Comparison of the efficacy and tolerability of policosanol with atorvastatin in elderly patients with type II hypercholesterolaemia

Comparison of the In Vivo Efficacy of Cuban (Raydel®) and Chinese (BOC Science) Policosanol in Alleviating Dyslipidemia and Inflammation via Safeguarding Major Organs and Reproductive Health in Hyperlipidemic Zebrafish: A Twelve-Week Consumption Study

Policosanol is a blend of long-chain aliphatic alcohols (LCAAs) and is well-known for several health-beneficial activities; however, the functionality of policosanol varied substantially based on the composition of LCAAs. In this study, two distinct policosanols, Raydel® (extracted from Cuban sugarcane wax) and BOC Sciences (extracted from Chinese sugarcane wax), were dietarily supplemented (0.1% w/w) for 12 weeks in hyperlipidemic zebrafish to examine their influence on the blood lipid profile and functionality of the liver, kidney, and reproductive organs. The results demonstrated a noteworthy impact of both policosanols on preventing high-cholesterol diet (HCD, 4% w/w)-induced dyslipidemia by decreasing total cholesterol (TC) and triglyceride (TG) levels in the plasma. However, compared to BOC Sciences, the Raydel® policosanol exhibited a significantly (p < 0.05) higher efficacy in reducing HCD-induced TC and TG levels. A substantial effect was observed exclusively with the Raydel® policosanol in mitigating HCD-impaired low-density-lipoprotein cholesterol (LDL-C) and high-density-lipoprotein cholesterol (HDL-C) levels. Hepatic histology and immunohistochemistry (IHC) analysis revealed the higher efficacy of Raydel® policosanol over BOC Sciences policosanol to prevent HCD-provoked fatty liver changes, cellular senescence, oxidative stress, and interleukin (IL)-6 production. Consistently, a significantly higher effect of Raydel® over BOC Sciences policosanol was observed on the protection of kidney, testis, and ovary morphology hampered by HCD consumption. In addition, Raydel® policosanol exhibited a notably stronger effect (~2-fold, p < 0.05) on the egg-laying ability of the zebrafish compared to policosanol from BOC Sciences. Furthermore, Raydel® policosanol plays a crucial role in improving embryo viability and mitigating developmental defects caused by the intake of an HCD. Conclusively, Raydel® policosanol displayed a substantially higher efficacy over BOC Sciences policosanol to revert HCD-induced dyslipidemia, the functionality of vital organs, and the reproductive health of zebrafish.

Assessing the structural stability and drug encapsulation efficiency of poly(ethylene glycol)-poly(L-lactic acid) nanoparticles loaded with atorvastatin calcium: Based on dissipative particle dynamics

Block polymer micelles have been proven highly biocompatible and effective in improving drug utilization for delivering atorvastatin calcium. Therefore, it is of great significance to measure the stability of drug-loading nano micelles from the perspective of block polymer molecular sequence design, which would provide theoretical guidance for subsequent clinical applications. This study aims to investigate the structural stability of drug-loading micelles formed by two diblock/triblock polymers with various block sequences through coarse-grained dissipative particle dynamics (DPD) simulations. From the perspectives of the binding strength of poly(L-lactic acid) (PLLA) and polyethylene glycol (PEG) in nanoparticles, hydrophilic bead surface coverage, and the morphological alteration of nanoparticles induced by shear force, the ratio of hydrophilic/hydrophobic sequence length has been observed to affect the stability of nanoparticles. We have found that for diblock polymers, PEG3kda-PLLA2kda has the best stability (corresponding hydrophilic coverage ratio is 0.832), while PEG4kda-PLLA5kda has the worst (coverage ratio 0.578). For triblock polymers, PEG4kda-PLLA2kda-PEG4kda has the best stability (0.838), while PEG4kda-PLLA5kda-PEG4kda possesses the worst performance (0.731), and the average performance on stability is better than nanoparticles composed of diblock polymers.

Association of octacosanol supplementation with redox status in patients on chronic statin therapy

Background

The uneven lipid-lowering statin effects and statin intolerance raise interest regarding the involvement of coadministration of statins and dietary supplements. This study aimed to evaluate the effects of octacosanol supplementation on markers of redox status in cardiovascular patients on chronic atorvastatin therapy.

Methods

A double-blind, randomized, placebo-controlled, single-centre study was conducted. Redox status homeostasis parameters [i.e., advanced oxidation protein products (AOPP), pro-oxidant-antioxidant balance (PAB), total oxidant status (TOS), total antioxidant status (TAS), superoxide dismutase activity (SOD), total protein sulfhydryl (SHgroups), and paraoxonase 1 (PO N 1) activity] were assessed in 81 patients. According to favorable changes in lipid profile, patients were classified into two groups: responders (n = 35) and non-responders (n = 46), and followed for 13 weeks. A principal component analysis (PCA) was applied to explore the effect of octacosanol supplementation and the relationship between investigated parameters as predictors of responders' and non-responders' status.

Results

Significant decrease in Oxy-score value was found at the endpoint compared to baseline in responders' group (21.0 (13.4-25.5) versus 15.1 (12.4-18.0); P < 0.01). PCA analysis extracted 4 significant factors in the both groups, whereas extracted factors containing "octacosanol status" variable explained 14.7% and 11.5% of the variance in responders' and non-responders' subgroups, respectively.

Conclusions

Octacosanol supplementation leads to an improvement of lipid profile and markers of redox status in responders' group. New studies are needed to validate our results in order to find the best approach for personalized supplementation as a useful adjunct to standard statin therapy.

Therapeutic potential of policosanol in the concurrent management of dyslipidemia and non-alcoholic fatty liver disease

Background

High-fat diet (HFD) possesses a major cause of cardiovascular disease, and hepatosteatosis. Unfortunately, long-term use of statins has a theoretical possibility of worsening of hepatic histology in the patients with non-alcoholic fatty liver disease (NAFLD). The objective of the study was to explore hepatoprotective potential of policosanol as an alternative to statins in experimental NAFLD. For the same, young male Wistar rats were fed with HFD for 8 weeks to induce NAFLD. 48 adult Wistar rats were distributed into six investigational groups: normal control, HFD control, and four treatment groups, receiving policosanol (50 and 100 mg/kg/day), atorvastatin (30 mg/kg/day), and silymarin (100 mg/kg/day) for 8 weeks along with HFD.

Result

HFD consumption caused profound hepatotoxicity evident by hepatic oxidative stress, increased Serum glutamic oxaloacetic transaminase (SGOT), Serum glutamic pyruvic transaminase (SGPT), Alkaline phosphatase (ALP), and bilirubin content. Treatment with policosanol (100 mg/kg) markedly reduced the elevated SGOT, SGPT, and ALP levels in HFD-fed rats. Moreover, policosanol significantly reduced hepatic oxidative stress manifest by reduced malondialdehyde (MDA) and increased glutathione (GSH) level. The treatment with policosanol (100 mg/kg) was found to be more active in attenuating the HFD-induced hepatotoxicity as compared to policosanol (50 mg/kg) and atorvastatin (30 mg/kg). Moreover, we observed that the hepatoprotective potential of policosanol was comparable to the silymarin.

Conclusions

The results of the study clearly indicated that the policosanol could be considered an intriguing approach for the treatment of NAFLD.

Yanyu Decoction for Aged Patients with Stable Coronary Artery Disease: A Systematic Review and Meta-Analysis

Background

There was limited evidence of treatments aiming at aged coronary artery disease (CAD) patients. Yanyu decoction (YD) has been used as adjuvant therapy in aged patients with stable CAD and might be a new treatment worthy of recommendation for CAD patients. This study was to evaluate the combined effects of YD plus conventional pharmaceutical treatment (CPT) on senile patients with stable CAD.

Methods

This review was designed according to the PRISMA (Preferred Reported Items for Systematic Reviews and Meta-Analysis) recommendations. A literature search was conducted in seven electronic databases from their inception until August 2020. Primary outcomes of interest were adverse cardiovascular events, including cardiac mortality, acute myocardial infarction (AMI), and unstable angina (UA). The secondary outcomes were blood lipids and hemorheology. Studies were pooled to calculate the risk ratio or weighted mean difference and corresponding 95% confidence interval.

Results

Five studies recruiting 848 aged patients with stable CAD were included. Patients receiving YD as an adjuvant have fewer adverse cardiovascular events, including cardiac mortality, AMI, and UA. Besides, YD plus CPT has a better effect on reducing triglycerides, low-density lipoprotein cholesterol, and improving high-density lipoprotein cholesterol. Moreover, significant effects of YD plus CPT for reducing blood viscosity, plasma viscosity, and platelet aggregation rate were found compared with CPT alone.

