The Role of Nutraceuticals in the Optimization of Lipid-Lowering Therapy in High-Risk Patients with Dyslipidaemia

Abstract

Purpose of Review We aimed to summarize recent guidelines, position papers, and high-quality clinical research relating the use of nutraceuticals in the management of individuals at high risk of atherosclerotic cardiovascular disease. Recent Findings It is essential that individuals at high risk of cardiovascular disease receive guideline-directed evidence-based therapies to reduce their risk of morbidity and mortality from cardiovascular events. Compared with conventional therapeutics, nutraceuticals have undergone relatively little investigation in randomized controlled trials. Thus, recommendations for nutraceuticals in international guidelines are rare, and nutraceuticals should not be used preferentially in place of statins. Nevertheless, recent position papers from the International Lipid Expert Panel and clinical evidence from studies of triglyceride reduction by polyunsaturated fatty acid administration demonstrate that nutraceuticals do have an important role in optimizing therapy in individuals at high risk of cardiovascular disease. Roles for nutraceuticals include as follows: (1) managing residual risk associated with lipids other than low-density lipoprotein cholesterol (LDL-C); (2) managing non-lipid-mediated residual risk; (3) optimizing LDL-C treatment in statin intolerance; (4) optimizing LCL-C treatment when add-on therapies for statins are not available; (5) as adjuncts to lifestyle for individuals at high lifetime risk of atherosclerotic cardiovascular disease (ASCVD). The strength of evidence for each of these applications is variable. Summary In addition to guideline-directed therapeutics, nutraceuticals may have roles in optimizing preventative therapy and targeting residual risk in individuals at high risk of ASCVD. Application of Good Manufacturing Practice and randomized controlled trials when producing and evaluating nutraceuticals will expand the armoury of evidence-based agents for the prevention of ASCVD.

Practical guidance for combination lipid-modifying therapy in high- and very-high-risk patients: A statement from a European Atherosclerosis Society Task Force

“…Combinations of nutraceuticals with confirmed lipid-lowering may enhance their effects [64]. In randomized clinical trials, the combination of berberine, policosanol and RYR achieved LDL-C lowering of up to 25%, similar to low-dose statins [58].…”

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

“…These include: patients with elevated lipids, but low overall risk of CVD [29]. Patients at high risk of CVD who fail to meet lipid treatment goals with conventional phrmaceuticals [8], athletes and patients performing regular intense exercise [30], patients with heart failure [15] and individuals who experience statin intolerance [13,17]. These are discussed further in Section 9, below.…”

“…One such product, Armolipid Plus ®, has been demonstrated to reduce TC by 11-21% and LDL-C by 15-31%, a response similar to that expected with low-dose statins [69,70] (albeit without long-term follow-up data on outcomes). At the other end of the risk spectrum, ILEP experts have outlined how nutraceuticals might be used in high risk subjects who cannot achieve treatment targets with statins and conventional therapies, and for whom more potent agents such PCSK9 inhibitors may not be affordable or appropriate [8]. ILEP have also produced advice on the management of statin intolerance, which may include the use of nutraceuticals, especially in the vast majority of cases where intolerance is 'partial' (i.e.…”

“…These publications describe investigations into a very wide range of whole foods, and specific natural products with putative anti-atherosclerotic actions. The foods and substances have been identified by a variety of mechanisms, including studies comparing dietary patterns (and disease prevalence) between different countries, from determining the constituents of traditional remedies, and from experimental studies which have identified effects of natural products on biological targets involved in the pathogenesis of atherosclerosis [7][8][9].…”

Pharmacological Activities of Sulfated Fucose-Rich Polysaccharides after Oral Administration: Perspectives for the Development of New Carbohydrate-Based Drugs

“…Thus, the management of blood lipid levels has an enormous significance for the control of these diseases. However, many patients fail to reach target levels of lipids with currently available drugs and still experience adverse clinical evolution [ 35 ]. Thus, additional pharmaceutical strategies are required to fill these gaps in efficacy and tolerability.…”