People concerned with their cholesterol (Who isn't?) got some good news earlier this year. A major meta-analysis of natural anti-cholesterol therapies, published in the journal Pharmacotherapy, found that the sugarcane derivative policosanol was far superior for controlling cholesterol to standard dietary modification and plant sterols and stanols (found in certain vegetable oils, margarines and other foods).1
Policosanol has also been found to be on a par with statin drugs (eg, Lipitor®), the multibillion-dollar pharmaceutical cash cows that have become the virtual automatic first response of most physicians to a high cholesterol alarm.
The latest data confirm that, compared to statins, policosanol is a safe and highly valid and viable alternative for controlling cholesterol. They demonstrate that policosanol bypasses both the high costs and serious health questions associated with these drugs while controlling cholesterol equally as well.
People concerned with their cholesterol are faced with several options:
- Ignore the problem and hope it won't make any difference. Many heart attacks and strokes happen even when cholesterol levels are perfectly normal. On the other hand, many people live long, happy lives despite elevated cholesterol. So if you've got good genes (ie, no cardiovascular disease in your family), and if you're feeling lucky, this may be strategy for you.
- Alter your diet and lifestyle to lower risks. Certainly, this is good advice for everyone, even "Mr. Lucky" from the previous paragraph. Reducing saturated and trans-fats in your diet, eating lots of fruits, veggies, and fiber; losing weight, exercising, and stopping smoking, can only help and should form the basis of any therapeutic program for preventing cardiovascular disease.
But does it really work? For some people, who may be highly motivated to stick with such a strict regimen for the rest of their lives, and whose disease may not be too far along, these measures might offer some real benefit. As for the rest of us, as noted above, it's a good start.
- Take statin drugs. Show up at most physicians's offices today with your blood cholesterol in disarray, and out comes the little blue pad with a prescription for a statin drug, such as Lipitor® (atorvastatin), Zocor® (simvastatin), Lescol® (fluvastatin), Mevacor® (lovastatin), Pravachol® (pravastatin), or Crestor® (rosuvastatin). All these drugs do a reasonable job of reducing total cholesterol, LDL, and triglycerides.
Statins have two major drawbacks, though. First, they may do little or nothing to raise HDL (high-density lipoprotein, the "good") cholesterol; and second, they can cause serious — even deadly — side effects, including liver and kidney dysfunction, and myopathy (muscle pain or tenderness due to a weakness or wasting of the muscles). One particularly severe form of statin-associated myopathy is called rhabdomyolysis, and it can be fatal. The statin drug Baychol® (cerivastatin) was pulled from the market in 2001 due to an excessive incidence of rhabdomyolysis. Recently, questions have been raised about the safety of Crestor® for similar reasons.
- Use products containing phyto- (plant-based) sterols and stanols. Plant sterols are naturally occurring cholesterol derivatives (eg, sitosterol, campesterol, brassicasterol, stigmasterol) that are found in certain vegetable oils (eg, rapeseed oil), nuts, soy, corn, and beans, in certain man-made margarines, and in various other foods. Hydrogenation of plant sterols yields stanols. Many experts recommend foods containing plant sterols and stanols as part of a heart-conscious diet due to their documented ability to reduce LDL levels, although they have no effect on HDL and may actually increase triglycerides.
- Use policosanol. Policosanol is a natural derivative of sugarcane (Saccharum officinarum), consisting of mixtures of primary alcohols, including octosanol, triacontanol, and hexacosanol. While policosanol is not that well known in this US, it is commonly used for controlling cholesterol in more than 25 other countries, especially in South America and the Caribbean. Most of the research on policosanol comes from Cuba, which is understandable, considering its origin in sugarcane. Clinical studies indicate that policosanol 1) consistently lowers LDL and triglycerides, 2) raises HDL, and 3) has no apparent toxicity.1 Moreover, even though it is a product of sugarcane, policosanol does not increase blood sugar levels, so it safe for people with diabetes.
Policosanol Controls Cholesterol Better than Plant Sterols and Stanols
The recent meta-analysis of plant sterol/stanol and policosanol trials1 focused primarily on the reduction of LDL cholesterol, but it also evaluated the effects of these products on levels of HDL, triglycerides, and total cholesterol (TC), as well as the LDL:HDL and TC:HDL ratios. The researchers limited their analysis to randomized, double-blind, placebo-controlled trials (23 plant sterol/stanol trials and 29 policosanol trials), which are considered the strongest, least likely to be biased evidence.
