Lowering Cholesterol Case Studies

case 1: omega-3 fatty acids

question: TZ, a 52-year-old woman with borderline triglyceride levels, wants to purchase an omega-3 fatty acid supplement. Her doctor suggested she increase her intake of these compounds by eating more fish, but TZ dislikes seafood. What should a pharmacist recommend?

answer: Very long chain polyunsaturated fatty acids such as docosahexaenoic acid (DHA) and eicosapentaenoic acid (EPA) lower triglyceride levels.¹ Seafood and fatty fish are good sources of DHA and EPA, and the American Heart Association recommends consuming such foods two to three times a week to reduce cardiovascular risk. .² However, the recommended omega-3 fatty acid intake for patients who need to lower triglycerides is 2-4 g per day, which is difficult to achieve through diet alone. Fish oil supplements contain varying amounts of his DHA and EPA and can lower triglyceride levels by 25% to 34%.³

One thing to consider about fish oil supplements, especially DHA, is that high doses can increase low-density lipoprotein (LDL) cholesterol. Products containing only EPA have no effect on LDL.³ In addition to recommending EPA-only supplements that have been awarded the United States Pharmacopoeia’s Symbol of Quality Assurance, pharmacists also take TZ with flaxseeds, almonds, hazelnuts, pecans, or peanuts that are rich in omega-3s. should be advised.

Case 2: garlic

question: HY is a 47 year old male seeking advice on garlic supplements for high cholesterol. He has high cholesterol and high blood pressure and will have oral surgery in a month. HY takes 40mg atorvastatin and 10mg lisinopril daily. His relatives told him that garlic helps lower cholesterol and is good for heart health. What should a pharmacist recommend?

answer: Garlic supplements may reduce low-density lipoprotein (LDL) and total cholesterol, but research results are conflicting. Data from a meta-analysis of 39 trials showed that garlic reduced LDL by 9 mg/dL and total cholesterol by 17 mg/dL in patients with total cholesterol >200 mg/dL, but had no significant effect on high-density lipoproteins. It has been shown not to affect HDL) and triglyceride levels.^Four Results from another meta-analysis of patients with coronary artery disease showed that total cholesterol levels were 16 mg/dL lower in those who took garlic than those who took placebo (P = 0.032), although there was no significant difference between garlic and garlic. It was shown that there was no Placebo and his effect on HDL, LDL and triglycerides.^Five Garlic is associated with an increased bleeding risk. Consuming 4 g or more of garlic daily has been shown to increase prothrombin time and prolong bleeding after several weeks.⁶ HY may benefit somewhat from garlic, but should not start taking supplements as surgery is approaching. Pharmacists should instruct patients to maintain a diet high in omega-3 fatty acids and low in saturated fats and to engage in regular physical activity.

Case 3: Aspirin as primary prevention

question: NW wants to take infant aspirin. He is 64 years old, has diabetes and hyperlipidemia, and is on metformin 500 mg and atorvastatin 20 mg daily. He has no previous history of cardiovascular disease, but he had gastrointestinal bleeding 2 months earlier. He is worried about his high cholesterol levels and hears that baby aspirin can prevent heart attacks. What should a pharmacist recommend?

answer: The decision to initiate low-dose aspirin for primary prevention of cardiovascular disease (CVD) must be weighed against the risk of major bleeding. The United States Preventive Services Task Force (USPSTF) recommends low-dose aspirin for adults aged 40 to 59 who have a 10-year risk of atherosclerotic heart disease of at least 10% and an increased risk of CVD. .⁷ Patients who are at high risk of bleeding or who cannot take low-dose aspirin daily are less likely to benefit.⁷

The USPSTF recommends against using low-dose aspirin for primary prevention of CVD in adults over the age of 60 because of the increased risk of bleeding.⁷ Similarly, the American College of Cardiology and the American Heart Association do not recommend low-dose aspirin for people over the age of 70 or those at high bleeding risk.⁸ Adults with a history of gastrointestinal bleeding, bleeding elsewhere, thrombocytopenia, and use of anticoagulants or nonsteroidal anti-inflammatory drugs are at increased risk of bleeding.⁸. NW is not a candidate for primary prophylaxis with low-dose aspirin because she is 64 years old and has experienced gastrointestinal bleeding.