Conclusion

YD plus CPT showed better efficacy than CPT on reducing adverse cardiovascular events and improving hemorheology and blood lipids for aged patients with stable CAD. Our findings may suggest YD as an adjuvant natural-based treatment for CAD. However, more rigorous and larger trials are essential to validate our results, and further consideration of CAD studies specific to aged patients is needed.

The potential of Atorvastatin for chronic lung diseases therapy

Atorvastatin (ATO) is of the statin class and is used as an orally administered lipid-lowering drug. ATO is a reversible synthetic competitive inhibitor of 3-hydroxy-3-methyl-glutaryl-CoA (HMG-CoA) reductase thus leading to a reduction in cholesterol synthesis. It has recently been demonstrated that ATO has different pharmacological actions, which are unrelated to its lipid-lowering effects and has the ability to treat chronic airway diseases. This paper reviews the potential of ATO as an anti-inflammatory, antioxidant, and anti-proliferative agent after oral or inhaled administration. This paper discusses the advantages and disadvantages of using ATO under conditions associated with those found in the airways. This treatment could potentially be used to support the formulating of ATO as an inhaler for the treatment of chronic respiratory diseases.

The position of functional foods and supplements with a serum LDL-C lowering effect in the spectrum ranging from universal to care-related CVD risk management

A wealth of data demonstrates a causal link between serum low-density lipoprotein cholesterol (LDL-C) concentrations and cardiovascular disease (CVD). Any decrease in serum LDL-C concentrations is associated with a decreased CVD risk, and this benefit is similar to a comparable LDL-C reduction after drug treatment and dietary intervention. Moreover, life-long reductions in serum LDL-C levels have a large impact on CVD risk and a long-term dietary enrichment with functional foods or supplements with a proven LDL lowering efficacy is therefore a feasible and efficient approach to decrease future CVD risk. Functional foods with an LDL-C lowering effect can improve health and/or a reduce the risk of disease. However, it has not been mentioned specifically whether this concerns mainly universal prevention or whether this can also be applied to the hierarchy towards care related prevention. Therefore, we here describe the effects of a list of interesting functional food ingredients with proven benefit in LDL-C lowering. In addition, we pay particular attention to the emerging evidence that the addition of these functional ingredients and supplements is advisable as universal and selective prevention in the general population. Moreover, functional ingredients and supplements are also helpful in care related prevention, i.e. in patients with elevated LDL-C concentrations who are statin-intolerant or are not able to achieve their LDL-C target levels. Furthermore, we will highlight practical aspects regarding the use of functional foods with an LDL-C lowering effect, such as the increasing importance of shared decision making of medical doctors and dieticians with patients to ensure proper empowerment and better adherence to dietary approaches. In addition, we will address costs issues related to the use of these functional foods, which might be a barrier in some populations.

Potential role of phytochemicals in metabolic syndrome prevention and therapy

Metabolic syndrome (MetS) is a set of cardiovascular risk factors which severely increases the risk of type II diabetes, renal disease and cardiovascular disease. Over the last decades, the role of dietary bioactive substances in features of MetS has been extensively investigated. Due to their multiple properties, these plant-derived natural compounds have demonstrated to provide positive effects in obesity, diabetes, renal and in cardiovascular disease. Catechins of green tea and caffeine reduce body mass index and waist circumference. Catechins, anthocyanins and proanthocyanidins of cocoa reduce blood pressure and blood glucose. Curcumin and silymarin exert hepatoprotective effects. Monacolins of red yeast rice are effective cholesterol-lowering agents. However, inconsistent or conflicting results have been found in clinical trials when other promising compounds in vitro or in animal studies, such as policosanol, curcumin or silymarin, were used. Low oral bioavailability of substances, ineffective dosages, inadequate treatment duration and insufficient statistical approach may explain the lack of effectiveness observed in some human studies. Further clinical studies are needed to better understand the role of bioactive compounds in the prevention and management of MetS.

Food Ingredients That Inhibit Cholesterol Absorption

Cholesterol is a vital component of the human body. It stabilizes cell membranes and is the precursor of bile acids, vitamin D and steroid hormones. However, cholesterol accumulation in the bloodstream (hypercholesterolemia) can cause atherosclerotic plaques within artery walls, leading to heart attacks and strokes. The efficiency of cholesterol absorption in the small intestine is of great interest because human and animal studies have linked cholesterol absorption with plasma concentration of total and low density lipoprotein cholesterol. Cholesterol absorption is highly regulated and influenced by particular compounds in the food supply. Therefore, it is desirable to learn more about natural food components that inhibit cholesterol absorption so that food ingredients and dietary supplements can be developed for consumers who wish to manage their plasma cholesterol levels by non-pharmacological means. Food components thus far identified as inhibitors of cholesterol absorption include phytosterols, soluble fibers, phospholipids, and stearic acid.

Functional foods and dietary supplements for the management of dyslipidaemia

Dyslipidaemia is characterized by increased blood levels of total or LDL cholesterol and triglycerides, or decreased HDL cholesterol levels, and is a risk factor for cardiovascular disease. Dyslipidaemia has a high worldwide prevalence, and many patients are turning to alternatives to pharmacotherapy to manage their lipid levels. Lifestyle modification should be emphasized in all patients to reduce cardiovascular risk and can be initiated before pharmacotherapy in primary prevention of cardiovascular disease. Many functional foods and natural health products have been investigated for potential lipid-lowering properties. Those with good evidence for a biochemical effect on plasma lipid levels include soy protein, green tea, plant sterols, probiotic yogurt, marine-derived omega-3 fatty acids and red yeast rice. Other products such as seaweed, berberine, hawthorn and garlic might confer some limited benefit in certain patient groups. Although none of these products can reduce lipid levels to the same extent as statins, most are safe to use in addition to other lifestyle modifications and pharmacotherapy. Natural health products marketed at individuals with dyslipidaemia, such as policosanol, guggulsterone and resveratrol, have minimal definitive evidence of a biochemical benefit. Additional research is required in this field, which should include large, high-quality randomized controlled trials with long follow-up periods to investigate associations with cardiovascular end points.

Safety and efficacy of policosanol in patients with high on-treatment platelet reactivity after drug-eluting stent implantation: two-year follow-up results

OBJECTIVES

To investigate safety and efficacy of policosanol in patients with high on-treatment platelet reactivity after drug-eluting stent implantation.

BACKGROUND

Certain number of patients has high residual platelet reactivity on clopidogrel after coronary intervention, and their risk of thrombotic events is high.

METHOD

In this prospective, randomized trial conducted in four Chinese sites, 350 patients with high on-treatment platelet reactivity (HPR, defined as platelet aggregation >65%) were randomized by the ratio of 1:3:3 to: group A, clopidogrel 75 mg/d for 1 year (n=50); group B, clopidogrel 150 mg/d for 30 days followed by 75 mg/d until 1 year (n=150); or group C, policosanol 40 mg/d for 6 month and clopidogrel 75 mg/d for 1 year (n=150). All of them were treated with aspirin. The primary endpoint was the reversion rate of HPR at 1 month (reversion was defined as platelet aggregation <65%). The secondary endpoints were 6-month major adverse cardiac events (MACE), which included cardiac death, nonfatal myocardial infarction, or ischemic symptoms driven target vessel revascularization.

RESULTS

At 30 days, the reversion rate of HPR was 34.0%, 55.2%, and 48.7% in group A, group B, and group C, respectively (P=.029). Major adverse cardiac events occurred in 4 (8.0%), 6(4.0%), and 5(3.3%) patients (P=.342). There was 1 (0.7%) major bleeding and 1 (0.7%) minor bleeding event in high maintenance dose clopidogrel group, no major or moderate bleeding in the other two groups. The minimal bleeding in group B was significantly higher than group C (10.7% vs 2.7%, P=.022). At 2-year follow-up, the benefits of policosanol on bleedings persisted compared with group B.

CONCLUSIONS

Policosanol reduced platelet reactivity to a similar extent as high maintenance dose of clopidogrel without increasing bleeding rate.

