Red Yeast Rice for Hypercholesterolemia

Red Yeast Rice for Hypercholesterolemia

When rice is steamed with the yeast Monascus purpureus it ferments, creating a red pigment that contains monacolin. Monacolin K is similar in chemical structure to lovastatin. In fact, the makers of lovastatin sued to prevent the marketing of red yeast rice (RYR), but they lost as nature has been making this chemical long before the statin industry.

Think of RYR as a mild statin that inhibits HMG-CoA reductase; but, for reasons unknown, RYR appears to be better tolerated than prescription statins with less associated myositis. Like statins, studies have found it to have other benefits beyond LDL reduction (Table 1).

The risk of these products is that they are not FDA-regulated, and the quality standards can vary. Most of the research has shown benefit from doses of monacolin K between 4 and 10 mg/day. But this is not standardized and rarely included on the label by manufacturers. The average dose is 1200 to 2400 mg daily, which generally contains this amount of monacolin K; but buyer beware.

In the fermentation process of RYR, a nephrotoxic, oncogenic chemical called citrinin can contaminate RYR supplements. Have patients buy products that are citrinin-free. A citrinin-free RYR product will cost about $20/month for 2400 mg daily.

There are good data on RYR showing cardiovascular outcomes similar to those achieved with low- to moderate-dose statins; but statins should be used first line for patients at high cardiovascular risk.

How To Prescribe RYR for Those Who Don’t Tolerate Statins or Don’t Want To Take One

• To reduce the need for a pill or supplement, remind patients that they can reduce their LDL by an average of 20% with a plant-based, high-fiber Mediterranean-type diet; or they can take
• 1200–4800 mg of citrinin-free RYR at bedtime or divided twice daily. Titrate as needed.

RYR inhibits production of LDL. To reduce LDL further, consider adding one of the products below to also reduce cholesterol absorption.

• Ezetimibe 10 mg daily or
• Beta sitosterol (plant sterols) 2.4 g daily (or eat vegetables that contain plant sterols) or
• Psyllium (soluble fiber) 1 tsp in 8–10 oz of water before meals. This also lowers HgbA1c by 0.58% in diabetics.¹

Reference

1. Jovanovski E, Khayyat R, Zurbau A, et al. Should viscous fiber supplements be considered in diabetes control? Results from a systematic review and meta-analysis of randomized controlled trials. Diabetes Care. 2019;42(5):755-766. https://care.diabetesjournals.org/content/42/5/755.long