Page 939 - Cardiac Nursing

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LWBK340-c41_p906-920.qxd 29/06/2009 11:20 PM Page 915 Aptara
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C HAPTER 41 / Complementary and Alternative Approaches in Cardiovascular Disease 915
progression of coronary vascular disease. ALA suppresses produc- (nephrotoxin) in red yeast rice products. 74 American College of
tion of interleukin-1, tumor necrosis factor, leukotriene B4, and Cardiology recommends not using red yeast rice. 75
oxygen-free radicals by polymorphonuclear leukocytes and
monocytes. 62 ALA from flaxseed oil might have antitumor Garlic
effects. Garlic is used to treat various cardiac and vascular conditions, but
there is controversy about its effectiveness. Some studies have
Chinese Red Yeast Rice shown that garlic reduces hyperlipidemia, but other studies have
Chinese red yeast rice, called Xuezhikang, is the fermentation shown no benefit. 76,77 In a meta-analysis of 45 randomized clini-
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product resulting when red yeast (Monascus purpureus) is grown cal trials, Stevinson et al. 78 concluded that when used for 4 to 25
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on rice. Ancient documents from the Tang Dynasty (800 AD) weeks, garlic usually lowers total cholesterol levels by 4% to 12%.
describe the product; the Ming Dynasty (1368–1644) pharma- However, the six studies judged to be the most rigorous failed to
copoeia Ben Cao Gang Mu notes that the product evokes mild show a significant difference between the garlic and placebo
useful circulatory improvements. 65 Red yeast rice remains com- groups. By comparison, “statin” drugs typically decrease choles-
mon in the Chinese and Japanese diets (e.g., in Peking duck). terol levels by 17% to 32%. Garlic’s antihyperlipidemic effects are
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Animal 65,66 and human studies 67 note reductions in serum cho- possibly caused by a component of garlic (S-allyl cysteine), likely
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lesterol and triacylglycerol concentrations. Heber et al. 67 con- an HMG-CoA reductase inhibitor. 79,80 HMG-CoA reductase in-
ducted a randomized, double-blind, repeated-measures, con- hibitors inhibit hepatic cholesterol synthesis; statin-type drugs
trolled trial of 46 men and 37 women (ages 34–78 years) with and red yeast rice act via a similar mechanism.
moderate hypercholesterolemia. Half of the subjects took 600 mg Garlic is sometimes used to improve hypertension. There is
of red yeast rice in a capsule; the control group took a similar- some evidence that garlic can modestly reduce blood pressure by
appearing placebo capsule; all subjects were counseled to con- 2% to 7% after 4 weeks of treatment. 81 This effect is thought to
sume American Heart Association Step 1 diet. Triacylglycerol and be caused by nitric oxide release, which relaxes smooth muscle,
LDL cholesterol were significantly reduced in the test group (by causing vasodilatation. Garlic is sometimes used as an anticoagu-
approximately 16% and 7%, respectively) compared with the lant. 82,83 Other medicinal applications of garlic include antifun-
placebo control group; high-density lipoprotein cholesterol did gal, antibacterial, anthelmintic, antiviral, antispasmodic, di-
not change. Improvements were noted at 8 and 12 weeks. Several aphoretic, expectorant, and immunostimulant. These effects are
subjects in the placebo group noted adverse effects (headaches, not proven. 84
pneumonia, rash); one test subject noted chest pain. None of the It is difficult to compare studies of garlic and to achieve con-
subjects had abnormal liver or renal function studies during the sistent dosing. There are several active ingredients present; it is not
trial (these complications are reported for red yeast rice). The always clear which component might induce a therapeutic effect.
menopausal status of the women was not discussed, nor was re- Because some components are more labile than others, this issue
sults separated for men versus women. Because ovarian hormone complicates clinical trials and treatment recommendations. Gar-
state is known to affect lipid metabolism, studies are needed ex- lic’s pharmacologic properties are attributed to organosulfur com-
plicating the interaction of this dietary component with ovarian pounds, particularly allicin and ajoene. Alliin is an odorless com-
hormone status. pound in the garlic bulb. When the bulb is crushed, the cells
Red yeast rice contains various monacolins (including mona- release an enzyme called allinase. Allinase converts alliin to the un-
colin K, also known as lovastatin, an HMG-CoA reductase in- stable, odiferous compound, allicin, and then to ajoene. The com-
hibitor that is an allopathic drug prescribed to lower serum cho- pounds present in a garlic preparation depend on how the prod-
lesterol). Also present in red yeast rice are sterols, isoflavone ucts are prepared. Processes that macerate the garlic clove increase
glycosides, and monounsaturated fatty acids. It is likely that the allinase activity. Freeze-dried garlic may contain little or no allicin.
cholesterol-lowering effects are caused by multiple active ingredi- Gastric acids may degrade products without enteric coating before
67
ents, not just the monacolin K. In the study by Heber et al., the the active ingredients are absorbed. When heat and steam distilla-
monacolin K concentration consumed by the test group was lower tion are used to produce garlic oil from crushed garlic, allicin is
than that in clinical trials of lovastatin alone, 68 yet the lipid re- converted to less biologically active allyl sulfides. Garlic is some-
ductions were almost as large. This could suggest that other red times aged to reduce the content of sulfur compounds and the
yeast rice ingredients contribute to its therapeutic effect. More odor commonly associated with garlic. However, the process of
studies are needed to determine the efficacy, mechanism, and producing odorless aged garlic extract reduces the alliin content to
safety of red yeast rice. only 3% of what is typically contained in fresh garlic. Aged garlic
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Many precautions are needed if the patient is taking red yeast extract is usually standardized to S-allyl cysteine, another majorS
rice. Side effects associated with red yeast rice include gastroin- organosulfur constituent in garlic, but this is not the compound
testinal symptoms and liver problems 69,70 ; anaphylaxis has been thought to be the most biologically active. All these factors make
reported after inhalation. 71 Because they have a similar chemical it difficult to know what dose of garlic the patient is receiving.
composition, red yeast rice has a potential to cause the same side Garlic is associated with noxious breath and body odor; it can
effects and drug interactions that are associated with HMG-CoA burn the skin and irritate the gastrointestinal track. Garlic’s effects
reductase drugs such as lovastatin. Similar to lovastatin, rhab- could be additive with warfarin. Patients taking cyclosporine are
72
domyolysis has been reported with red yeast rice. The effects of advised to avoid garlic because it may activate the liver enzyme
red yeast rice and HMG-CoA reductase-inhibiting drugs could be (cytochrome P450 3A4), which metabolizes cyclosporine. 85
additive. It is well known that grapefruit products can increase the Other drugs that are potentially affected by this mechanism in-
serum levels of lovastatin by inhibiting the cytochrome P450- clude some calcium channel blockers (diltiazem, nicardipine, ver-
73
based drug metabolism ; the same is likely to be true of red yeast apamil), chemotherapeutic agents (etoposide, paclitaxel, vinblas-
rice. Incorrect fermentation can result in the presence of citrinin tine, vincristine, vindesine), antifungals (ketoconazole, itraconazole),