Joint position statement on "Nutraceuticals for the treatment of hypercholesterolemia" of the Italian Society of Diabetology (SID) and of the Italian Society for the Study of Arteriosclerosis (SISA)

AIM

Evidence showed that LDL-cholesterol lowering is associated with a significant cardiovascular risk reduction. The initial therapeutic approach to hypercholesterolemia includes dietary modifications but the compliance to recommendations is often inadequate. Some dietary components with potential cholesterol-lowering activity are present in small amounts in food. Therefore, in recent years the use of "nutraceuticals" (i.e., nutrients and/or bioactive compounds with potential beneficial effects on human health) has become widespread. Such substances may be added to foods and beverages, or taken as dietary supplements (liquid preparations, tablets, capsules). In the present manuscript, the cholesterol-lowering activity of some nutraceuticals (i.e. fiber, phytosterols, soy, policosanol, red yeast rice and berberine) will be discussed along with: 1) the level of evidence on the cholesterol-lowering efficacy emerging from clinical trial; 2) the possible side effects associated with their use; 3) the categories of patients who could benefit from their use.

DATA SYNTHESIS

Based on the current literature, the cholesterol-lowering effect of fiber, phytosterols and red yeast rice is consistent and supported by a good level of evidence. Over berberine, there is sufficient evidence showing significant cholesterol-lowering effects, although the results come from studies carried out almost exclusively in Asian populations. Data on the effects of soy are conflicting and, therefore, the strength of recommendation is quite low. The evidence on policosanol is inconclusive.

CONCLUSION

Although health benefits may arise from the use of nutraceuticals with cholesterol-lowering activity, their use might be also associated with possible risks and pitfalls, some of which are common to all nutraceuticals whereas others are related to specific nutraceuticals.

Lipid-lowering efficacy of atorvastatin

BACKGROUND

This represents the first update of this review, which was published in 2012. Atorvastatin is one of the most widely prescribed drugs and the most widely prescribed statin in the world. It is therefore important to know the dose-related magnitude of effect of atorvastatin on blood lipids.

OBJECTIVES

Primary objective To quantify the effects of various doses of atorvastatin on serum total cholesterol, low-density lipoprotein (LDL)-cholesterol, high-density lipoprotein (HDL)-cholesterol and triglycerides in individuals with and without evidence of cardiovascular disease. The primary focus of this review was determination of the mean per cent change from baseline of LDL-cholesterol. Secondary objectives • To quantify the variability of effects of various doses of atorvastatin.• To quantify withdrawals due to adverse effects (WDAEs) in placebo-controlled randomised controlled trials (RCTs).

SEARCH METHODS

We searched the Cochrane Central Register of Controlled Trials (CENTRAL) (Issue 11, 2013), MEDLINE (1966 to December Week 2 2013), EMBASE (1980 to December Week 2 2013), Web of Science (1899 to December Week 2 2013) and BIOSIS Previews (1969 to December Week 2 2013). We applied no language restrictions.

SELECTION CRITERIA

Randomised controlled and uncontrolled before-and-after trials evaluating the dose response of different fixed doses of atorvastatin on blood lipids over a duration of three to 12 weeks.

DATA COLLECTION AND ANALYSIS

Two review authors independently assessed eligibility criteria for studies to be included and extracted data. We collected information on withdrawals due to adverse effects from placebo-controlled trials.

MAIN RESULTS

In this update, we found an additional 42 trials and added them to the original 254 studies. The update consists of 296 trials that evaluated dose-related efficacy of atorvastatin in 38,817 participants. Included are 242 before-and-after trials and 54 placebo-controlled RCTs. Log dose-response data from both trial designs revealed linear dose-related effects on blood total cholesterol, LDL-cholesterol, HDL-cholesterol and triglycerides. The Summary of findings table 1 documents the effect of atorvastatin on LDL-cholesterol over the dose range of 10 to 80 mg/d, which is the range for which this systematic review acquired the greatest quantity of data. Over this range, blood LDL-cholesterol is decreased by 37.1% to 51.7% (Summary of findings table 1). The slope of dose-related effects on cholesterol and LDL-cholesterol was similar for atorvastatin and rosuvastatin, but rosuvastatin is about three-fold more potent. Subgroup analyses suggested that the atorvastatin effect was greater in females than in males and was greater in non-familial than in familial hypercholesterolaemia. Risk of bias for the outcome of withdrawals due to adverse effects (WDAEs) was high, but the mostly unclear risk of bias was judged unlikely to affect lipid measurements. Withdrawals due to adverse effects were not statistically significantly different between atorvastatin and placebo groups in these short-term trials (risk ratio 0.98, 95% confidence interval 0.68 to 1.40).

AUTHORS' CONCLUSIONS

This update resulted in no change to the main conclusions of the review but significantly increases the strength of the evidence. Studies show that atorvastatin decreases blood total cholesterol and LDL-cholesterol in a linear dose-related manner over the commonly prescribed dose range. New findings include that atorvastatin is more than three-fold less potent than rosuvastatin, and that the cholesterol-lowering effects of atorvastatin are greater in females than in males and greater in non-familial than in familial hypercholesterolaemia. This review update does not provide a good estimate of the incidence of harms associated with atorvastatin because included trials were of short duration and adverse effects were not reported in 37% of placebo-controlled trials.

Policosanol attenuates statin-induced increases in serum proprotein convertase subtilisin/kexin type 9 when combined with atorvastatin

Objective. Statin treatment alone has been demonstrated to significantly increase plasma proprotein convertase subtilisin/kexin type 9 (PCSK9) levels. The effect of policosanol combined with statin on PCSK9 is unknown. Methods. Protocol I: 26 patients with atherosclerosis were randomly assigned to receive either atorvastatin 20 mg/d or policosanol 20 mg/d + atorvastatin 20 mg/d for 8 weeks. Protocol II: 15 healthy volunteers were randomly assigned to either policosanol 20 mg/d or a control group for 12 weeks. Serum levels of PCSK9 were determined at day 0 and the end of each protocol. Results. Protocol I: atorvastatin 20 mg/d significantly increased serum PCSK9 level by 39.4% (256 ± 84 ng/mL versus 357 ± 101 ng/mL, P = 0.002). However, policosanol 20 mg/d + atorvastatin 20 mg/d increased serum PCSK9 level by only 17.4% without statistical significance (264 ± 60 ng/mL versus 310 ± 86 ng/mL, P = 0.184). Protocol II: there was a trend toward decreasing serum PCSK9 levels in the policosanol group (289 ± 71 ng/mL versus 235 ± 46 ng/mL, P = 0.069). Conclusion. Policosanol combined with statin attenuated the statin-induced increase in serum PCSK9 levels. This finding indicates that policosanol might have a modest effect of lowering serum PCSK9 levels.

Nutraceutical and functional scenario of wheat straw

In the era of nutrition, much focus has been remunerated to functional and nutraceutical foodstuffs. The health endorsing potential of such provisions is attributed to affluent phytochemistry. These dynamic constituents have functional possessions that are imperative for cereal industry. The functional and nutraceutical significance of variety of foods is often accredited to their bioactive molecules. Numerous components have been considered but wheat straw and its diverse components are of prime consideration. In this comprehensive dissertation, efforts are directed to elaborate the functional and nutraceutical importance of wheat straw. Wheat straw is lignocellulosic materials including cellulose, hemicellulose and lignin. It hold various bioactive compounds such as policosanols, phytosterols, phenolics, and triterpenoids, having enormous nutraceutical properties like anti-allergenic, anti-artherogenic, anti-inflammatory, anti-microbial, antioxidant, anti-thrombotic, cardioprotective and vasodilatory effects, antiviral, and anticancer. These compounds are protecting against various ailments like hypercholesterolemia, intermittent claudication, benign prostatic hyperplasia and cardiovascular diseases. Additionally, wheat straw has demonstrated successfully, low cost, renewable, versatile, widely distributed, easily available source for the production of biogas, bioethanol, and biohydrogen in biorefineries to enhance the overall effectiveness of biomass consumption in protected and eco-friendly environment. Furthermore, its role in enhancing the quality and extending the shelf life of bakery products through reducing the progression of staling and retrogradation is limelight of the article.

Lipid lowering efficacy of atorvastatin

BACKGROUND

Atorvastatin is one of the most widely prescribed drugs and the most widely prescribed statin in the world. It is therefore important to know the dose-related magnitude of effect of atorvastatin on blood lipids.

OBJECTIVES

To quantify the dose-related effects of atorvastatin on blood lipids and withdrawals due to adverse effects (WDAE).

