This article is about primary prevention in cholesterol reduction ie. for people who have no history of heart disease themselves. Risk of heart disease should always consider the range of risk factors including overweight, smoking, significant family history in parents and brothers and sisters. If you have heart disease herbs and supplements may be helpful but you should see a knowledgeable practitioner (www.iimh.org tel. 01 443 4115).

This article will consider some of the supplements and drugs most usually recommended. This is a vast subject so I have taken some of the commonly recommended preparations.

Supplements

• Niacin –1.3-3gms per day (See notes below)
• Omega 3 fatty acids
• Co Q 10 30-200mgd per day
• Red Rice Yeast -600mgs twice daily
• Garlic-minimum 4,000mcg alliciin
• Policinosol
• Lecithin

Omega 3 Fatty Acids.

A supplement of these is definitely recommended if you will not eat Essential Fatty Acids in your diet (see Leaflets www.healtandherbs.ie). These are essential to the very fabric of all cells and the heart is the work horse of body! These are the anti-inflammatory ‘healthy’ fats and inflammation underlies heart disease.

Omega 3 Fats are recommended as part of the European Cardiac Guidelines for any patient who has had a heart attack. Yet few patients are commenced on these despite the evidence.

Garlic.

Research shows mixed results, probably reflecting the variety of both dosage and the differences between formulations. Although the direct effect of lowering overall cholesterol is debatable the combination of effects that are beneficial makes this worth considering. Particularly the beneficial effects on platelets which influence the clotting of blood and the beneficial effect of raising HDL (helpful) cholesterol. Include garlic in your food and if you are considering a supplement look at the Alliciin (4,000mgs per day) content in different preparations as these are most consistently linked to potential benefit.

Niacin Vit B3

History of Niacin for cholesterol

First described in 1950’s and well researched by pharmaceutical companies as one of the first effective drug therapies. It has fallen from favour because the newer drugs are simpler to prescribe and because the main side effects were much more common with the pharmaceutical preparation (sustained release) than with the simple vitamin.

Proven Effects

• Lowers LDL (unhelpful)
• Lowers Triglyceride (unhelpful)
• Raises HDL (helpful)

Niacin reduces overall mortality! This is very significant as much research on other agents (including statins drugs for primary prevention) report various statistical outcomes that reduce risk factors but do not reduce mortality! ie;‘you have the same date on your death certificate, the cause of death has different words’. This is particularly relevant for people who have no history of heart disease.

So why are more people not taking it? Mainly because it takes time to explain how to take it, minimising the side effect of flushing which is harmless but uncomfortable.

Side effects;

70% of people can experience generalised flushing, a sensation of a wave of heat throughout the body. This is harmless but uncomfortable.

To minimise this consider different preparations:

• Immediate release preparations (straightforward Niacin)– start with 100mgs daily and increase gradually by 100mgs every few days until flushing occurs, go back to previous non flushing dose and continue for a week. Then try again to increase by 100mgs. Continue to increase gradually until you achieve therapeutic effect. This requires blood test monitoring every 3 months.
• The flushing effect wears off within 1-2 weeks but it is quite uncomfortable/scary for some people.
• Tablets are also available as 500mgs as you build up the dose you can switch for convenience.
• Dose 1.5-3 gms per day in divided doses with food and water. Drinking water at the onset of a flush may diminish the symptoms.
• Check Liver Function after 3 months, then yearly with cholesterol check.
• Straightforward Niacin has the safest track record and is the most researched of the Niacin preparations. The rare problem of abnormal liver function tests are associated with sustained release preparations. These are generally the ones available on prescription or through pharmacies.
• Niacin as inisotol hexaniacate- (extended release, often marketed as no-flush niacin) 500mgs three times daily and build up to 1,000mgs three times daily.

These are available in pharmacies and health food shops. They have less

problems with flushing but don’t have the same level of research data. They do not appear to have problems with Liver toxicity. They are effective according to the research available but do not have the extensive research available for immediate release preparations.

There is a big difference in cost between immediate release and the Inisotol hexaniacate especially over the long term. For this reason (a larger profit margin) and the long education process involved in the immediate release, retailers often do not mention the different options.

Combining Niacin with statins may increase the risks associated with the statins and requires additional professional advice.

Red Rice Yeast – up to 1200mgs per day in divided doses.

This is prepared from cooked, non glutinous white rice. This is fermented by the yeast Monascus purpureus. It is then sterilised, dried, concentrated and ground. This is a ‘whole’ food which is dried. It is not an extracted constituent. It is a common foodstuff in many Asian countries. The constituent in this food most likely to be effective in reducing cholesterol is Monacolin K which inhibits the enzyme HMGCoA in a similar effect to Statin drugs. However this represents a concentration of only 0.2% of the product. It also contains other potential lipid lowering ingredients. Because of the overlap with statins I do not recommend the two together and I recommend CoQ10 30 mgs daily when using Red Rice Yeast. I also check Liver Function Tests after 3 months and then annually.