Case 4: red yeast rice

question: DP is a 49 year old female who wants to know about natural cholesterol lowering products. A month ago, she was diagnosed with hypercholesterolemia and she was started on rosuvastatin 5 mg daily, which she recently had to discontinue due to severe muscle pain. DP prefers to avoid statin therapy altogether. She remembers seeing an article online about the power of red yeast rice (RYR) to lower cholesterol levels. What should a pharmacist recommend?

answer: RYR has been shown to lower cholesterol levels. One of its ingredients, monacolin K, inhibits cholesterol production and is chemically identical to the first commercial statin, lovastatin.⁹. A meta-analysis of 20 trials showed that, on average, RYR reduced low-density lipoprotein (LDL) cholesterol by 39.4 mg/dL compared with placebo after 2 to 24 months. In 10 studies, RYR doses varied from 1200 to 4800 mg daily and contained the following components: Monacolin K 4.8-24 mg. Three of the studies compared RYR to low-intensity statins and found similar LDL reductions in both groups (mean difference, 0.54 mg/dL).^Ten RYR minimally improved high-density lipoprotein and triglyceride levels, and no increase in myopathy was observed with daily monacolin K doses of 3-10 mg.¹¹

DP may experience some LDL-lowering effects with RYR, but should not be combined with statins or citachrome P450 3A4 inhibitors due to increased risk of myotoxicity. You should also be advised to choose his RYR product, US Pharmacopoeia certified, which contains 3-10 mg of monacolin K per day. The DP should notify her doctor if she starts taking RYR.

References

1. Goldberg RB, Sabawal AK. Fish oil in the treatment of dyslipidemia. Current opinion Endocrinology Diabetes Obesity. 2008;15(2):167-174. Doi: 10.1097/MED.0b013e3282f76728
2. Lichtenstein AH, Appel LJ, Vadiveloo M, et al. Dietary Guidance to Improve Cardiovascular Health: A Scientific Statement by the American Heart Association. Circulation. 2021;144(23):e472-e487. Doi: 10.1161/CIR.0000000000001031
3. Bradbury JC, Hillman DE. An overview of omega-3 fatty acid therapy. P T. 2013;38(11):681-691.
4. Ried K, Toben C, Fakler P. Effects of garlic on serum lipids: an updated meta-analysis. Nutr Rev. 2013;71(5):282-299. Doi: 10.1111/nure.12012
5. Kheirmandparizi M, Keshavarz P, Nowrouzi-Sohrabi P, et al. Effect of garlic extract on lipid profiles in patients with coronary artery disease: a systematic review and meta-analysis of randomized clinical trials. International J Clinical Practice. 2021;75(12):e14974. doi:10.1111/ijcp.14974
6. Woodbury A, Sniecinski R. Garlic Surgical Bleeding: How Much Is Too Much? AA Case Manager 2016;7(12):266-269. Doi: 10.1213/XAA.0000000000000403
7. United States Task Force on Preventive Services, Davidson KW, Barry MJ, et al. Aspirin Use to Prevent Cardiovascular Disease: Statement of Recommendations from the United States Task Force on Preventive Services. jam. 2022;327(16):1577-1584. Doi: 10.1001/jama.2022.4983
8. Arnett DK, Blumenthal RS, Albert MA, et al. 2019 ACC/AHA Guidelines for Primary Prevention of Cardiovascular Disease: Report of the American College of Cardiology/American Heart Association Task Force on Clinical Practice Guidelines. Circulation. 2019;140(11):e596-e646. Doi: 10.1161/CIR.0000000000000678
9. California Red Yeast Rice Formulation: Is it a Good Alternative to Statins? I’m J Med. 2017;130(10):1148-1150. doi:10.1016/j.amjmed.2017.05.013
10. Gerrards MC, Teru RJ, Yu H, Kok CHW, and Gerdes VEA. Red yeast rice, a traditional Chinese lipid-lowering agent, produces significant LDL reduction, but safety is uncertain – a systematic review and meta-analysis. Atherosclerosis. 2015;240(2):415-423. Doi:10.1016/j.atherosclerosis.2015.04.004
11. Fogach F, Banach M, Mihairidis DP, et al. Safety of red yeast rice supplements: a systematic review and meta-analysis of randomized controlled trials. Institute of Pharmacology 2019;143:1-16. Doi: 10.1016/j.phrs.2019.02.028

About the author

Jahnavi Yetukuri, Doctor of Pharmacy, is the PGY-1 pharmacy resident at Atlantic Health System in Morristown, New Jersey.

Rupal Patel Mansukhani, PharmD, FAPhA, NCTTP, He is a Clinical Associate Professor of Pharmacy Practice and Administration at the Ernest Mario School of Pharmacy, University of New Jersey Rutgers, Piscataway, and a Transitional Clinical Pharmacist at Morristown Medical Center.