Red yeast rice and LDL

Patients may be asking about red yeast rice for the treatment of hypercholesterolemia because of a recent study in the Annals of Internal Medicine. Patients were recruited from a cardiology practice in suburban Philadelphia who had had a history of statin-associated myalgias. Thirty-one patients were randomized to receive red yeast rice 1800 mg or placebo twice daily for 24 weeks. All patients were also enrolled in a 12-week therapeutic lifestyle program. Red yeast rice was effective in lowering LDL-cholesterol an average of 43 mg/dL from baseline at week 12 and 35 mg/dL at week 24 compared to reductions of 11 mg/dL at week 12 (P < 0.001) and 15 mg/dL at week 24 (P = 0.011) in the lifestyle-only group. Total cholesterol was also lowered in the treatment group, although there was no change in HDL-cholesterol or triglycerides. Treatment with red yeast rice was not associated with changes in liver enzymes or CPK levels and there was no difference in weight loss or pain severity scores between the two groups. The authors conclude that red yeast rice and therapeutic lifestyle change decreased LDL-cholesterol without increasing CPK or pain levels in patients with a history of statin-related myopathy (Ann Intern Med 2009;150:830-839).

The study is interesting because of the large number of patients who do not tolerate statins due to muscle pain and weakness. These patients frequently experience myalgias without myositis (normal CPK levels), and the majority continue to have symptoms despite dose adjustments or changing to a different statin. Red yeast rice is a Chinese supplement known to contain naturally occurring lovastatin (monocolin K) and other monocolins that inhibit HMG-CoA reductase, the same enzyme targeted by statins. It is unclear why red yeast rice is better tolerated than commercial statins, but the authors suggest it may be due to the relatively low dose of the statin, or other, yet undiscovered properties of red yeast rice. The authors also point out that since red yeast rice is a supplement, the chemical composition of different manufacturers is problematic and that patients should be monitored while taking the product. These findings beg the question whether low-dose generic lovastatin may be equally well tolerated, but future studies may help determine if red yeast rice has unique properties that make it an option for the many patients who do not tolerate statins and need to lower cholesterol. In 2007, the FDA issued a warning to consumers to avoid red yeast rice because it contains a pharmaceutical drug, though most products marketed in this country contain negligible amounts of lovastatin.