Probiotic and functional potential of lactic acid bacteria isolated from pulque and evaluation of their safety for food applications

Pulque is a traditional Mexican non-distilled alcoholic beverage to which several beneficial functions are attributed, mainly associated with gastrointestinal health, which can be explained by the presence of probiotic bacteria in its microbiota. Therefore, the objective of this work was to evaluate the safety, probiotic activity, and functional characteristics of seven strains of lactic acid bacteria (LAB) isolated from pulque using the probiotic strain Lactobacillus acidophilus NCFM as control. The LAB isolates were identified by 16S rRNA sequencing and MALDI Biotyper® MS as belonging to three different Lactobacillaceae genera and species: Lactiplantibacillus plantarum, Levilactobacillus brevis and Lacticaseibacillus paracasei. Most strains showed resistance to gastric juice, intestinal juice and lysozyme (10 mg/L). In addition, all strains exhibited bile salt hydrolase (BSH) activity and antibacterial activity against the pathogenic strain Listeria monocytogenes. Additionally, cell surface characteristics of LAB were evaluated, with most strains showing good hydrophobicity, auto-aggregation, and co-aggregation towards enteropathogenic Escherichia coli and L. monocytogenes. In terms of safety, most of the strains were sensitive to the tested antibiotics and only the Lact. paracasei UTMB4 strain amplified a gene related to antibiotic resistance (mecA). The strains Lact. plantarum RVG2 and Lact. plantarum UTMB1 presented γ-hemolytic activity, and the presence of the virulence-related gene agg was identified only in UTMB1 strain. Regarding functional characterization, the tested bacteria showed good β-galactosidase activity, antioxidant activity and cholesterol reduction Based on principal component analysis (PCA) and heat mapping, and considering the strain Lact. acidophilus NCFM as the probiotic reference, the strains Lacticaseibacillus paracasei UTMB4, Lactiplantibacillus plantarum RVG4 and Levilactobacillus brevis UTMB2 were selected as the most promising probiotic strains. The results of this study highlighted the probiotic, functional and safety traits of LAB strains isolated from pulque thus supporting the health benefits attributed to this ancestral beverage.

Genetic diversity, cholesterol reduction, and presence of conserved bile salt hydrolase gene in probiotic strains from human milk

Probiotics are known to possess strain- and species-specific functional properties, of which hypocholesteremia is of major interest. Bile salt hydrolase (BSH) activity is one of the key mechanisms involved in the hypocholesterolemic effect. The study was designed to genetically characterize probiotics obtained from human milk on the basis of simple sequence repeat (SSR), isolate potent hypocholesterolemic strains, and detect BSH activity, deconjugation of bile salts, and bsh polymorphism. This study, for the first time, linked genetic diversity with cholesterol reduction potential and proved the presence of conserved bsh of Levilactobacillus brevis in genetically diverse species. The strains displayed 2.78%-42.23% cholesterol reduction, which was not influenced by prebiotics. In this study, data obtained from SSR markers indicated 93.3% diversity, and based on cluster analysis, they were distributed into XI clades; out of five potent cholesterol-reducing strains, three belonged to clade I. The strains could deconjugate both sodium glycocholate and sodium taurocholate, but we preferred using sodium glycocholate. The variation in cholesterol reduction potential and BSH activity pointed toward the presence of more than one bsh in the strains. Weissella confusa MW051433 displayed highest cholesterol reduction (42.23%) and specific BSH activity (2.64 U ml -1). Search for other bsh and in vivo assessments of cholesterol reduction by W. confusa MW051433 have been proposed.

Evaluation of the health properties of lactobacilli isolated from an Iranian traditional dairy product

The different lactobacillus strains isolated from dairy resources may have unique functional properties on human health. Thus, the present study aimed to evaluate the health properties of the lactobacilli isolated from a traditional dairy product in vitro. A total of seven isolated lactobacilli abilities were evaluated for environmental pH reduction, antibacterial activity, cholesterol reduction, and antioxidant activity. Based on the results, the highest decrease in the environment pH was observed in Lactobacillusfermentum B166 with 57%. The antipathogen activity test showed the best results for inhibiting Salmonella typhimurium and Pseudomonas aeruginosa to be obtained by Lact. fermentum 10-18 and Lact. brevis SKB1021 strains, respectively. However, Lact. plantarum H1 and Lact. plantarum PS7319 represented the maximum activity in preventing Escherichia coli; also, Lact. fermentum APBSMLB166 inhibited Staphylococcus aureus more than other strains. Additionally, Lact. crustorum B481 and fermentum 10-18 strains significantly led to a higher reduction in the medium cholesterol than the other strains. The results of antioxidant tests demonstrated that Lact. brevis SKB1021 and Lact. fermentum B166 inhabited radical substrate significantly more than the other lactobacilli. Therefore, four lactobacilli isolated from a traditional dairy product improved some safety indexes positively; thus, they are suggested to be used in manufacturing probiotic supplements.

