogenic natural compounds. The article focuses on agents which are discussed in international guidelines and are supported by extensive high-quality randomized-controlled trial (RCT) data. We focus on micronutrients (compounds present in food in small quantities) and nutraceuticals, in particular, phytosterols, polyunsaturated ω-3 fatty acids and red-yeast rice. We conclude that the 'nutraceutical approach' (identify the active ingredients in natural products; produce high-quality products according to Good Manufacturing Practice guidelines; evaluate them in long-term outcomes trials) is the mechanism by which the domains of natural product research and evidence-based medicine can move closer together.

Medicinal plants and bioactive natural compounds as inhibitors of HMG-CoA reductase: A literature review

Cardiovascular diseases (CVDs) are one of the most important causes for mortality worldwide. Elevated levels of total cholesterol, and particularly LDL-cholesterol (LDL-C) are the main risk factor for acute myocardial infarction (AMI) and ischemic heart disease. The risk of CVDs could be reduced by decreasing the elevated cholesterol levels. β-hydroxy β-methylglutaryl-CoA reductase (HMGCoAR) is the primary and rate-limiting enzyme in the cholesterol biosynthesis pathway. Recently, the crucial role of nutraceuticals in maintaining normal physiological function was established. Nutraceuticals play an important role in preventing several non-communicable diseases such as obesity, CVDs, cancer, diabetes, and reducing hyperlipidemia. Although the effect of nutraceuticals and herbal medicine on CVDs and dyslipidemia was previously investigated thoroughly, the effect of these natural products on HMGCoAR as one of the important enzymes involved in CVDs etiopathogenesis has not yet been investigated. Therefore, the major aim of this paper was to review the effects of nutraceuticals and medicinal plants on HMGCoAR. Results indicate that different types of natural foods, isolated nutrients, herbal products, and dietary supplements as nutraceuticals decrease the expression and activity of HMGCoAR. This review shows that medicinal plants and nutraceuticals could be used to decrease HMGCoAR activity as accessible and convenient and economical natural compounds to prevent dyslipidemia and CVDs.

The effect of regular consumption of lupin-containing foods on glycaemic control and blood pressure in people with type 2 diabetes mellitus

Type 2 diabetes mellitus is a metabolic disorder characterized by high glucose and insulin resistance.

Effects of cardamom supplementation on lipid profile: A systematic review and meta-analysis of randomized controlled clinical trials

Cardiovascular disease is a highly prevalent issue worldwide and one of its main manifestations, dyslipidemia, needs more attention. Recent studies have suggested that cardamom has favorable effects beyond lipid lowering, but the result are contradictory. Our objective was to conduct a systematic review and meta-analysis on randomized controlled trials (RCTs) that assessed the effect of cardamom on lipids. The search included PubMed, Scopus, ISI Web of Science, Google Scholar, and the Cochrane library (up to March, 2019) to identify RCTs investigating the effects of cardamom supplementation on serum lipid parameters. Weighted mean differences (WMDs) were pooled using a random-effect model. Meta-analysis of data from five eligible RCTs showed that cardamom supplementation did not significantly change the concentrations of total cholesterol (WMD: -6.11 mg/dl, 95% CI [-13.06, 0.83], I² = 0.0%), low-density lipoprotein cholesterol (WMD: -4.31 mg/dl, 95% CI [-9.75, 1.13], I² = 0.0%), or high-density lipoprotein cholesterol (WMD: 1.75 mg/dl, 95% CI [-1.95 to 5.46], I² = 71.4%). However, a significant reduction was observed in serum triglyceride (TG; WMD: -20.55 mg/dl, 95% CI [-32.48, -8.63], I² = 0.0%) levels after cardamom supplementation. Cardamom might be able to change TG, but for confirming the results, more studies exclusively on dyslipidemia patients and considering the intake of lipid lowering agents as exclusion criteria are necessary.