SEARCH METHODS

We searched the Cochrane Central Register of Controlled Trials (CENTRAL) on The Cochrane Library Issue 4, 2011, MEDLINE (1966 to November 2011), EMBASE (1980 to November 2011), ISI Web of Science (1899 to November 2011) and BIOSIS Previews (1969 to November 2011). No language restrictions were applied.

SELECTION CRITERIA

Randomised controlled and uncontrolled before-and-after trials evaluating the dose response of different fixed doses of atorvastatin on blood lipids over a duration of 3 to 12 weeks.

DATA COLLECTION AND ANALYSIS

Two review authors independently assessed trial quality and extracted data. WDAE information was collected from the placebo-controlled trials.

MAIN RESULTS

Two hundred fifty-four trials evaluated the dose-related efficacy of atorvastatin in 33,505 participants. Log dose-response data revealed linear dose-related effects on blood total cholesterol, low-density lipoprotein (LDL)-cholesterol and triglycerides. Combining all the trials using the generic inverse variance fixed-effect model for doses of 10 to 80 mg/day resulted in decreases of 36% to 53% for LDL-cholesterol. There was no significant dose-related effects of atorvastatin on blood high-density lipoprotein (HDL)-cholesterol. WDAE were not statistically different between atorvastatin and placebo for these short-term trials (risk ratio 0.99; 95% confidence interval 0.68 to 1.45).

AUTHORS' CONCLUSIONS

Blood total cholesterol, LDL-cholesterol and triglyceride lowering effect of atorvastatin was dependent on dose. Log dose-response data was linear over the commonly prescribed dose range. Manufacturer-recommended atorvastatin doses of 10 to 80 mg/day resulted in 36% to 53% decreases of LDL-cholesterol. The review did not provide a good estimate of the incidence of harms associated with atorvastatin because of the short duration of the trials and the lack of reporting of adverse effects in 37% of the placebo-controlled trials.

Stress Degradation Behavior of Atorvastatin Calcium and Development of a Suitable Stability-Indicating LC Method for the Determination of Atorvastatin, its Related Impurities, and its Degradation Products

A rapid, reversed-phase liquid chromatographic method was developed for the quantitative determination of Atorvastatin calcium, its related substances (12 impurities), and degradation impurities in bulk drugs. The chromatographic separation was achieved on a Zorbax Bonus-RP column by employing a gradient elution with water–acetonitrile–trifluoroacetic acid as the mobile phase in a shorter run time of 25 min. The flow rate was 1.0 mL/min and the detection wavelength was 245 nm. The drug substance was subjected to stress studies such as hydrolysis, oxidation, photolysis, and thermal degradation, and considerable degradation was observed in acidic hydrolysis, oxidative, thermal, and photolytic stress conditions. The formed degradation products were reported and were well-resolved from the Atorvastatin and its related substances. The stressed samples were quantified against a qualified reference standard and the mass balance was found to be close to 99.5% (w/w) when the response of the degradant was considered to be equal to the analyte (i.e. Atorvastatin), which demonstrates the stability-indicating capability of the method. The method was validated in agreement with ICH requirements. The method developed here was single and shorter (25 min method for the determination of all 12 related impurities of Atorvastatin and its degradation products), with clearly better resolution and higher sensitivity than the European (85 min method for the determination of six impurities) and United States pharmacopeia (115 min and 55 min, two different methods for the determination of six related substances).

Comparison of the effects of policosanol and atorvastatin on lipid profile and platelet aggregation in patients with dyslipidaemia and type 2 diabetes mellitus

BACKGROUND

Diabetes mellitus and hypercholesterolaemia increase the risk for coronary heart disease, with type 2 diabetes mellitus being the most prevalent form of diabetes, frequently accompanied by dyslipidaemia. The main goal of dyslipidaemia control in nondiabetic and diabetic patients is to lower elevated low-density lipoprotein-cholesterol (LDL-C) levels. Policosanol is a cholesterol-lowering drug, purified from sugarcane wax, with a therapeutic range of 5-20 mg/day, which significantly reduces LDL-C levels. Atorvastatin is an HMG-CoA reductase inhibitor that, across its dose range (10-80 mg/day), has shown significantly greater lipid-lowering effects than all previously marketed statins.

OBJECTIVE

To compare the effects on lipid profile and platelet aggregation of policosanol and atorvastatin in patients with dyslipidaemia due to type 2 diabetes.

PATIENTS AND METHODS

This randomised, single-blind, parallel-group study was conducted in patients with type 2 diabetes (fasting glucose </=7 mmol/L and glycosylated haemoglobin [HbA(1c)] <8.5%) and high LDL-C levels (>/=3.0 mmol/L). After 6 weeks on a cholesterol-lowering diet, 40 patients were randomised to policosanol or atorvastatin 10mg tablets taken once daily with the evening meal for 8 weeks. Assessments of lipid profile, platelet aggregation tests, safety indicators and adverse events were performed.

RESULTS

After 8 weeks of therapy, policosanol significantly lowered LDL-C by 25.7% (p < 0.0001 versus baseline) and total cholesterol (TC) by 18.2% (p < 0.001 versus baseline). In turn, atorvastatin 10 mg/day decreased LDL-C by 41.9% and TC by 31.5% (p < 0.0001 versus baseline). Atorvastatin was more effective than policosanol in reducing LDL-C and TC (p < 0.001). Policosanol also significantly reduced the TC/high-density lipoprotein-cholesterol (HDL-C) ratio (25.2%; p < 0.0001) and triglycerides (15.6%; p < 0.001), while atorvastatin lowered TC/HDL-C by 30.5% (p < 0.0001) and triglycerides by 13.9% (p < 0.001); the reductions on these variables were similar in the two groups. Policosanol, but not atorvastatin, significantly increased HDL-C (11.1%; p < 0.01), the effect being significantly different from that of atorvastatin (p < 0.0001). Also, policosanol, but not atorvastatin, significantly inhibited platelet aggregation induced by arachidonic acid 0.75 and 1.5 mmol/L (39.0% and 33.3%, respectively) and by collagen 0.25 and 0.5 mug/mL (15.7% and 28.5%, respectively) [p < 0.001]; these inhibitions were significantly different (p < 0.05) from the changes that occurred with atorvastatin. Neither drug significantly changed platelet aggregation elicited by adenosine diphosphate (ADP). Both treatments were well tolerated, with glycaemic control being unaffected. Neither drug impaired physical safety indicators or glucose control indicators (fasting glucose and HbA(1c)). Atorvastatin significantly increased levels of alanine aminotransferase (ALT) [p < 0.05] and creatine phosphokinase (CPK) [p < 0.01], while policosanol did not significantly change any safety indicator. Only three atorva-statin recipients showed individual values of ALT and CPK that were moderately enhanced (<3 times above the normal upper limit). No patients withdrew from the study. Four patients reported adverse events: two policosanol (insomnia and pruritus) and two atorvastatin (myalgia and raised arterial blood pressure) recipients.

CONCLUSION

Policosanol (10 mg/day) for 8 weeks was less effective than similar doses of atorvastatin in reducing LDL-C and TC in patients with dyslipidaemia due to type 2 diabetes, but more effective in increasing HDL-C. Both drugs similarly reduced the TC/HDL-C ratio and triglycerides. Policosanol showed additional advantages regarding inhibition of platelet aggregation. Nevertheless, further studies of longer duration and using dose-titration schemes to achieve LDL-C goals are needed for wider conclusions about the respective effects of these two drugs in such a population subset.

Policosanols as nutraceuticals: fact or fiction

Policosanols (PC) are very long chain aliphatic alcohols derived from the wax constituent of plants. In the early 1990s, researchers at Dalmer Laboratories in La Habana Cuba isolated and produced the first PC supplement from sugarcane wax. The original PC supplement has been approved as a cholesterol-lowering drug in over 25 countries throughout the Caribbean and South America. Cuban studies claim that 1 to 20 mg/day of the original PC supplement are effective at producing significant reductions in total cholesterol (TC) and low density lipoprotein cholesterol (LDL-C). These studies also show that PC supplements are potent antioxidants, promote proper arterial endothelial cell function, inhibit platelet aggregation and thrombosis, and serve as effective treatments for intermittent claudication. However, for the most part, those studies reporting therapeutic efficacy of PC were carried out by one research group situated in Cuba. Conversely, research groups outside of Cuba have failed to validate the cholesterol-lowering and antioxidant efficacy of PC. Cuban researchers, however, continue to claim that the efficacy is attributed to the unique purity and composition of the original PC preparation, a mixture not found in PC products used by external research groups. The absence of independent and external studies confirming the therapeutic benefits of PC in disease prevention and treatment raises questions regarding their true efficacy.