In-silico validation of novel therapeutic activities of withaferin a using molecular docking and dynamics studies

Withaferin A is a bioactive molecule of W. somnifera. We access its efficacy against various target proteins associated with Cancer, Type-II Diabetes and hypercholesterolemia using molecular docking. Although it's efficacy against some of these targets have been reported earlier, we validate each mechanism in order to report the most appropriate mechanism of action. We explain the anti-cancer activity of Withaferin A by inhibition of Mortalin (mtHsp70) and Nrf2 protein with binding energies -8.85 kcal/mol and -12.59 kcal/mol respectively. Similarly, the anti-diabetic activity could be explained by inhibition of alpha and betα-glucosidase with binding energies -6.44 and -4.43 kcal/mol respectively and the cholesterol reduction could be explained by its ability to inhibition of NPC1 and SRB1 with binding energies -5.73 and -7.16 kcal/mol respectively. The molecular dynamics of the apoprotein and the protein-ligand complex simulated for the best targets of each activity namely Nrf2 protein for anti-cancer, α-glucosidase for anti-diabetic and SR-B1 for anti-hypercholesterolemia activity indicated the formation of stable complexes due to low RMSD deviations, low RMSF fluctuations and low RG values after the docking simulation. Finally, an ADME + T (Adsorption, distribution, metabolism, excretion and toxicity) prediction on Withaferin A showed that it obeyed all the Lipinsky's rules and qualified the drug-like criteria. All these results validate that Withaferin A possess potential anti-cancer, anti-diabetic and cholesterol reducing properties. This is the first report that indicates the possibility of Withaferin A binding and inhibiting SR-B1 as a mechanism of its anti-hypercholesterolemia activity.

Identification and New Indication of Melanin-Concentrating Hormone Receptor 1 (MCHR1) Antagonist Derived from Machine Learning and Transcriptome-Based Drug Repositioning Approaches

Melanin-concentrating hormone receptor 1 (MCHR1) has been a target for appetite suppressants, which are helpful in treating obesity. However, it is challenging to develop an MCHR1 antagonist because its binding site is similar to that of the human Ether-à-go-go-Related Gene (hERG) channel, whose inhibition may cause cardiotoxicity. Most drugs developed as MCHR1 antagonists have failed in clinical development due to cardiotoxicity caused by hERG inhibition. Machine learning-based prediction models can overcome these difficulties and provide new opportunities for drug discovery. In this study, we identified KRX-104130 with potent MCHR1 antagonistic activity and no cardiotoxicity through virtual screening using two MCHR1 binding affinity prediction models and an hERG-induced cardiotoxicity prediction model. In addition, we explored other possibilities for expanding the new indications for KRX-104130 using a transcriptome-based drug repositioning approach. KRX-104130 increased the expression of low-density lipoprotein receptor (LDLR), which induced cholesterol reduction in the gene expression analysis. This was confirmed by comparison with gene expression in a nonalcoholic steatohepatitis (NASH) patient group. In a NASH mouse model, the administration of KRX-104130 showed a protective effect by reducing hepatic lipid accumulation, liver injury, and histopathological changes, indicating a promising prospect for the therapeutic effect of NASH as a new indication for MCHR1 antagonists.

