Pharmacological Research 143 (2019) 1–16

Contents lists available at ScienceDirect

Pharmacological Research

journal homepage: www.elsevier.com/locate/yphrs

Review Safety of red yeast rice supplementation: A systematic review and meta- analysis of randomized controlled trials T ⁎⁎ Federica Fogaccia,1, Maciej Banachb,c,d, ,1, Dimitri P. Mikhailidise, Eric Bruckertf, Peter P. Tothg,h, Gerald F. Wattsi, Željko Reinerj, John Mancinik, Manfredi Rizzol, Olena Mitchenkom, Daniel Pellan, Zlatko Fraso, Amirhossein Sahebkarp,q, Michal Vrablikr, ⁎ Arrigo F.G. Ciceroa, , on behalf of the Lipid and Blood Pressure Meta-analysis Collaboration (LBPMC) Group, the International Lipid Expert Panel (ILEP) a Department of Medicine and Surgery Sciences, University of Bologna, Bologna, Italy b Department of Hypertension, Chair of Nephrology and Hypertension, Medical University of Lodz, Poland c Polish Mother’s Memorial Hospital Research Institute (PMMHRI), Lodz, Poland d Cardiovascular Research Centre, University of Zielona Gora, Zielona Gora, Poland e Department of Clinical Biochemistry, Royal Free Campus, University College London Medical School, University College London (UCL), London, UK f Institute of Cardiometabolism and Nutrition (ICAN), Endocrinology Department, Hopital Pitié Salpetrière, Paris, France g The Johns Hopkins Ciccarone Center for the Prevention of Heart Disease, Baltimore, MD, USA h Preventive Cardiology, CGH Medical Center, Sterling, IL, USA i Cardiometabolic Service, Department of Cardiology, Royal Perth Hospital, School of Medicine, University of Western Australia, Perth, Western Australia, Australia j University Hospital Centre Zagreb, School of Medicine, University of Zagreb, Department of Internal Medicine, Zagreb, Croatia k Department of Medicine, Division of Cardiology, University of British Columbia, Vancouver, British Columbia, Canada l Biomedical Department of Internal Medicine and Medical Specialties, University of Palermo, Palermo, Italy m Dyslipidaemia Department, Institute of Cardiology AMS of Ukraine, Ukraine n 1st Department of Internal Medicine, Faculty of Medicine, Pavol Jozef Safarik University, Košice, Slovakia o Preventive Cardiology Unit, Department of Vascular Medicine, Division of Internal Medicine, University Medical Centre Ljubljana, Slovenia p Biotechnology Research Center, Pharmaceutical Technology Institute, Mashhad University of Medical Sciences, Mashhad, Iran q Neurogenic Inflammation Research Center, Mashhad University of Medical Sciences, Mashhad, Iran r Third Department of Internal Medicine, First Medical Faculty, Charles University, Prague, Czech Republic

ARTICLE INFO ABSTRACT

Keywords: Recently, concerns regarding the safety of red yeast rice (RYR) have been raised after the publication of some Safety case reports claiming toxicity. Since the previous meta-analyses on the effects of RYR were mainly focused on its Red yeast rice efficacy to improve lipid profile and other cardiovascular parameters, we carried out a meta-analysis on safety Musculoskeletal disorders data derived from the available randomized controlled clinical trials (RCTs). Non-musculoskeletal adverse events Primary outcomes were musculoskeletal disorders (MuD). Secondary outcomes were non-musculoskeletal Serious adverse events adverse events (Non-MuD) and serious adverse events (SAE). Subgroups analyses were carried out considering the intervention (RYR alone or in association with other nutraceutical compounds), monacolin K administered daily dose (≤3, 3.1–5 or > 5 mg/day), follow-up (> 12 or ≤12 weeks), with statin therapy or statin-intolerance and type of control treatment (placebo or statin treatment). Data were pooled from 53 RCTs comprising 112 treatment arms, which included 8535 subjects, with 4437 in