Effect of sugar cane policosanol on lipid profile in primary hypercholesterolemia

Policosanol, a mixture of long-chain aliphatic primary alcohols, is used as a cholesterol-lowering supplement. The effectiveness of policosanol is still questionable. To determine the lipoprotein-lowering effects of Cuban sugar cane-derived policosanol a double-blind, randomized, placebo controlled trial was performed. Sixty-eight primary hypercholesterolemic subjects were enrolled and randomly assigned to the treatment or to the control group. The first group received sugar cane policosanol 20 mg daily for 8 weeks, while the control group was treated with placebo. All subjects followed a normocaloric diet. The content of policosanol in the supplement tablets was assessed by gas chromatography. A total of 32 subjects in the policosanol group and 31 subjects in the control group completed the study. Body mass index, total cholesterol, HDL-cholesterol, LDL-cholesterol and triglyceride plasma levels did not change significantly in either group. In conclusion, sugar cane policosanol at doses of 20 mg daily showed no lipid lowering effects in subjects with primary hypercholesterolemia.

Comparison of composition and absorption of sugarcane policosanols

Policosanols (PC) exist as very-long-chain alcohols derived from sugarcane currently used in many countries as a cholesterol-lowering therapy. PC purity and relative percentage composition have been suggested as primary reasons why the original Cuban PC (OPC) supplements possess lipid-lowering efficacy. The purpose of the present study was, first, to compare the relative percentage purity and PC composition of both OPC and alternative sources of PC (APC). A second objective was to feed Syrian hamsters a diet containing 0.275 mg PC/g of either the OPC or an APC product (APC1) and compare subsequent tissue, plasma and faecal PC levels. Five animals from the APC1 dietary group received a diet containing ten times the original amount of PC. Results indicate that the APC formulations have a composition that is highly consistent with the OPC supplement, with octacosanol being present within the cited 60-70 % range. PC were undetectable in the small intestine, liver, adipose or plasma in animals fed either source. Hamsters fed OPC excreted octacosanol (C28) more rapidly (P < 0.05) than hamsters receiving APC1. If the cholesterol-lowering efficacy of PC mixtures is dependent on their purity and composition, then sugarcane-derived APC products should possess similar therapeutic properties as the OPC supplement.

Effects of a policosanol supplement on serum lipid concentrations in hypercholesterolaemic and heterozygous familial hypercholesterolaemic subjects

Policosanol is a mixture of higher aliphatic primary alcohols that is extracted from purified sugar cane wax or a variety of other plant sources, and has been shown to have beneficial effects on serum lipid concentrations. The objective of this study was to investigate the effects of a policosanol supplement (Octa-60) on lipid profiles of hypercholesterolaemic and heterozygous familial hypercholesterolaemic subjects. Nineteen hypercholesterolaemic and familial hypercholesterolaemic subjects completed this randomised, placebo-controlled, double-blind study. The subjects received either a daily dose of 20 mg policosanol or placebo for 12 weeks. After a wash-out period of 4 weeks, the interventions were crossed over. Lipid levels were measured at baseline and at the end of each intervention period. No significant differences in total cholesterol and LDL-cholesterol from baseline to end or between policosanol and placebo were seen in the hypercholesterolaemic or familial hypercholesterolaemic groups. There were small reductions in total cholesterol and LDL-cholesterol from baseline to end in the hypercholesterolaemic group, but these changes did not differ significantly from the changes with the placebo, indicating that the observed decrease in cholesterol in the policosanol group was not due to the specific effect of policosanol treatment. The differences in response may be ascribed to the differences in composition of the higher aliphatic primary alcohols in the previously used products, compared with the local policosanol supplement. An intake of 20 mg/d policosanol for 12 weeks had no significant effect on serum lipid levels in hypercholesterolaemic and heterozygous familial hypercholesterolaemic patients when compared with placebo intake.

Policosanol is ineffective in the treatment of hypercholesterolemia: a randomized controlled trial

BACKGROUND

Policosanol is one of the fastest growing over-the-counter supplements sold in the United States. The use of policosanol to treat elevated cholesterol is based on clinical trials conducted in Cuba, which showed sugar cane-derived policosanol to be similar in efficacy to statins. Recent studies have challenged these findings, but there have been no trials conducted in North America that have examined the ability of sugar cane-derived policosanol to lower cholesterol.

OBJECTIVES

This study investigated the efficacy of sugar cane-derived policosanol in healthy adults with mild hypercholesterolemia. The primary outcome was the percentage change in LDL cholesterol after 8 wk of therapy. Secondary outcome measures included changes in total cholesterol, HDL cholesterol, triacylglycerols, C-reactive protein, and nuclear magnetic resonance-determined lipoprotein profile. Dietary habits, weight, and blood pressure were also monitored.

DESIGN

Ambulatory, community-dwelling healthy adults with mild hypercholesterolemia (n = 40) were assigned to receive oral policosanol (20 mg) or placebo once daily for 8 wk. This was a double-blind, randomized controlled trial conducted from January through August 2005.

RESULTS

No significant differences in the change in LDL cholesterol were observed between the placebo (n = 20) and policosanol (n = 20) groups. Also, no significant changes in secondary outcome measures, including total cholesterol, HDL cholesterol, triacylglycerol, C-reactive protein, and nuclear magnetic resonance spectroscopy-determined profiles were observed. Policosanol was well tolerated, and no significant adverse events were noted.

CONCLUSION

Policosanol does not alter the serum lipid profile over an 8-wk period in adults with mild hypercholesterolemia.

Lack of cholesterol-lowering efficacy of Cuban sugar cane policosanols in hypercholesterolemic persons

BACKGROUND

More than 50 studies have reported substantial reductions in plasma lipid concentrations in response to 2-40 mg Cuban sugar cane policosanol (SCP) mixtures/d. However, several animal and human trials conducted outside of Cuba that used non-Cuban mixtures have failed to reproduce the efficacy of policosanols observed in earlier studies.

OBJECTIVE

The objective was to evaluate lipid-modulating actions of the authentic Cuban SCPs on plasma lipids in healthy hypercholesterolemic volunteers.

DESIGN

Twenty-one volunteers consumed, under supervision, 10 mg SCPs/d or a placebo incorporated in margarine as an afternoon snack, for a period of 28 d with the use of a randomized, double-blind crossover study design. Subjects maintained their habitual diet and physical activity and were weighed daily throughout the study period. Blood was collected at days 1, 2, 28, and 29 of the feeding trial, and lipid concentrations were measured.

RESULTS

Body weights did not vary significantly throughout the trial and did not affect plasma lipid values. No significant difference was observed between treatment and control groups in plasma total, LDL-, HDL-cholesterol, and triacylglycerol concentrations.

CONCLUSION

Present results show no beneficial effects of Cuban SCPs on lipid indicators in hypercholesterolemic persons and question the clinical usefulness of policosanol mixtures as cholesterol-lowering neutraceutical agents.

Comparative lipid-lowering effects of policosanol and atorvastatin: a randomized, parallel, double-blind, placebo-controlled trial

BACKGROUND

Policosanol, commonly derived from purified sugar cane wax, has been reported to exert lipid-lowering effects. Policosanol is available in the United States as a nutritional supplement despite no US research clinical experience. This trial was designed to rigorously establish the lipid-lowering efficacy of policosanol as monotherapy and its potential additive and possibly synergistic effects when added to statin therapy.

METHODS

A randomized, parallel, double-blind, double-dummy, placebo-controlled design was used. Patients with low-density lipoprotein cholesterol (LDL-C) levels from 140 to 189 mg/dL were assigned into 1 of 4 groups to receive policosanol 20 mg, atorvastatin 10 mg, combination therapy, or placebo for 12 weeks.

RESULTS

A total of 99 patients were examined. Baseline characteristics were similar among all treatment groups. Policosanol (20 mg/d for 12 weeks) did not significantly change plasma total cholesterol, LDL-C, high-density lipoprotein cholesterol, or triglyceride levels when compared with baseline values or with values of placebo-treated patients. Atorvastatin (10 mg/d for 12 weeks) reduced total cholesterol by 27% and LDL-C by 35%. Addition of policosanol to atorvastatin failed to produce any further reduction in lipid levels above that of atorvastatin alone. Policosanol was safe and did not affect liver enzyme or creatinine phosphokinase levels.