Probiotic Effector Compounds: Current Knowledge and Future Perspectives

Understanding the mechanism behind probiotic action will enable a rational selection of probiotics, increase the chances of success in clinical studies and make it easy to substantiate health claims. However, most probiotic studies over the years have rather focused on the effects of probiotics in health and disease, whereas little is known about the specific molecules that trigger effects in hosts. This makes it difficult to describe the detailed mechanism by which a given probiotic functions. Probiotics communicate with their hosts through molecular signaling. Meanwhile, since the molecules produced by probiotics under in vitro conditions may differ from those produced in vivo, in vitro mechanistic studies would have to be conducted under conditions that mimic gastrointestinal conditions as much as possible. The ideal situation would, however, be to carry out well-designed clinical trials in humans (or the target animal) using adequate quantities of the suspected probiotic molecule(s) or adequate quantities of isogenic knock-out or knock-in probiotic mutants. In this review, we discuss our current knowledge about probiotic bacteria and yeast molecules that are involved in molecular signaling with the host. We also discuss the challenges and future perspectives in the search for probiotic effector molecules.

Improvement of physicochemical properties of reduced-cholesterol butter by the addition of β-sitosteryl oleate

Beta-cyclodextrin (β-CD) has been shown to successfully lower the cholesterol content of dairy products, such as butter, but the process tends to negatively impact the overall quality and consistency. In this study, β-sitosterol, which is similar in structure as cholesterol, was reacted with oleic acid to form β-sitosteryl oleate (BSO), and this was used to improve the consistency of reduced-cholesterol butter. The reaction was catalyzed by sodium bisulfate (2%, w/w) at 140 °C, and the highest degree of esterification (94.3%) was obtained after 9 hr of reaction using a β-sitosterol-oleic acid molar ratio of 1:5. Ultra-pasteurized cream was then treated with 15% (w/v) β-CD at 40 °C with stirring (100 rpm), for 30 min. Results indicated a 95.4% reduction in cholesterol content. Finally, the reduced-cholesterol cream was constituted to contain 3, 5, and 10% (w/w) BSO, after which fat was extracted from the three formulations and their melting profiles compared to that of milk fat. The cream containing 3% BSO showed a profile similar to milk fat and was, therefore, used to formulate BSO-incorporated reduced-cholesterol butter (BSOB). Instrumental analyses showed that BSOB was comparable to the control butter with respect to physical properties, such as hardness/firmness and adhesiveness. PRACTICAL APPLICATION: A modified plant sterol, beta-sitosteryl oleate, was incorporated into a reduced-cholesterol butter to improve its physicochemical properties. The reduced-cholesterol butter was comparable to regular butter with respect to its consistency and melting properties and could be made into sticks. In addition to the reduced-cholesterol butter, this product could provide the foundation for new products blending butter and oils to create other low-cholesterol, reduced saturated-fat products, possibly in stick form.

Assimilation of Cholesterol by Monascus purpureus

Monascus purpureus, a filamentous fungus known for its fermentation of red yeast rice, produces the metabolite monacolin K used in statin drugs to inhibit cholesterol biosynthesis. In this study, we show that active cultures of M. purpureus CBS 109.07, independent of secondary metabolites, use the mechanism of cholesterol assimilation to lower cholesterol in vitro. We describe collection, extraction, and gas chromatography-flame ionized detection (GC-FID) methods to quantify the levels of cholesterol remaining after incubation of M. purpureus CBS 109.07 with exogenous cholesterol. Our findings demonstrate that active growing M. purpureus CBS 109.07 can assimilate cholesterol, removing 36.38% of cholesterol after 48 h of incubation at 37 °C. The removal of cholesterol by resting or dead M. purpureus CBS 109.07 was not significant, with cholesterol reduction ranging from 2.75-9.27% throughout a 72 h incubation. Cholesterol was also not shown to be catabolized as a carbon source. Resting cultures transferred from buffer to growth media were able to reactivate, and increases in cholesterol assimilation and growth were observed. In growing and resting phases at 24 and 72 h, the production of the mycotoxin citrinin was quantified via high-performance liquid chromatography-ultraviolet (HPLC-UV) and found to be below the limit of detection. The results indicate that M. purpureus CBS 109.07 can reduce cholesterol content in vitro and may have a potential application in probiotics.

Gaps in Dyslipidemia Care Among Working-Aged Individuals With Employer-Sponsored Health Care

Background

The American Heart Association and American College of Cardiology guidelines defined patient‐management groups that would benefit from lowering of low‐density lipoprotein cholesterol (LDL‐C). We assessed gaps in dyslipidemia care among employees and spouses with health benefits.