Co Q10 (Coenzyme Q 10)

Statins (see below) affect muscle enzymes. Think of the heart as the most phenomenal 24 hour a day/7days a week lifetime marathon runner and you can begin to appreciate the heart as ‘the work horse that is the rhythm of our lives’. The energy releasing enzyme CoQ10 is partly responsible for this and this is depleted in all muscle cells. The heart is particularly vulnerable to reduced levels as it can never take a break! Anyone taking a statin should seriously consider taking a supplement of CoQ10. How much is debatable and a very practical consideration as it is quite costly.

The smallest useful dose is probably 30mgs to accommodate the effect of the drug. Higher doses up to 200mgs may offer support to heart muscle under strain. So if you have had a heart attack or angina (heart pain) you may benefit from higher

amounts, seeing a practitioner is recommended.

Lecithin

This is derived from Soya beans and the dose is 7.5mgs per day taken with food. It is an inexpensive supplement. It acts on the cholesterol in several ways;

It is a source of Choline which beneficially influences lipid (fat) transport in the blood.

It is a building block for cell walls and affects chemical messages, influencing how hormone and nervous stimuli affect the work of the cell.

It inhibits the stickiness of the blood.

Although these are researched actions, few clinical studies have been undertaken regarding cholesterol. All of the above actions are likely to be helpful and it is virtually non-toxic at the above recommended dose.

Policosanol

All supplies and research evidence from one country ie. Cuba and it is a by-product of the sugar cane industry. However research has not been consistently reproducible by others.

Vitamin D3

• From diet (primarily oily fish) and also sunlight. Living in northern Europe we are at risk of Vitamin D deficiency especially if we work indoors. Remember to roll up your sleeves. Avoid burning but enjoy sunshine.
• 70% of new patients to Cork University Hospital Rheumatology Clinic were deficient in Vit D (winter 2007)!
• It is necessary for stress, cancer prevention and the cholesterol metabolic pathways.
• Supplement 1-3,000 iu per day (this is low dose maintenance, to put in context we produce 15-20,000iu via the skin on a sunny day). We store Vitamin D for 6 months so we are especially vulnerable to low levels from February to May.

Drugs

The most commonly prescribed are Statins and Cholesterol Absorption Inhibitors

Statins; eg. Atorvastatin (Lipitor)

• Simvastatin (Zocor)
• Pravastatin (Lipostat)

How do statins work?

• They block the manufacture of cholesterol in the liver by blocking an enzyme HMG-CoA reductase.
• They have additional anti-inflammatory actions.

Side effects of statins;

They are generally well tolerated and side effects are dose related.

However they can cause;

• Upset digestion
• Headache
• Generalised weakness
• Muscle stiffnes/soreness
• Insomnia
• Elevated liver enzymes/muscle enzymes
• Rarely liver damage/severe muscle damage

Monitoring while you take statins;

Check liver function before starting, then after 3 months, then annually. Check muscle enzymes levels after three months or if symptoms.

Interactions between statins and other drugs

• Be careful with Antibiotics-some interact with statins. Macrolides eg. Erythromycin, Clarithromycin (Klacid), Arithromycin.
• Always check with pharmacist regarding other drugs.

Remember Alcohol is a drug and can cause problems

When to stop statins and check with your doctor.

If you experience severe muscular aches and pains stop the medication and see your GP for a blood test to check muscle enzyme levels.

Cholesterol absorption inhibitors;

Eg. Ezetimbe (Ezetrol)

(Combined with statin -(Inegy))

Side Effects

• Headache, upset digestion.
• If combined with a statin the above side effects add to those of the statin.

Other blood markers associated with higher risk of heart attack or stroke.

• CRP-risk factor for inflammation (C-Reactive Protein).
• Homocysteine .

I don’t routinely do these blood tests as they don’t usually influence the action plan. However the added information from these tests can be useful for model patients who have an ideal lifestyle (yes some of my patients do exactly as I tell them!) yet still have raised cholesterol. In this case normal homocysteine and CRP especially when accompanied by a high HDL is reassuring when advising people regarding drug therapy.

Remember cholesterol does not cause heart disease, it is an inflammatory condition. These are markers of inflammation and if they are normal it is reassuring.

Medical conditions Associated with Raised Cholesterol;

• Diabetes mellitus.
• Hypothyroid (low)
• Familial cholesterol disorders.

If you have these conditions you are slightly more likely to have raised cholesterol.

This is a very summarised overview of a complicated and controversial subject. I hope it is helpful in giving you a place to start to make sense of the claims of some products.

As an overview

EFA’S- Essential Fatty Acids

F+V=Fruit and Vegetables

* for members of the Irish Institute of Medical Herbalists see www.iimh.org or tel;014434115

This stepwise approach involves concerted effort and regular monitoring. Usually this programme involves 6-12 months to work through to come to helpful conclusions, including whether drug therapy may be required. As the side effect of statins are dose related it still makes sense to offer an integrated solution with food and herbs, exercise, supplements and drugs.

The benefits of an integrated approach extend beyond the cholesterol ‘number’ and encourage healthy habits that go beyond ‘number crunching’.