CONCLUSIONS

Policosanol did not reduce LDL-C or total cholesterol levels either alone or in combination with atorvastatin. This observation supports the need for systematic evaluation of available products containing policosanol to determine their clinical lipid-lowering efficacy under rigorous experimental conditions. We propose that policosanol should be added to the list of nutritional supplements lacking scientific validity to support their use.

["Natural" treatments of hypercholesterolemia]

In this article we briefly review the evidence on the effect of different "natural" products on cholesterolemia. Plant stanols and sterols reduce cholesterol intestinal absorption and decrease total and LDL cholesterol by approximately 10%. Polycosanol is a mixture of saturated alcohols that seem to inhibit cholesterol hepatic synthesis and decrease total and LDL cholesterol by up to 25%. The effects on the cholestorolemia of soy and soluble fiber are modest.

Effects of Policosanol on Patients with Ischemic Stroke: A Pilot Open Study

Stroke is a major health problem worldwide. Its pharmacological management includes thrombolytic therapy for the acute phase and antiplatelet drugs for stroke recovery and prevention. Statins can help in the acute phase and in preventing stroke in secondary prevention patients. Policosanol is a cholesterol-lowering drug with concomitant antiplatelet effects, with protective effects in stroke models. This observational study investigated the effects of policosanol (20 mg/day) administered during the acute phase and for 5 years later on the neurological recovery of patients with ischemic stroke treated with antiplatelets and vitamins. After hospital discharge, patients were followed up every 3 (first year) and 6 (thereafter) months. Neurological improvement was assessed with the modified Canadian Neurological Scale. Adverse events were recorded. Fifty patients were included; all completed the study. Neurological score improved throughout the study. No patient died, and most [40 (80.0%)] did not experience new vascular events; only one (2.0%) suffered a new stroke, and two (4.0%) suffered more than one transient ischemic attack. The time to the first recurrent event was 46.2 months. Policosanol persistently lowered serum total cholesterol, with such reduction correlating with the neurological improvement (R = 0.995253301). Triglycerides were unchanged. Treatment was well tolerated. Policosanol administered to patients suffering ischemic stroke treated with aspirin and vitamins showed good results on neurological outcomes and recurrent events. This study, however, has limitations, since it was open and uncontrolled, and patients also consumed aspirin and vitamins. New randomized, controlled studies are needed to assess the usefulness of policosanol in stroke management.

Effects of combination treatment with policosanol and omega-3 fatty acids on platelet aggregation: A randomized, double-blind clinical study

BACKGROUND

Policosanol is a mixture of long-chain primary aliphatic alcoholspurified from sugar cane wax that has cholesterol lowering and antiplatelet effects. Omega-3 fatty acids (FA) have triglyceride lowering and antiplatelet effects. Combination treatment with policosanol and omega-3 FA (Ω23FA) has been associated with significant inhibition of platelet aggregation in rabbits compared with either drug alone.

OBJECTIVE

The aim of this study was to investigate the effects of combination treatment with Ω3FA (1 g/d) and policosanol (Ω3FA+Poli) compared with Ω3FA (1 g/d) plus placebo (Ω3FA+Pla) on platelet aggregation in human patients with hypercholesterolemia.

METHODS

This randomized, double-blind, clinical study at the Surgical Medical Research Center (Havana City, Cuba) recruited outpatients from lipid clinics, with some atherosclerotic risk factors. Outpatients of both sexes aged 20 to 75 years with serum total cholesterol (TC) levels ≥5 and <6 mmol/L were eligible to enroll. They were included in the study at the end of a 4-week diet stabilization period if their platelet aggregation to arachidonic acid (AA) was ≥50% and serum TC level remained ≥5 mmol/L. Patients were then evenly randomized to receive Ω3FA (1 g/d) + placebo or Ω3FA (1 g/d) + policosanol (10 mg/d) to be taken PO with the evening meal for 21 days. Treatment was assigned according to a randomization code using balanced blocks and a 1:1 allocation ratio. Inhibition of platelet aggregation to AA was the primary efficacy variable, while effects on platelet aggregation to collagen and epinephrine and on lipid profile were secondary variables. Drug compliance and adverse events (AEs) were monitored. Tolerability was assessed using physical examinations and laboratory test results.

RESULTS

Sixty-four subjects were initially enrolled. Fifty-four patients (30 women, 24 men; mean [SD] age, 58.4 [12] years, [range, 40-70 years]) met the inclusion criteria and were randomized to treatment; 2 groups of 27. After 21 days, platelet aggregation to AA was significantly inhibited in the 2 groups. Ω3FA+Poli inhibited platelet aggregation to all agonists by ≥20%. Platelet aggregation to AA 1.0 and 1.5 mM was inhibited with combination treatment (39.6% and 33.9%, respectively; both P < 0.001 vs baseline; P < 0.001 and P < 0.01, respectively, vs Ω3FA+Pla) and with Ω3FA+Pla (11.0% and 13.3%; both, P < 0.001). Combination treatment was more effective in inhibiting platelet aggregation to AA 1.0 and 1.5 mM in 28.6% (P < 0.001) and 20.6% (P < 0.01), respectively. Platelet aggregation to collagen 1 μg/mL was significantly inhibited with combination treatment and with Ω3FA+Pla compared with baseline (43.2% and 15.1%, respectively; both, P < 0.001), but the effects of combination treatment were significantly greater (P < 0.01). Platelet aggregation to epinephrine 0.1 mM was inhibited with Ω3FA+Poli and Ω3FA+Pla (34.8% and 20.1%; both, P < 0.001), with similar results for both groups. Bleeding time did not change significantly for either group and Ω3FA+Pla did not significantly change the lipid profile. Combination treatment did significantly reduce levels of low-density lipoprotein cholesterol (LDL-C) (17.4%; P < 0.001 vs baseline, P < 0.05 vs Ω3FA+Pla) and TC (10.1%; P < 0.001 vs baseline, P < 0.05 vs Ω3FA+Pla), increase high-density lipoprotein cholesterol (HDL-C) levels (18.0%; P < 0.001 vs baseline), but did not significantly change triglyceride levels. Three patients (2 from the Ω3FA+Poli group and 1 from the Ω3FA+Pla group) withdrew from the trial, though none were due to AEs. Two patients receiving combination treatment reported mild AEs (headache). All treatments were well tolerated.

CONCLUSIONS

In these patients, policosanol (10 mg/d) administered concomitantly with Ω3FA (1 g/d) enhanced the inhibition of platelet aggregation to AA and collagen, but not to epinephrine, compared with Ω3FA+Pla, without significantly affecting bleeding time. Concomitant treatment was also associated with reduced levels of LDL-C and TC and raised HDL-C levels. All treatments were well tolerated.

Antihyperlipidaemic effect of a Monascus purpureus brand dietary supplement on a large sample of subjects at low risk for cardiovascular disease: A pilot study

OBJECTIVES

We planned to carry out a pilot study to evaluate the efficacy and safety as an antihypercholesterolemic agent of a brand dietary supplement made of Monascus purpureus titrated extract, octacosanols and niacin on 111 Caucasian patients with low cardiovascular disease risk (<20% by Framingham algorithms), comparing them with the antihypercholesterolemic effect of a low dosage of Pravastatin on 20 subjects with similar risk profile.

RESULTS

In our study, the tested dietary supplement determined a significant decrease of Total Cholesterol (TC), Low Density Lipoprotein Cholesterol (LDL-C), and Triglycerides (TG) in moderately hypercholesterolemic subjects without clinically relevant change in liver and muscular toxicity markers. The reduction of LDL-C reached the 20%, and it is similar to that obtained with a well-known effective statin like Pravastatin.

CONCLUSIONS

Further long-term and double blind evaluation have to be carried out before to infer the observed results, however it appears that the studied dietary supplements could be a safe and efficacious antihypercholesterolemic agent for patients at low risk for cardiovascular diseases.

In Vitro and In Vivo Study of Octacosanol Metabolism

BACKGROUND

Policosanol is a mixture of very-long-chain aliphatic alcohols purified from sugar cane wax with cholesterol-lowering effects, whose main component is octacosanol. Scarce data about the metabolism of octacosanol and the other fatty alcohols composing policosanol have been published.