Abbreviations: ATP, Adult treatment panel; BMI, Body mass index; BP, Blood pressure; CAD, Coronary artery disease; CHD, Coronary heart disease; CK, Creatine kinase; CMA, Comprehensive Meta-Analysis; Cr, Creatinine; CV, Cardiovascular; CVD, Cardiovascular disease; CI, Confidence interval; FMD, Flow-mediated dilation; FSGS, Focal segmental glomerulosclerosis; GCP, Good clinical practice; H, High risk of bias; HDL-C, High-density lipoprotein cholesterol; HMG-CoA, 3-hydroxy-3- methyl-glutaryl-CoA; ILEP, International Lipid Expert Panel; IRB, Institutional Review Board; L, Low risk of bias; LDL-C, Low-density lipoprotein cholesterol; MPGN, Membranoproliferative glomerulonephritis; MuD, Musculoskeletal disorders; Non-MuD, Non-musculoskeletal adverse events; NA, Not available; OR, Odds-ratios; PWV, Pulse wave velocity; RCTs, Randomized controlled clinical trials; RYR, Red yeast rice; SAE, Serious adverse events; SAMS, Statin-associated muscle symptoms; SAMS-CI, SAMS clinical index; SD, Standard deviation; TC, Total cholesterol; TG, Triglycerides; U, Unclear risk of bias; ULN, Upper limit of normal; USA, United States of America ⁎ Corresponding author at: Medical and Surgical Sciences Department, Sant’Orsola-Malpighi University Hospital, Via Albertoni, 15, 40138, Bologna, Italy. ⁎⁎ Corresponding author at: Department of Hypertension, WAM University Hospital in Lodz, Medical University of Lodz, Zeromskiego, 113; 90-549, Lodz, Poland. E-mail addresses: [email protected] (M. Banach), [email protected] (A.F.G. Cicero). 1 These authors contributed equally to this paper. https://doi.org/10.1016/j.phrs.2019.02.028 Received 21 February 2019; Received in revised form 28 February 2019; Accepted 28 February 2019 Available online 04 March 2019 1043-6618/ © 2019 Elsevier Ltd. All rights reserved. F. Fogacci, et al. Pharmacological Research 143 (2019) 1–16

the RYR arm and 4303 in the control one. Monacolin K administration was not associated with increased risk of MuD (odds ratio (OR) = 0.94, 95% confidence interval (CI) 0.53,1.65). Moreover, we showed reduced risk of Non-MuD (OR = 0.59, 95%CI 0.50, 0.69) and SAE (OR = 0.54, 95%CI 0.46, 0.64) vs. control. Subgroups ana- lyses confirmed the high tolerability profile of RYR. Furthermore, increasing daily doses of monacolin K were negatively associated with increasing risk of Non-MuD (slope: -0.10; 95%CI: -0.17, -0.03; two-tailed p < 0.01). Based on our data, RYR use as lipid-lowering dietary supplement seems to be overall tolerable and safe in a large kind of moderately hypercolesterolaemic subjects.