Statin Toxicity

There is now overwhelming evidence to support lowering LDL-c (low-density lipoprotein cholesterol) to reduce cardiovascular morbidity and mortality. Statins are a class of drugs frequently prescribed to lower cholesterol. However, in spite of their wide-spread use, discontinuation and nonadherence remains a major gap in both the primary and secondary prevention of atherosclerotic cardiovascular disease. The major reason for statin discontinuation is because of the development of statin-associated muscle symptoms, but a range of other statin-induced side effects also exist. Although the mechanisms behind these side effects have not been fully elucidated, there is an urgent need to identify those at increased risk of developing side effects as well as provide alternative treatment strategies. In this article, we review the mechanisms and clinical importance of statin toxicity and focus on the evaluation and management of statin-associated muscle symptoms.

Effect of Berberine on C-reactive protein: A systematic review and meta-analysis of randomized controlled trials

OBJECTIVES

Clinical evidence suggests the beneficial effects of Berberine (BER) on inflammatory markers. However, these results are controversial. The aim of this systematic review was to assess the effects of BER on C-reactive protein (CRP) using clinical trials in adults.

DESIGN

Systematic review and meta-analysis.

MAIN OUTCOME MEASURES

We searched randomized controlled trials in PubMed and Scopus up to November 2018. The mean differences (MD) and confidence interval (CI) of CRP (mg/L) concentrations were pooled with a random- or a fixed-effects model depending on the results of heterogeneity tests.

RESULTS

Of 1242 studies identified, 5 were included in the meta-analysis. Pooled analysis showed that serum levels of CRP were decreased after BER supplementation (MD:-0.64 mg/L, 95% CI(-0.67 to -0.61) P < 0.001)) without any significant heterogeneity (I2 = 0.0% and P = 0.984).

CONCLUSION

This meta-analysis showed BER supplementation may ameliorate the state of chronic inflammation. Patients with cardiovascular disease and diabetes are two important groups which may benefit from BER supplementation. Further well-designed investigations with larger samples are needed to ascertain the long-term effects of BER on chronic inflammation.

Mechanisms of statin‐induced new‐onset diabetes

Statins, with their lipid‐lowering properties, are a first‐line therapy for the prevention of cardiovascular diseases. Recent evidence, however, suggests that statins can increase the risk of new‐onset diabetes (NOD). The molecular mechanisms of statin‐induced NOD are not precisely known, although some pathophysiologic mechanisms have been suggested. Specific to the beta cell, these mechanisms include alterations in insulin secretion, changes in ion channels, modulation of signaling pathways, and inflammation/oxidative stress. Outwith the beta cell, other suggested mechanisms involve adipocytes, including alterations in adipocyte differentiation and modulation of leptin and adiponectin, and genetic and epigenetic mechanisms, including alterations in microRNA. The evidence supporting these and other mechanisms will be discussed. Greater understanding of the underlying mechanisms linking the onset of diabetes to statin therapy is essential and clinically relevant, as it may enable novel preventative or therapeutic approaches to be instituted and guide the production of a new generation of statins lacking this side effect.

Effects of a nutraceutical combination of monacolin, γ-oryzanol and γ-aminobutyric acid on lipid profile and C-reactive protein in mice

INTRODUCTION

The aim of this study was to evaluate the efficacy of two nutraceutical agents aimed to improve lipid profile in a sample of mice.

MATERIAL AND METHODS

Fifty mice were randomly divided into four groups. Control mice were fed a standard diet (SD), while the other three groups were fed with a high-fat diet (HFD) for 4 weeks. At the end of the run-in period, mice fed with the SD continued to follow the SD, while mice fed with the HFD were divided into three groups: one continued with the HFD, one continued to follow the HFD + a blend of natural components derived from rice and fermented rice (monacolin K 3%, γ-oryzanol, and γ-aminobutyric acid) (S1), and the other one followed the HFD + one nutraceutical containing monacolin K 3% alone for 24 weeks.