METHODS

Human fibroblasts were cultured in presence of (3)H-octacosanol during 0.5, 2 and 4 h. Lipid extracts were analyzed by thin layer chromatography, and the spots corresponding to octacosanol and octacosanoic acid were identified comparing with authentic standards. Spots were scraped, transferred to vials and radioactivity was measured. For corroborating the presence of octacosanol and octacosanoic acid, samples were analyzed by gas chromatography-mass spectrometry (GC-MS). The in vivo study of octacosanol metabolism was conducted in rats and Macaca arctoides monkeys. Rats were orally administered with policosanol (60 mg/kg) and free octacosanol and octacosanoic acid were identified in liver and plasma by GC-MS at various time intervals. Monkeys were orally and endovenously treated with policosanol (10 mg/kg) and the presence of free octacosanol, octacosanoic acid and some chain-shortened FA was investigated.

RESULTS

When fibroblasts were cultured in presence of (3)H-octacosanol, three spots were found: a first one corresponded to octacosanoic acid, a second to octacosanol and a third one remained unidentified. The radioactivity on the spot of octacosanoic acid slightly decreased throughout the incubation but increased in the third spot. Octacosanol and free octacosanoic acids were also identified in plasma of monkeys orally administered with policosanol. In addition, plasma samples showed free saturated acids, palmitic acid being the most abundant, followed by oleic and mystiric acids. Unsaturated acids (oleic and palmitoleic) were also observed.

CONCLUSIONS

The present study demonstrates that octacosanoic acid is formed after incubation of fibroblast cultures with (3)H-octacosanol and after oral dosing with policosanol to rats. In addition, we demonstrated that shortened saturated (myristic, palmitic and stearic) and unsaturated (oleic, palmitoleic) FA are also formed after oral dosing with policosanol to monkeys. The present results are consistent with the fact that octacosanol metabolism is linked to FA metabolism via beta-oxidation, but further studies need to explore the occurrence of more metabolites proving such hypothesis.

Meta-Analysis of Natural Therapies for Hyperlipidemia: Plant Sterols and Stanols versus Policosanol

STUDY OBJECTIVE

To compare the efficacy and safety of plant sterols and stanols as well as policosanol in the treatment of coronary heart disease, as measured by a reduction in low-density lipoprotein cholesterol (LDL) levels.

DESIGN

Systematic review and meta-analysis of randomized controlled trials.

PATIENTS

A total of 4596 patients from 52 eligible studies.

MEASUREMENTS AND MAIN RESULTS

We searched MEDLINE, EMBASE, the Web of Science, and the Cochrane Library from January 1967-June 2003 to identify pertinent studies. Reduction of LDL levels was the primary end point; effects on other lipid parameters and withdrawal of study patients due to adverse effects were the secondary end points. Weighted estimates of percent change in LDL were -11.0% for plant sterol and stanol esters 3.4 g/day (range 2-9 g/day [893 patients]) versus -2.3% for placebo (769 patients) in 23 eligible studies, compared with -23.7% for policosanol 12 mg/day (range 5-40 mg/day [1528 patients]) versus -0.11% for placebo (1406 patients) in 29 eligible studies. Cumulative p values were significantly different from placebo for both (p<0.0001). The net LDL reduction in the treatment groups minus that in the placebo groups was greater with policosanol than plant sterols and stanols (-24% versus -10%, p<0.0001). Policosanol also affected total cholesterol, high-density lipoprotein cholesterol (HDL), and triglyceride levels more favorably than plant sterols and stanols. Policosanol caused a clinically significant decrease in the LDL:HDL ratio. Pooled withdrawal rate due to adverse effects and combined relative risk for patients who withdrew were 0% and 0.84, respectively (95% confidence interval [CI] 0.36-1.95, p=0.69), for plant sterols and stanols across 20 studies versus 0.86% and 0.31, respectively (95% CI 0.20-0.48, p<0.0001), for policosanol across 28 studies.

CONCLUSION

Plant sterols and stanols and policosanol are well tolerated and safe; however, policosanol is more effective than plant sterols and stanols for LDL level reduction and more favorably alters the lipid profile, approaching antilipemic drug efficacy.

Effects of Rice Policosanol on Serum Lipoproteins, Homocysteine, Fibrinogen and C-Reactive Protein in Hypercholesterolaemic Patients

BACKGROUND

Policosanol is an agent that includes mixtures of aliphatic primary alcohols extracted primarily from sugar-cane wax. This mixture has been shown to lower total and low-density lipoprotein (LDL) cholesterol in animal models, healthy volunteers and hypercholesterolaemic patients.

PATIENTS AND METHODS

This study investigated the efficacy and tolerability of rice policosanol (Oryza sp.) 10 mg/day in 70 hypercholesterolaemic patients of both sexes aged 20-78 years in a randomised, double-blind, crossover, placebo-controlled, single-centre trial. After an 8-week run-in period during which patients were placed on therapeutic lifestyle changes, in particular a cholesterol-lowering diet, they were randomly assigned to receive rice policosanol 10mg tablets or placebo tablets once daily with the evening meal for 8 weeks. During the next 8 weeks those patients who received policosanol during the first 8 weeks received placebo, and those who received placebo during the first 8 weeks, received policosanol. Total, LDL, high-density lipoprotein (HDL), HDL2 and HDL3 cholesterol, triglycerides, oxidised LDL (ox-LDL), apoproteins (Apos) AI and B, lipoprotein (a) [Lp(a)], fibrinogen, homocysteine and C-reactive protein (CRP) levels were measured.

RESULTS

Rice policosanol significantly reduced plasma total cholesterol from 7.37 +/- 1.42 mmol/L to 6.99 +/- 1.33 mmol/L (p = 0.007) and increased Apo AI from 1.49 +/- 0.39 mmol/L to 1.58 +/- 0.38 mmol/L (p = 0.037) but did not change plasma triglycerides, HDL, HDL2, HDL3 and LDL cholesterol, ox-LDL, Lp(a), Apo B, fibrinogen, homocysteine or CRP levels.

CONCLUSION

Rice policosanol 10 mg/day moderately decreased plasma total cholesterol and increased Apo AI. Rice policosanol was also well tolerated, with no drug-related effects on safety parameters such as serum aminotransferases and creatine phosphokinase detected or found on physical examination.

Effects of Concurrent Therapy with Policosanol and Omega-3 Fatty Acids on Lipid Profile and Platelet Aggregation in Rabbits

BACKGROUND

Policosanol is a mixture of high-molecular-weight aliphatic primary alcohols isolated from sugarcane wax with cholesterol-lowering and antiplatelet effects. Omega-3 fatty acids (FA) from fish oil can protect against coronary disease. An antiarrhythmic mechanism is emerging as the most convincing explanation for omega-3 FA cardiovascular protection, but triglyceride (TG)-lowering effects and inhibition of platelet function could play a role. In view of the effects of policosanol and omega-3 FA on lipid profile and platelet function, potential benefits of combined therapy were expected.

OBJECTIVE

To investigate whether combined therapy with policosanol and omega-3 FA would offer some benefit, compared with policosanol or omega-3 FA alone, on serum lipid profile and platelet aggregation in rabbits.

METHODS

Male rabbits were randomly distributed in four groups (n = 9 per group). A control group received vehicle, one group was treated with policosanol 5 mg/kg and one with omega-3 FA (eicosapentaenoic acid; EPA [47.0%], docosahexaenoic acid; DHEA [41%]) 250 mg/kg, and the fourth received policosanol 5 mg/kg + omega-3 FA 250 mg/kg. Treatments were orally administered for 60 days. Bodyweight, food consumption and animal behaviour were performed at baseline and study completion.

RESULTS

Policosanol significantly lowered low-density lipoprotein cholesterol (LDL-C) [42.7%; p < 0.01] and total cholesterol (TC) [29.4%; p < 0.05], increased high-density lipoprotein (HDL-C) [15.4%; p < 0.05], but left TG levels unchanged. Omega-3 FA significantly lowered TG (47.1%; p < 0.05), but left TC, LDL-C and HDL-C unchanged. Combined therapy decreased LDL-C (38.7%; p < 0.05). Changes in TC, LDL-C and HDL-C obtained with combined therapy were greater (p < 0.05) than those with omega-3 FA, but similar to those with policosanol, whereas the opposite applied to TG reduction. No significant changes in lipid profile were observed in the control group. Policosanol and omega-3 FA significantly (p < 0.05) but moderately inhibited platelet aggregation induced with arachidonic acid (13.3% and 12.4%, respectively); combined therapy achieved greater inhibition (23.9%; p < 0.05). All groups showed similar food consumption and bodyweight gain. No toxic signs were observed in any animal.

