Red yeast rice with monacolin K for the improvement of hyperlipidemia: A narrative review

Table 1 Other nutraceuticals and their main effects on low density lipoprotein cholesterol

Nutraceutical	Active ingredient(s)	Mechanism of action	Side effect(s)	Dosing
Bergamot (Citrus bergamia)	Flavonoids	Inhibits HMG-CoAR and ACAT	GI discomfort and muscle cramps	500-1500 mg/day
Garlic extract	Allicin (diallyl thiosulfinate)	Inhibits HMG-CoAR, acetyl-CoA synthetase, and squalene-monooxygenase	GI upset, body odor, and increase risk of bleeding	0.3-20 g/day
Artichoke leaf extract	Flavonoids, caffeic acid, volatile sesquiterpene, and mono- and dicaffeoylquinic acid	Flavonoids (luteolin) inhibits HMG-CoAR, SREBP, ACAT, and increase GI excretion of bile acids	Skin reactions, GI upset, and potential asthma exacerbation	500-2800 mg/day
Green tea	Catechins	Inhibits inducible NO synthase and HMG-CoAR. Activates AMPK	GI discomfort, hypertension, and skin rashes. Rare adverse effects include hepatotoxicity, hypokalemia, and TTP	100-500 mg/day
Oryza sativa	Gamma-Oryzanol	Inhibition of GI cholesterol absorption and increase fecal excretion of bile acids	Well tolerated	100-300 mg/day
Olive extract	Phenols	Reduce lipid peroxidation, increases bile excretion, inhibits HMG-CoAR and ACAT activity	Well tolerated	136.2 mg of oleuropein and 6.4 mg of hydroxytyrosol per day
Lupin protein	Lupin	Inhibits HMG-CoA and PCSK9 activity. Upregulated SREBP-2	GI discomfort	≤ 35 g/day
β-Glucan	β-Glucan	Decrease absorption from GI tract	Well tolerated	3-5 g/day
Plantago seed	Psyllium	Increases hepatic LDL receptor expression	GI discomfort, allergic reactions, bowel and esophageal obstruction	2-20 g/day
Amorphophallus konjac	Glucomannan	Inhibits HMG-CoAR	GI upset, esophageal, and bowel obstruction	1-15 g/day
Guar (Cyamopsis tetragonoloba or Cyamopsis psoraloides)	Guar Gum	Prevent absorption of cholesterol in the GI tract and increase bile acid excretion	GI upset, esophageal, and bowel obstruction	30-100 g/day
Nigella Sativa	Thymoquinone, flavonoids, and PUFA	Increase biliary excretion, reduce cholesterol synthesis, inhibit lipid oxidation, and upregulate LDL receptors	GI discomfort and transaminitis	200 to 3000 mg for capsules, powders, and extracts. 1-2 mL for oil suspensions
Silymarin	Flavonolignans	Increase lipolysis and β-oxidation via the upregulation. Increase cholesterol efflux via the increased expression of ABCA1	GI discomfort, headache, ureteric stones, and hemolytic anemia	140-700 mg/day
Anthocyanins	Flavonoids	Downregulate the messenger RNA expression of SREBP-1c	Well tolerated	100-450 mg/day
Spirulina	C-phycocyanin	Activates heme oxygenase-1	GI discomfort, rashes, bleeding, cholestasis, and elevated transaminases	1-10 g/day
Alpha lipoic acid	Alpha lipoic acid	Module fat synthesis, mitochondrial β-oxidation of fat, clearance of TG-rich lipoproteins in the liver, and adipose TG accumulation	GI discomfort, skin rashes, and rarely, insulin autoimmune syndrome	300-1800 mg/day
Chitin	Chitosan	Interferes with GI absorption by binding to negatively charged fatty acids and bile acids and disrupting the emulsification of neutrally charged cholesterol	GI discomfort. Avoid use in patients with allergies to shellfish or crustaceans	0.3-3 g/day
Pantothenic acid (B5)	Pantethine	Inhibits HMG-CoA reductase and acetyl-CoA carboxylase	GI upset	600-1200 mg/day

ABCA1: ATP-binding cassette transporter A1; ACAT: Acyl-coenzyme A cholesterol acyltransferase; AMPK: AMP-activated protein kinase; GI: Gastrointestinal; HMG-CoA: 3-hydroxy-3-methylglutaryl coenzyme A; NO: Nitric oxide; PCSK9: Proprotein convertase subtilisin/kexin type 9; PUFA: Polyunsaturated fatty acid; SREBP: Sterol regulatory element-binding protein; TTP: Thrombotic thrombocytopenic purpura.