RESULTS

The results showed that mice treated with HFD + S1 and HFD + S2 had lower levels of TC compared to mice fed with the HFD alone (p < 0.01, and p < 0.05, respectively). Moreover, mice treated with HFD + S1 had lower TC and LDL-C levels compared to mice fed with HFD + S2 (p < 0.05). Mice treated with HFD + S1 or S2 had lower Tg levels compared to mice fed with the HFD (p < 0.05).

CONCLUSIONS

We can conclude that a combination of monacolin K 3%, γ-oryzanol, and γ-aminobutyric acid is more effective than monacolin K 3% alone in reducing the negative effects of a HFD in a sample of specific pathogen-free mice.

An updated review of lipid-modifying therapy

Statin drugs reduce low-density lipoprotein (LDL)-cholesterol (LDL-C) and cardiovascular risk. Ezetimibe may be used to supplement statin therapy, or used alone in cases of statin intolerance. Statin-associated side effects do occur, especially muscle symptoms and new onset diabetes, but they do not detract from the benefits of statin therapy. Inhibitors of proprotein convertase subtilisin/kexin type 9 (PCSK9) reduce LDL-C and cardiovascular risk. Evolocumab is subsidised in Australia for patients with familial hypercholesterolaemia when LDL-C is not adequately controlled with maximum doses of statin or ezetimibe or when statin therapy is contraindicated. Fenofibrate reduces triglycerides and cardiovascular risk in patients with type 2 diabetes when triglycerides are elevated and high-density lipoprotein (HDL) is low. A role for dietary omega-3 fatty acids and esters in reducing cardiovascular risk remains controversial. All cases of secondary cardiovascular disease prevention merit intensive lipid therapy, unless a contraindication exists. Lipid therapy is justified in cases of primary prevention when absolute risk is high, especially when lipids are highly elevated or when multiple risk factors are present. Clinical management requires a focus on the predominant lipid disorder present, namely hypercholesterolaemia, hypertriglyceridaemia or combined hyperlipidaemia. There is an ongoing problem of poor long term persistence on lipid therapy, as well as reduced awareness by practitioners of poor risk factor control.

Impact of ursodeoxycholic acid on circulating lipid concentrations: a systematic review and meta-analysis of randomized placebo-controlled trials

OBJECTIVE

The aim of this meta-analysis of randomized placebo-controlled trials was to examine whether ursodeoxycholic acid treatment is an effective lipid-lowering agent.

METHODS

PubMed-Medline, SCOPUS, Web of Science and Google Scholar databases were searched in order to find randomized controlled trials evaluating the effect of ursodeoxycholic acid on lipid profile. A random-effect model and the generic inverse variance weighting method were used for quantitative data synthesis. Sensitivity analysis was conducted using the leave-one-out method. A random-effects meta-regression model was performed to explore the association between potential confounders and the estimated effect size on plasma lipid concentrations.

RESULTS

Meta-analysis of 20 treatment arms revealed a significant reduction of total cholesterol following ursodeoxycholic acid treatment (WMD: - 13.85 mg/dL, 95% CI: -21.45, - 6.25, p < 0.001). Nonetheless, LDL-C (WMD: -6.66 mg/dL, 95% CI: -13.99, 0.67, p = 0.075), triglycerides (WMD: - 1.42 mg/dL, 95% CI: -7.51, 4.67, p = 0.648) and HDL-C (WMD: -0.18 mg/dL, 95% CI: -5.23, 4.87, p = 0.944) were not found to be significantly altered by ursodeoxycholic acid administration. In the subgroup of patients with primary biliary cirrhosis, ursodeoxycholic acid reduced total cholesterol (WMD: - 29.86 mg/dL, 95% CI: -47.39, - 12.33, p = 0.001) and LDL-C (WMD: -37.27 mg/dL, 95% CI: -54.16, - 20.38, p < 0.001) concentrations without affecting TG and HDL-C.