CONCLUSIONS

Concurrent therapy with policosanol 5 m/kg and omega-3 FA 250 mg/kg lowered LDL-C, TC and TG and increased HDL-C. All treatments inhibited platelet aggregation, but better effects were observed with policosanol + omega-3 FA compared with either treatment alone. Combined therapy was well tolerated. These results suggest that treatment with policosanol + omega-3 FA could be useful for regulating lipid profile and inhibiting platelet aggregation, but conclusive demonstration of such effects requires further experimental and clinical studies.

Effects of Addition of Policosanol to??Omega-3 Fatty Acid Therapy on the??Lipid Profile of Patients with Type??II Hypercholesterolaemia

BACKGROUND

Policosanol is a mixture of higher aliphatic primary alcohols purified from sugar-cane wax. The mixture has cholesterol-lowering efficacy, its specific effects being to reduce serum total (TC) and low-density lipoprotein cholesterol (LDL-C), and to increase high-density lipoprotein cholesterol (HDL-C). The effects of policosanol on triglycerides (TG) are modest and inconsistent. Omega-3 fatty acids (FA) from fish oil protect against coronary disease, mainly through antiarrhythmic and antiplatelet effects. Omega-3 FA also have lipid-modifying effects, mostly relating to TG reduction. Thus, potential benefits could be expected from combined therapy with omega-3 FA and policosanol.

OBJECTIVE

To investigate whether combined therapy with omega-3 FA + policosanol offers benefits compared with omega-3 FA + placebo with respect to the lipid profile of patients with type II hypercholesterolaemia.

METHODS

This randomised, double-blind study was conducted in 90 patients with type II hypercholesterolaemia. After 5 weeks on a cholesterol-lowering diet, patients were randomised to omega-3 FA + placebo, omega-3 FA + policosanol 5 mg/day or omega-3 FA + policosanol 10 mg/day for 8 weeks. Omega-3 FA was supplied as 1g capsules (two per day); placebo and policosanol were provided in tablet form. Physical signs and laboratory markers were assessed at baseline and after 4 and 8 weeks on therapy. Drug compliance and adverse experiences (AEs) were assessed at weeks 4 and 8. The primary efficacy variable was LDL-C reduction; other lipid profile markers were secondary variables.

RESULTS

After 8 weeks, omega-3 FA + policosanol 5 and 10 mg/day, but not omega-3 FA + placebo, significantly reduced LDL-C by 21.1% and 24.4%, respectively (both p < 0.0001). Omega-3 FA + policosanol 5 mg/day also significantly lowered TC (12.7%; p < 0.01) and TG (13.6%; p < 0.05), and significantly increased HDL-C (+14.4%; p < 0.001). Omega-3 FA + policosanol 10 mg/day significantly decreased TC (15.3%; p < 0.001) and TG (14.7%; p < 0.01), and significantly increased HDL-C (+15.5%; p < 0.0001). Omega-3 FA + placebo significantly reduced TG (14.2%; p < 0.05) but had no significant effect on other lipid profile variables. The proportion of randomised patients in the omega-3 FA + policosanol 5 or 10 mg/day groups that achieved LDL-C targets or reductions 15% was significantly greater than in the omega-3 FA + placebo group (p < 0.001). Combined therapy with omega-3 FA + policosanol 5 or 10 mg/day resulted in significantly greater changes in LDL-C, TC and HDL-C than treatment with omega-3 FA + placebo, but did not modify the TG response compared with the omega-3 FA + placebo group. Four patients (two in the omega-3 FA + placebo group and two in the omega-3 FA + policosanol 10 mg/day group) withdrew from the study; none of these withdrawals was due to AEs. Two patients reported mild AEs, namely nausea/headache (one in the omega-3 FA + placebo group) and heartburn (one in the omega-3 FA + policosanol 5 mg/day group).

CONCLUSIONS

Policosanol 5 or 10 mg/day administered concomitantly with omega-3 FA 1 g/day improved LDL-C, TC and HDL-C, maintained the reduction in TG attributable to omega-3 FA monotherapy, and was well tolerated. Treatment with omega-3 FA + policosanol could be useful for regulating lipid profile in patients with type II hypercholesterolaemia, but further studies involving larger sample sizes are needed before definitive conclusions can be drawn.

A pharmacological surveillance study of the tolerability of policosanol in the elderly population

BACKGROUND

Policosanol is a drug derived from sugar cane wax that has cholesterol-lowering and antiplatelet properties. Randomized, controlled studies are the gold standard for demonstrating drug efficacy, safety, and tolerability, but postmarketing surveillance studies are encouraged for corroborating drug effects. A valid proof of the safety of a drug is a well-documented, good tolerability profile in older individuals, since this population is more prone to drug-related adverse events (AEs).

OBJECTIVE

This study investigated the tolerability of policosanol in the elderly population by monitoring the incidence and nature of AEs occurring in older Cuban patients treated with policosanol in routine clinical practice.

METHODS

All patients aged > or =60 years treated with policosanol at 7 major medical centers from January 2000 to May 2003 were included. Policosanol (5, 10, or 20 mg/d) was prescribed to patients eligible to receive cholesterol-lowering and/or antiplatelet drugs, with the dosage recommended according to their individual atherosclerotic risk. Patients had follow-up visits approximately every 6 months. Data on AEs and other relevant information, including changes in policosanol treatment, concomitant medications, and discontinuations, were recorded on individual case-report forms.

RESULTS

This study included 2252 patients (1306 women, 946 men): 647 (28.7%), 244 (10.8%), and 173 (7.7%) patients had coronary, cerebrovascular, and peripheral artery disease, respectively. A total of 1485 patients had hypercholesterolemia (65.9%), 1322 (58.7%) had hypertension, and 323 (14.3%) had diabetes mellitus. Of the enrolled patients, 1123 (49.9%), 644 (28.6%), and 485 (21.5%) received policosanol 5, 10, and 20 mg/d, respectively. Treatment duration varied: 2169 (96.3%), 1861 (82.6%), 1116 (49.6%), and 412 (18.3%) patients were treated for 6, 12, 24, and 36 months, respectively. Thirty-one patients (1.4%) experienced serious AEs, 18 of them fatal. Death was most often due to vascular events: myocardial infarction (4 patients), sudden cardiac arrest (1), ventricular arrhythmia (2), ischemic stroke (1), lung thromboembolism (1), cancer (5), pneumonia (1), peritonitis (1), lung edema (1), and dehydration (1). Another 13 patients (0.6%) were hospitalized, and 61 (2.7%) reported moderate or mild AEs. Overall, 21 patients (0.9%) discontinued prematurely from the study, 18 of them due to a fatal serious AE.

CONCLUSIONS

Long-term tolerability of policosanol in elderly patients at high vascular risk was very good, as assessed under conditions of routine clinical practice. These results are consistent with those obtained in randomized, double-blind clinical studies of older patients treated with policosanol.

Wheat germ policosanol failed to lower plasma cholesterol in subjects with normal to mildly elevated cholesterol concentrations

Sugar cane policosanol, a mixture of long-chain primary alcohols (approximately 67% as octacosanol), has been reported to lower plasma low-density lipoprotein (LDL)-cholesterol. We investigated the effect of wheat germ policosanol (WGP) on plasma lipid profiles in 58 adults (30 men and 28 women, aged 49 +/- 11 years) with normal to mildly elevated plasma cholesterol concentrations in a double-blind, randomized, parallel placebo-controlled study. Subjects consumed chocolate pellets with or without 20 mg/d WGP for 4 weeks. Plasma lipid concentrations, routine blood chemistry and hematology were determined at the start and the end of the study. The initial plasma total, LDL-cholesterol, high-density lipoprotein (HDL)-cholesterol, and triacylglycerol concentrations in the WGP and the control groups were identical. Over the 4 weeks, neither the WGP nor the control treatment significantly changed plasma total cholesterol, LDL- and HDL-cholesterol, or triacylglycerol concentrations when compared to baseline values. In addition, there was no significant difference in plasma lipid profiles between the WGP and the control groups at the end of the study. WGP did not result in any adverse effects as indicated by plasma activities of L-gamma-glutamyltransferase (gamma-GT), ALT, AST, bilirubin concentrations, and blood cell profiles. Chemical analysis showed that WGP consists of 8% hexacosanol, 67% octacosanol, 12% triacosanol, and 13% other long-chain alcohols, which is similar to the composition of sugar cane policosanol. In conclusion, WGP at 20 mg/d had no beneficial effects on blood lipid profiles. It therefore seems unlikely that the long chain (C24-34) alcohols have any cholesterol-lowering activity.