Red yeast rice for hypercholesterolemia

A number of years ago, a patient in his mid-50s came to see me for hypercholesterolemia. His father died from a myocardial infarction in his late 50s and the patient’s older brother had just experienced non-fatal MI. His LDL was moderately elevated. After discussion, I prescribed a statin.

Several weeks later, he returned for follow-up. His LDL had decreased by about 20%. “The statin is working!” I said.

Then he smiled, “I have a confession to make: I never filled your prescription. Instead I’m taking a supplement my son recommended.” He showed me the bottle. Curious, I read the label and saw that it contained red yeast rice.

Red yeast rice is the fermented product of cooked rice upon which the yeast Monascus purpureus has been grown. It has been used for centuries in Asia as a food additive and colorant. More recently, it has been marketed as a dietary supplement to “naturally” lower cholesterol. Red yeast rice contains monacolin K and several other compounds which are HMG-CoA reductase inhibitors. Monacolin K is identical in chemical structure to lovastatin. Red yeast rice has been shown to reduced LDL, total cholesterol, triglycerides and apolipoprotein B in several randomized, placebo-controlled studies.

My patient requested to stay on the red yeast rice product. He thought it would be safer than a prescription statin because it was natural. His LDL was now at goal which made it difficult for me to argue that he switch. I explained that given that red yeast rice contains a statin, no one can say that it would be safer and not have any of the potential side effects of a statin. As long as he understood that, I did not have a problem with him continuing such therapy, as long as he allowed me to monitor as I would any drug.

Unfortunately, about six months later and despite having an LDL at goal, he had a non-fatal MI. When I saw him for follow-up after discharge, he requested to be switched to a prescription statin. I wrote him the prescription. I also explained that even if he had been on a prescription statin, there was no guarantee that he would have never had his event.

In 2007, the FDA advised consumers not to buy or eat red yeast rice products because they contained lovastatin, a prescription drug. The FDA cited potential dangers of side effects and interactions with other medications. Warning letters were sent to three manufacturers of red yeast rice products.

Since then, many manufacturers of red yeast rice have removed the statin component from their products sold in the United States. Nevertheless, many patients still take red rice yeast supplement to lower cholesterol, with mixed results. It is possible that other components such beta-sitosterol, campesterol, and stigmasterol could promote lipid lowering independent of HMG CoA reductase inhibition.

My greatest concern is not when someone takes red yeast rice but when they do not realize that it could interact with other medications and have side effects identical to any statin. There have been reports of rare but serious adverse events with red yeast rice as there have been for prescription statins. Just because something is natural does not mean it is safe.

For more information:

Lin C. Efficacy and safety of Monascus purpureus Went rice in subjects with hyperlipidemia. Eur J Endocrinol. 2005;153:679-686.

Prasad GV. Rhabdomyolysis due to red yeast rice (Monascus purpureus) in a renal transplant recipient. Transplantation. 2002;74:1200-1201.