CONCLUSION

This meta-analysis suggests that ursodeoxycholic acid therapy might be associated with significant total cholesterol lowering particularly in patients with primary biliary cirrhosis.

Clinical guidance on the contemporary use of proprotein convertase subtilisin/kexin type 9 monoclonal antibodies

There is now significant evidence for the benefits of lowering low-density lipoprotein cholesterol (LDL-c) to reduce the risk of atherosclerotic cardiovascular disease (ASCVD). Although statins are the most widely prescribed lipid-lowering therapy that effectively lower LDL-c, especially in combination with ezetimibe, some patients require adjunctive therapy to further lower LDL-c and mitigate attendant risk of ASCVD. The gap can be filled by proprotein convertase subtilisin/kexin type 9 (PCSK9) monoclonal antibodies whose use is currently supported by two recent cardiovascular outcome studies and new treatment guidelines. We provide an overview of extant studies investigating PCSK9 monoclonal antibodies in various patient populations, an update of the guidelines regarding their use and a case-based discussion.

Usefulness of Low-Dose Statin Plus Ezetimibe and/or Nutraceuticals in Patients With Coronary Artery Disease Intolerant to High-Dose Statin Treatment

High-dose statin (HDS) therapy is recommended to reduce low-density lipoprotein cholesterol (LDL-C); however, some patients are unable to tolerate the associated side effects. Nutraceuticals have shown efficacy in lowering LDL-C. The aim of this study was to evaluate whether the combination of low-dose statin (LDS) plus ezetimibe (EZE) or LDS plus nutraceutical (Armolipid Plus [ALP] containing red yeast rice, policosanol, and berberine) can lead to a higher proportion of high-risk patients achieving target LDL-C. A secondary objective was to assess the efficacy of triple combination LDS + EZE + ALP in resistant patients (LDL-C >70 mg/dl). A randomized, prospective, parallel-group, single-blind study was conducted in patients with coronary artery disease (n = 100) who had undergone percutaneous coronary intervention in the preceding 12 months, were HDS-intolerant, and were not at LDL-C target (<70 mg/dl) with LDS alone. Patients received either LDS + EZE or LDS + ALP. Of the 100 patients, 33 patients (66%) treated with LDS + EZE and 31 patients (62%) treated with LDS + ALP achieved target LDL-C after 3 months, which was maintained at 6 months. Patients who did not achieve the therapeutic goal received a triple combination of LDS + EZE + ALP for a further 3 months. At 6 months, 28 of 36 patients (78%) achieved LDL-C target. Overall, 92% of patients enrolled in this study were at target LDL-C at 6 months. No patients in any group experienced major side effects. In conclusion, in HDS-intolerant coronary artery disease patients, the combination of LDS plus EZE and/or ALP represents a valuable therapeutic option allowing most patients to reach target LDL-C within 3 to 6 months.

Progress and perspectives in plant sterol and plant stanol research

Current evidence indicates that foods with added plant sterols or stanols can lower serum levels of low-density lipoprotein cholesterol. This review summarizes the recent findings and deliberations of 31 experts in the field who participated in a scientific meeting in Winnipeg, Canada, on the health effects of plant sterols and stanols. Participants discussed issues including, but not limited to, the health benefits of plant sterols and stanols beyond cholesterol lowering, the role of plant sterols and stanols as adjuncts to diet and drugs, and the challenges involved in measuring plant sterols and stanols in biological samples. Variations in interindividual responses to plant sterols and stanols, as well as the personalization of lipid-lowering therapies, were addressed. Finally, the clinical aspects and treatment of sitosterolemia were reviewed. Although plant sterols and stanols continue to offer an efficacious and convenient dietary approach to cholesterol management, long-term clinical trials investigating the endpoints of cardiovascular disease are still lacking.