The results showed that both plant sterol/stanol and policosanol had beneficial effects on blood lipid levels, but on the whole, policosanol was significantly better (Figure 1). Compared to plant sterol/stanol treatment, policosanol treatment caused larger decreases in TC (-16% vs. –8%), LDL (-24% vs. –11%), triglycerides ( 12% vs. +4%) and LDL:HDL ratio (-33% vs. -12%) and resulted in a larger increase in HDL (+11% vs. 0%). Overall, the net decreases (treatment minus placebo) for LDL, TC, triglycerides, and the LDL:HDL ratio were significantly greater with policosanol than with plant sterols/stanols (P =0.0006); the net increase for HDL was also significantly greater (P =0.0001).
Like many other natural therapies, plant sterols/stanols and policosanol were both well tolerated with hardly any adverse side effects. In fact, the placebo was associated with more adverse side effects than policosanol.
Policosanol vs. Statins
The overall 24% reduction in LDL and the 11% increase in HDL seen in this meta-analysis suggest that policosanol is comparable to the most powerful pharmaceutical drugs in its ability to normalize lipid levels. More specifically, policosanol, at a relatively low dose of 10 mg per day was superior to fibric acid derivatives eg, Lopid® (gemfibrozil) and on a par with the "heavy hitters" of the anti-cholesterol drugs, the statins, eg, Lipitor®, et al.
A recent head-to-head comparison of policosanol vs. Lipitor®, the best-selling of the statin drugs demonstrated that policosanol was comparable in some ways and superior in others.2
This was a randomized, single-blind study in 75 patients (60-80 years old) with high levels of LDL. After 4 weeks on a cholesterol-lowering diet, the patients were divided into two groups: one group received policosanol 10 mg/day, and the second group received Lipitor® 10 mg/day. The researchers measured the patients' levels of LDL, HDL, triglycerides, and total cholesterol at the start of the trial (baseline) and again after 8 weeks of treatment.
Figure 2 shows that after 4 weeks of treatment, both treatments reduced total cholesterol, LDL, and LDL:HDL ratio, although Lipitor® was somewhat more effective. Nevertheless, policosanol was superior to Lipitor® in elevating HDL, a very important exception. After 8 weeks of treatment, the differences between the treatments were much less pronounced. Policosanol increased HDL even more at the 8week mark, while Lipitor® continued to reduce HDL levels, a potentially dangerous condition. Both treatments were equally effective in controlling triglyceride levels throughout the study. Had treatment continued beyond 8 weeks, it's quite possible that the differences between the two treatments might have been even smaller.
Not surprisingly, policosanol was far superior to Lipitor® in terms of safety and tolerability. Adverse side effects were fairly common in the Lipitor® group, and three Lipitor®-treated patients withdrew from the study due to muscle aches, cramps, gastritis, abdominal pain, or uncontrolled high blood pressure, all well-known side effects of these drugs. By contrast, not a single patient in the policosanol group reported any adverse events.
Besides controlling cholesterol, some evidence suggests that policosanol offers additional cardiovascular benefits that are just starting to be explored. These include controlling smooth muscle cell proliferation, reducing platelet aggregation, and blocking LDL peroxidation, all important contributors to atherosclerotic disease.3
Making the Choice
Studies have shown that for every 10% reduction in total cholesterol levels, the 5 year risk of ischemic heart disease shrinks by about 25%,4 and death due to heart disease declines by 15%.5 Thus, given the 15% to 24% reduction in total cholesterol seen with policosanol, we might expect as much as a 50% reduction in coronary disease-related mortality. While statins might offer similar benefits, we have to remember to balance these benefits with the very real risks of adverse side effects, including liver and kidney damage, myopathy, and rhabdomyolysis. Given a choice between these two therapies, which one would you pick?
- Chen J T, Wesley R, Shamburek R D, Pucino F, Csako G. Meta-analysis of natural therapies for hyperlipidemia: plant sterols and stanols versus policosanol. Pharmacotherapy. 2005;25:171-183.
- Castano G, Mas R, Fernandez L, et al. Comparison of the efficacy and tolerability of policosanol with atorvastatin in elderly patients with type II hypercholesterolaemia. Drugs Aging. 2003;20:153-163.
- Gouni-Berthold I, Berthold H K. Policosanol: clinical pharmacology and therapeutic significance of a new lipid-lowering agent. Am Heart J. 2002;143:356-365.
- Law M R, Wald N J, Thompson S G. By how much and how quickly does reduction in serum cholesterol concentration lower risk of ischaemic heart disease? BMJ.1994;308:367-372.
- Gould A L, Rossouw J E, Santanello N C, Heyse J F, Furberg C D. Cholesterol reduction yields clinical benefit: impact of statin trials. Circulation. 1998;97:946-952.