Methods and Results

We studied 17 889 employees and spouses who were covered by an employer‐sponsored health plan and participated in an annual health assessment. Using medical claims, laboratory tests, and risk assessment questionnaires, we found that 43% of participants were in one of 4 patient‐management groups: secondary prevention, severe hypercholesterolemia (LDL‐C ≥190 mg/dL at least once in the preceding 5 years), diabetes mellitus, or elevated 10‐year risk of cardiovascular disease. To assess gaps in dyslipidemia care, we used LDL‐C ≤70 mg/dL as the goal for both the secondary prevention group and those in the elevated 10‐year risk group with >20% risk; LDL‐C ≤100 mg/dL was used for the other groups. Among those in patient‐management groups, 27.3% were in the secondary prevention group, 7.4% were in the severe hypercholesterolemia group, 29.9% were in the diabetes mellitus group, and 35.4% were in the elevated 10‐year risk group. About 74% of those in patient‐management groups had above‐goal LDL‐C levels, whereas only 31% had evidence of a lipid‐lowering therapy in the past 6 months: 45% in the secondary prevention group, 31% in the severe hypercholesterolemia group, 36% in the diabetes mellitus group, and 17% in the elevated 10‐year risk group.

Conclusions

The substantial gaps in LDL‐C treatment and goal attainment among members of an employer‐sponsored medical plan who were mostly aware of their LDL‐C levels indicate the need for gap‐closure initiatives.

Microencapsulation as a Tool for the Formulation of Functional Foods: The Phytosterols' Case Study

Hypercholesterolemia, which is an increase in total and low-density lipoprotein (LDL) serum cholesterol, is an important risk factor for the development of cardiovascular diseases. Lifestyle modifications underpin any action plan for reducing serum cholesterol. Phytosterols are natural compounds belonging to the triterpenes family. Thanks to their structural analogy with cholesterol, phytosterols have the ability to reduce serum LDL-cholesterol levels. Phytosterols are used to enrich or fortify a broad spectrum of food products. Like unsaturated fatty acids and cholesterol, phytosterols are easily oxidized. Microencapsulation could be a useful tool to overcome this and other drawbacks linked to the use of phytosterols in food fortification. In this review, in addition to explaining the phytosterols’ mechanisms of action, a focus on the use of free and encapsulated phytosterols for the formulation of functional foods, taking also into account both technological and legislative issues, is given.

Cumulative Meta-Analysis of the Soy Effect Over Time

Background

Soy protein foods have attracted attention as useful plant protein foods with mild cholesterol‐lowering effects that are suitable for inclusion in therapeutic diets. But on the basis of the lack of consistency in significant cholesterol reduction by soy in 46 randomized controlled trials, the US Food and Drug Administration (FDA) is reassessing whether the 1999 heart health claim for soy protein should be revoked.

Methods and Results

We have, therefore, performed a cumulative meta‐analysis on the 46 soy trials identified by the FDA to determine if at any time, since the 1999 FDA final rule that established the soy heart health claim, the soy effect on serum cholesterol lost significance. The cumulative meta‐analysis for both total cholesterol and low‐density lipoprotein cholesterol demonstrated preservation of the small, but significant, reductions seen both before and during the subsequent 14 years since the health claim was originally approved. For low‐density lipoprotein cholesterol, the mean reduction in 1999 was −6.3 mg/dL (95% CI, −8.7 to −3.9 mg/dL; P=0.00001) and remained in the range of −4.2 to −6.7 mg/dL (P=0.0006 to P=0.0002, respectively) in the years after 1999. At no time point did the total cholesterol or low‐density lipoprotein cholesterol reductions lose significance or were the differences at individual time points in the cumulative meta‐analysis significantly different from those seen in 1999 when the health claim was approved.

Conclusions

A cumulative meta‐analysis of the data selected by the FDA indicates continued significance of total cholesterol and low‐density lipoprotein cholesterol reduction after soy consumption and supports the rationale behind the original soy FDA heart health claim.

