People take supplements for a variety of reasons, but typically, the goal is to enhance health. This month on Primary Care RAP, we dove into three supplements commonly used for heart health: Omega-3 Fatty Acids, Coenzyme Q10, and Red Yeast Rice. Curious what we found? Read on!
Omega-3 Fatty Acids: Heart and Mind Helpers?
Background:
Omega-3s are classified as essential fatty acids, meaning our bodies cannot produce them, and we must obtain them from external sources. The major biologically active Omega-3 fatty acids are alpha-linolenic acid (ALA), eicosapentaenoic acid (EPA), and docosahexaenoic acid (DHA). Omega-3s can be found in foods like fish, flaxseed, hempseed, eggs, and dairy products. Supplements are also available, with fish oil capsules being the most common. Alternatives include krill oil and algae supplements for vegetarians/vegans.
Dosage:
The adequate intake of ALA is 1.1 g/day for women and 1.6 g/day for men. Common supplemental doses range from 1-12 g per day of fish oil or 1-3 g of EPA + DHA. There are two prescription strength options: icosapent ethyl (Vascepa) is indicated for hypertriglyceridemia (HTG) and coronary artery disease risk reduction, and omega-3-acid ethyl esters is indicated for severe HTG.
Uses and Efficacy:
Omega-3s are often used for heart health, lowering blood pressure and triglycerides, and reducing atherosclerosis. They are also touted for mental health benefits, including the treatment of depression, ADHD, and bipolar disorder. Omega-3s have been shown to be effective in lowering triglycerides by 20-50%. Evidence is conflicting for atherosclerosis, with some guidelines stating no significant effect. Although some people use Omega-3 for mental health, studies have shown mixed results with no strong evidence supporting their use for depression or ADHD.
Side Effects, Interactions, and Safety:
Common side effects include gastrointestinal issues like fish burps and nausea. Taking supplements before bed may alleviate these. Icosapent ethyl can cause bleeding, atrial fibrillation, and atrial flutter. Potential interaction with antiplatelet drugs due to reduced platelet aggregation, although the clinical significance is unclear. Overall, these supplements are generally considered safe, but caution is advised for individuals with fish allergies.
Recommendation:
Omega-3 supplementation can be beneficial for patients with elevated triglycerides or CAD risk factors. For mental health concerns, discuss the lack of strong evidence, although the risk of harm is low. Overall, dietary sources are preferable for increasing Omega-3 intake, such as oily fish (salmon, anchovies), eggs and dairy with high Omega-3, and nuts/seeds.
CoQ10: The Cellular Powerhouse
Background and Uses:
Coenzyme Q10 (CoQ10) is a natural antioxidant essential for basic cellular function. It is produced by the body and found in foods like meat, fish, soybeans, nuts, fruits, vegetables, eggs, and dairy. Supplements come in two forms: ubiquinone and ubiquinol. Typical doses range from 100-200 mg daily. CoQ10 is used for a variety of health issues, including heart failure, migraines, fibromyalgia, and hypertension. It is also commonly recommended to alleviate muscle pain in patients taking statins.
Efficacy:
For heart failure, no convincing evidence supports or refutes its use, although some studies show positive correlations. CoQ10 may be effective in reducing BP in patients with cardiometabolic disorders. CoQ10 has been shown to be beneficial for glycemic control, particularly in diabetic patients. Although the evidence isn’t a slam dunk for statin-induced muscle symptoms, a 2020 meta-analysis indicated potential benefits in this area.
Side Effects, Interactions, and Safety:
Side effects include mild gastrointestinal upset like nausea, vomiting, and diarrhea. CoQ10 may have vitamin K-like procoagulant effects, potentially decreasing the efficacy of warfarin. It is generally considered safe with no major concerns, except for the potential interaction with warfarin.
Recommendation:
CoQ10 could be beneficial, especially for patients on statins experiencing muscle pain. It's not very expensive, so it might be worth considering if patients are interested and willing to try it.
Red Yeast Rice: The Natural Statin?
Background and Uses:
Red yeast rice, also known as Went Yeast, contains monacolin K, a weak HMG-CoA reductase inhibitor chemically identical to lovastatin. It is the product of yeast (Monascus purpureus) grown on white rice. The typical dose is 1200 mg per day, divided into one or two doses. It is commonly used to reduce LDL-C and the relative risk of cardiovascular disease (CVD).
Efficacy:
It does appear to reduce LDL-C and CVD risk, although not as effectively as a statin.
Side Effects, Interactions, and Safety:
Similar to statins, side effects include muscle pain, rhabdomyolysis, and hepatotoxicity. Milder reactions include GI upset, headache, dizziness, and rash. There are numerous drug-drug interactions akin to those of lovastatin. Patients should not take red yeast rice if they are also taking a statin. Red Yeast Rice is contraindicated in pregnancy, lactation, and hepatic disease. A 2017 review highlighted the variability in monacolin K content in red yeast rice products, ranging from 0.09 to 5.48 mg per 1,200 mg. Additionally, contamination with citrinin, a toxic substance harmful to kidneys, was found in many products.
Recommendation:
Red yeast rice may be a viable option for patients who cannot or will not take a statin, but it's not without risks. Regular follow-up to monitor cholesterol levels and liver function is essential, and patients should make sure to choose supplements that have been third-party tested to reduce the risk of contamination.
Conclusion:
While supplements like Omega-3, CoQ10, and Red Yeast Rice may offer potential benefits, the evidence is often conflicting. Supplements can play a role in patient care, but it's crucial to discuss the evidence (or lack thereof) and potential risks. Emphasizing dietary sources and regular follow-ups can help ensure patient safety and effectiveness.
As healthcare professionals, our role is to guide patients through the maze of information, helping them make informed choices based on the latest research and their individual health needs. Always prioritize safety, efficacy, and open communication when discussing supplement use with patients. Look for the USP-verified or Good Manufacturing Practices mark on supplement labels, which reduces the risk of contamination and ensures that the product is high-quality.
Do you have supplements you’d like us to review? Send us a note at pc@hippoeducation.com.