The Role of Nutraceuticals in Statin Intolerant Patients

Statins are the most common drugs administered for patients with cardiovascular disease. However, due to statin-associated muscle symptoms, adherence to statin therapy is challenging in clinical practice. Certain nutraceuticals, such as red yeast rice, bergamot, berberine, artichoke, soluble fiber, and plant sterols and stanols alone or in combination with each other, as well as with ezetimibe, might be considered as an alternative or add-on therapy to statins, although there is still insufficient evidence available with respect to long-term safety and effectiveness on cardiovascular disease prevention and treatment. These nutraceuticals could exert significant lipid-lowering activity and might present multiple non-lipid-lowering actions, including improvement of endothelial dysfunction and arterial stiffness, as well as anti-inflammatory and antioxidative properties. The aim of this expert opinion paper is to provide the first attempt at recommendation on the management of statin intolerance through the use of nutraceuticals with particular attention on those with effective low-density lipoprotein cholesterol reduction.

Cholesterol-Lowering Nutraceuticals Affecting Vascular Function and Cardiovascular Disease Risk

PURPOSE OF REVIEW

The aim of this review is to provide an update on the effects of the dietary supplementation with cholesterol-lowering nutraceuticals and nutraceutical combinations affecting vascular function and CV risk in clinical interventional studies.

RECENT FINDINGS

Current evidence supports the mild-to-moderate cholesterol-lowering efficacy of red yeast rice, berberine, plant sterols, fibers, and some nutraceutical combinations whereas data on the individual cholesterol-lowering action of other nutraceuticals are either less striking or even inconclusive. There is also promising evidence on the vascular protective effects of some of the aforementioned nutraceuticals. However, except for red yeast rice, clinical interventional studies have not investigated their impact on CV outcomes. Evidence of both cholesterol-lowering and vascular protection is a prerogative of few single nutraceuticals and nutraceutical combinations, which may support their clinical use; however, caution on their uncontrolled adoption is necessary as they are freely available on the market and, therefore, subject to potential misuse.

Nutraceuticals in the management of patients with statin-associated muscle symptoms, with a note on real-world experience

There is considerable evidence for the role of low-density lipoprotein cholesterol (LDL-C) in the development of atherosclerotic cardiovascular disease. Although statin therapy remains the most frequency prescribed medication to reduce LDL-C and lower risk of cardiovascular disease, a considerable number of patients develop muscle-related side affects. This review summarizes recent literature supporting the role of nutraceuticals as LDL-C-lowering therapy in statin-intolerant patients, with evidence from our own clinical practices.

Efficacy of functional foods mixture in improving hypercholesterolemia, inflammatory and endothelial dysfunction biomarkers-induced by high cholesterol diet

Background

Hypercholesterolemia associated with cardiovascular diseases is a global health issue that could be alleviated by functional foods. This study aimed to explore the effects of a high-cholesterol diet on lipid profile, cardiac, inflammatory, and endothelial dysfunction biomarkers, and the possible improvement by functional foods mixture.

Methods

Male albino rats weighing 100–150 g were randomly divided into four equal groups: 1st control, giving a normal diet; the 2nd received high-cholesterol diet for 8 weeks, the 3rd received the high-cholesterol diet + functional foods mixture, and the 4th administered high-cholesterol diet +atorvastatin (20 mg) orally.

Results

The results showed a significant increase in lipid profile and cardiac biomarkers levels (lactate dehydrogenase, creatine kinase and homocystein), also inflammatory markers, as, tumor necrotic factor alpha and chronic reactive proteins were elevated, moreover, vascular adhesion molecule-1 and nitric oxide synthase were disturbed in high-cholesterol diet compared with normal group. While administration of atorvastatin and functional foods mixture ameliorated these alterations.

Conclusions

Administration of functional foods mixture and atorvastatin were effective in treating hypercholesterolemia, reduce the risk of inflammation and cardiovascular biomarkers with a high safety margin. These efficiencies may be due to its active ingredient that improve the imbalance in the measured biomarkers.