See Editorial Petersen and Kris‐Etherton

Novel microencapsulated probiotic blend for use in metabolic syndrome: design and in-vivo analysis

The increasing prevalence of the metabolic syndrome has made it a medical issue that currently affects 1 in 5 Canadians. The metabolic syndrome is defined by risk factors that predispose an individual to diabetes and cardiovascular disease. Current forms of interventions have been inadequate as substantiated by the fact that the prevalence of metabolic syndrome has not reduced over the years. The objective of this study was to investigate the therapeutic benefits of a novel microencapsulated probiotic blend in treating the metabolic syndrome. Three probiotic strains were microencapsulated into alginate-polylysine-alginate (APA) microcapsules: L. rhamnosus NCIMB 6375, L. plantarum NCIMB 8826 and L. fermentum NCIMB 5221. From the results, it was observed that the microencapsulated probiotic blend significantly reduced serum total cholesterol, LDL cholesterol and triglyceride levels (reducing from 516 mg/dL to 379 mg/dL, 314 mg/dL to 231 mg/dL and 580 mg/dL to 270 mg/dL, respectively). In addition, the administration of the microencapsulated probiotic blend was found to favourably influence the gut microbiota, decreasing Firmicutes levels and increasing Bacteroidetes levels. Overall, this work demonstrates the potential a microencapsulated probiotic blend could have in targeting multiple risk factors of the metabolic syndrome; however, greater research is still needed.

Patients' views of a behavioral intervention including financial incentives

OBJECTIVES

Clinical trials are increasingly testing the effectiveness of paying patients' financial incentives for achieving desired clinical outcomes. Some researchers and providers are concerned that patient financial incentives will harm the doctor-patient relationship. How patients feel about these approaches, and these trials, is largely unknown. This study examined patients' perceptions of a compound behavioral and financial incentive intervention used in a large multicenter trial to lower low-density lipoprotein cholesterol (LDL-C), including their perceptions of benefits and challenges and the study's effect on patients' relationship with their primary care physicians (PCPs).

STUDY DESIGN

Semi-structured telephone interviews with patients post intervention.

METHODS

PCPs from 3 primary care practices in the northeastern United States were randomized to 1 of 4 arms: physician financial incentives, patient financial incentives, shared incentives between physicians and patients, and a control arm. Within each arm, 10 high, 10 medium, and 10 low performers in LDL-C reduction were interviewed. Interviews targeted reasons for enrolling in the study, the specific intervention elements that helped them reach the goal (incentives, engagement, monitoring), challenges faced in reducing cholesterol, and the impact of study participation on their relationship with their PCP.

RESULTS

Patients reported positive experiences with the study: 65% described personal changes to improve health and 61% reported increased awareness. Views about financial incentives varied: 71% clearly found them motivating and 36% claimed they made no difference. Patients noted that changing lifestyle (36%) and diet (65%) was difficult. Patients who substantially lowered their LDL-C revealed themes similar to those who did not.

CONCLUSIONS

Overall, behavioral interventions with financial incentives appear to be socially acceptable to patients who participate in them. Both adherence monitoring and financial incentives were well received, with little effect on the physician-patient relationship.

Deficiency of Cholesteryl Ester Transfer Protein Protects Against Atherosclerosis in Rabbits

OBJECTIVE

CETP (cholesteryl ester transfer protein) plays an important role in lipoprotein metabolism; however, whether inhibition of CETP activity can prevent cardiovascular disease remains controversial.

APPROACH AND RESULTS

We generated CETP knockout (KO) rabbits by zinc finger nuclease gene editing and compared their susceptibility to cholesterol diet-induced atherosclerosis to that of wild-type (WT) rabbits. On a chow diet, KO rabbits showed higher plasma levels of high-density lipoprotein (HDL) cholesterol than WT controls, and HDL particles of KO rabbits were essentially rich in apolipoprotein AI and apolipoprotein E contents. When challenged with a cholesterol-rich diet for 18 weeks, KO rabbits not only had higher HDL cholesterol levels but also lower total cholesterol levels than WT rabbits. Analysis of plasma lipoproteins revealed that reduced plasma total cholesterol in KO rabbits was attributable to decreased apolipoprotein B-containing particles, while HDLs remained higher than that in WT rabbits. Both aortic and coronary atherosclerosis was significantly reduced in KO rabbits compared with WT rabbits. Apolipoprotein B-depleted plasma isolated from CETP KO rabbits showed significantly higher capacity for cholesterol efflux from macrophages than that from WT rabbits. Furthermore, HDLs isolated from CETP KO rabbits suppressed tumor necrosis factor-α-induced vascular cell adhesion molecule 1 and E-selectin expression in cultured endothelial cells.

CONCLUSIONS

These results provide evidence that genetic ablation of CETP activity protects against cholesterol diet-induced atherosclerosis in rabbits.

Purification of Antilisterial Peptide (Subtilosin A) from Novel Bacillus tequilensis FR9 and Demonstrate Their Pathogen Invasion Protection Ability Using Human Carcinoma Cell Line

This study focuses on isolation, screening, and characterization of novel probiotics from gastrointestinal tract of free-range chicken (Gallus gallus domesticus). Fifty seven colonies were isolated and three isolates (FR4, FR9, and FR12) were selected and identified as Lactobacillus gasseri FR4, Bacillus tequilensis FR9, and L. animalis FR12 by 16S rRNA sequencing. Three strains were able to survive in stimulated acidic and bile conditions and inhibit the growth of pathogens. Especially, FR9 exhibited maximum inhibition against Listeria monocytogenes and none of them exhibited hemolytic activity. Native-PAGE revealed the presence of low molecular weight (3.4-5.0 KDa) antimicrobial peptide. The peptide was further purified by Sephadex G-50 column and RP-HPLC using C18 column. N-terminal amino acid sequencing of antimicrobial peptide showed 100% consensus to antilisterial peptide Subtilosin A and SboA gene was amplified from FR9 genome. FR9 showed maximum aggregation activity, exopolysaccharide production (85.46 mg/L) and cholesterol assimilation (63.12 ± 0.05 μg/mL). Strong adhesion property (12.6%) and pathogen invasion protection ability was revealed by B. tequilensis FR9 towards HCT-116 human colon carcinoma cell line. This is the first study to demonstrate antilisterial Subtilosin A production of B. tequilensis. Our results indicate that B. tequilensis FR9 strain furnish the essential characteristics of a potential probiotics and might be incorporated into human and animal food supplements.

Effect of Replacing Beef Fat with Poppy Seed Oil on Quality of Turkish Sucuk

Sucuk is the most popular dry-fermented meat product. Sucuk has a relatively high fat. Poppy seed oil as animal fat replacer was used in Turkish sucuk and effects of its use on sucuk quality were investigated. There was a significant (p<0.5) treatment × ripening time interaction for moisture, pH (p<0.05) and 2-thiobarbituric acid reactive substances (TBARS) values (p<0.01). Increasing poppy seed oil level decreased (p<0.05) TBARS values. Addition of poppy seed oil to the sucuks had a significant effect (p<0.01) on hardness, cohesiveness, gumminess, chewiness and springiness values. Cholesterol content of sucuks decreased (p<0.05) with poppy seed oil addition. Using pre-emulsified poppy seed oil as partial fat replacer in Turkish sucuk decreased cholesterol and saturated fatty acid content, but increased polyunsaturated fatty acids. Poppy seed oil as partial animal fat replacer in Turkish sucuk may have significant health benefits.

Enhanced cholesterol reduction by simvastatin in diltiazem-treated patients

AIMS

To investigate whether an interaction between diltiazem and the 3-hydroxy-3-methylglutaryl coenzyme A (HMG-CoA) reductase inhibitor simvastatin may enhance the cholesterol-lowering response to simvastatin in diltiazem-treated patients.

METHODS

One hundred and thirty-five patients attending the Sheffield hypertension clinic who started consecutively on simvastatin for primary or secondary prevention of coronary heart disease (CHD) during the 2 years June, 1996-May 1998 were surveyed. From the clinic records we extracted and recorded absolute and percentage cholesterol responses to the starting dose of simvastatin and coprescription of diltiazem.

RESULTS

The cholesterol reduction for the 19 patients on diltiazem was 33.3% compared with 24.7% in the remaining 116 patients (median difference 8.6%, 95% CI 1.1-12.2%, P<0.02). The interindividual variability of cholesterol response to simvastatin was greater for patients not taking diltiazem than for those patients taking diltiazem. The ratio of the variances in response for the nondiltiazem group relative to the diltiazem group was 1.34 at 10 mg simvastatin daily (not significant, 95% CI 0.16-4.11), and 3.42 at 20 mg daily (P<0.01, 95% CI 1.26-7.18). Concurrent diltiazem therapy (P<0.04), age (P=0.001) and starting dose of simvastatin (P=0.002) were found to be significant independent predictors of percentage cholesterol response.

CONCLUSIONS

Patients who take both simvastatin and diltiazem may need lower doses of simvastatin to achieve the recommended reduction in cholesterol. The pharmacokinetic and pharmacodynamic aspects of this interaction need further study to confirm an enhanced effect on cholesterol reduction, and exclude an increased risk of adverse events.