1. Background yeast-rice” OR “RYR” OR “R-Y-R” OR “Red yeast rice extract” OR “Red- yeast-rice extract” OR “Red rice yeast” OR “Red-rice-yeast” OR “Red Red yeast rice (RYR) is currently one of the most commonly used rice” OR “Riz rouge” OR “Monacolin k” OR “Cholestin” OR “Monascus” lipid-lowering dietary supplements in European and Asian countries OR “Monascus Purpureus” OR “Monascus Purpureus Went” OR “Zhi [1]. It is produced by the fermentation of a particular yeast (in general Tai” OR “Hong qu” OR “Red koji” OR “Xuezhikang” OR “Xuezhikang” Monascus purpureus) on rice [1]. The yeast enriches the rice during the OR “XZK” OR “Zhibituo” OR “Mevinolin”) AND (“Clinical trial” OR fermentation process with a complex of substances with important “Clinical study” OR “Randomized” OR “Double-blind” OR “Single- lipid-lowering activities including polyketides such as monacolins [2]. blind”) AND (“Safety” OR “Side effects” OR “Adverse reactions” OR Usually, the dietary supplements derived from red mould rice contain a “Myalgia” OR “Myopathy” OR “Musculoskeletal disorders” OR concentration of monacolins of up to 1.9% [3]. Depending on the yeast “Adverse events” OR “AE” OR “AE” OR “SAE” OR “SAE”). The search strain used and the condition of fermentation, several types of mon- was limited to studies in humans. The wild-card term “*” was used to acolins have been identified (compactin, monacolins M, L, J, X) in- increase the sensitivity of the search strategy. Additional searches for cluding the subtype monacolin K, which is structurally identical to lo- potential trials included the references of review articles on that issue, vastatin [4]. The main putative cholesterol-lowering mechanism of and the abstracts from selected congresses on the subject of the meta- action of RYR is reversible inhibition of 3-hydroxy-3-methyl-glutaryl- analysis. Literature was searched from inception to February 27th, CoA (HMG-CoA) reductase, the key enzyme in the synthesis of choles- 2019. The reference list of identified papers was manually checked for terol [2]. additional relevant articles. The lipid-lowering effect of RYR has been confirmed in many All paper abstracts were screened by two reviewers (FF and AFGC) available studies, including meta-analyses of randomized clinical trials in an initial process to remove ineligible articles. The remaining articles (RCTs); the most recent one, which included 20 trials showed that after were obtained in full-text and assessed again by the same two re- 2–24 months of supplementation, RYR reduced low-density lipoprotein searchers who evaluated each article independently, and carried out cholesterol (LDL-C) by an average of 1.02 mmol/L (39.4 mg/dL) (95% data extraction and quality assessment. Disagreements were resolved by confidence interval (CI) -1.20; -0.83) compared with placebo, not being discussion with a third party (MB). different from mild-intensity statin therapy (pravastatin 40 mg, sim- vastatin 10 mg, lovastatin 20 mg) [5], Furthermore, a small increase in 2.2. Study selection criteria high-density lipoprotein cholesterol (HDL-C) (0.007 mmol/L [0.3 mg/ dL]; 95%CI: 0.03; 0.11) and a decrease in triglycerides (TG) Original studies were included if they met the following criteria: (i) (-0.26 mmol/L [23 mg/dL]; 95%CI: -0.35; -0.17) were observed in being a RCT with either parallel or cross-over design, (ii) testing the comparison with placebo. The administered RYR doses ranged from safety of RYR supplementation alone or in combination with other 1200 to 4800 mg/day and contained from 2.4 to 4.8 mg of monacolin K nutraceutical compounds, (iii) reporting all the adverse events, (iv) [5]. These data consolidate the findings of a Chinese meta-analysis of having an appropriate controlled design and (v) blinding participants to 93 clinical trials - with 9625 participants included - with less strictly the treatment allocation. inclusion criteria [6]. RYR is also able to improve some vascular Exclusion criteria were: (i) lack of randomization for treatment al- parameters directly related to cardiovascular (CV) risk [7,8]. RYR sig- location, (ii) lack of blinding, (iii) lack of a control group receiving nificantly improves flow-mediated dilation (FMD)/endothelial re- placebo or statin treatment, and (iv) lack of sufficient information about activity [9,10] and carotid-femoral pulse wave velocity (PWV) (both the prevalence and nature of the adverse events. Studies were also markers of arterial health) [11,12]. excluded if they contained overlapping subjects with other studies. Recently, concerns regarding the safety of RYR have been raised – after the publication of some case reports claiming toxicity [13 15]. 2.3. Data extraction Since the previous meta-analyses on the effects of RYR were mainly ffi fi focused on its e cacy to improve lipid pro le and other CV parameters, Data abstracted from the eligible studies were: i) first author’s name; we carried out a meta-analysis on safety data derived from the available ii) year of publication; iii) study location; iv) study design; v) follow-up; controlled RCTs. vi) inclusion criteria and underlying disease; vii) tested intervention; viii) study groups; viii) number of participants in the active and control 2. Methods group; ix) age of study participants; x) musculoskeletal disorders, non- musculoskeletal adverse events and serious adverse events occurred 2.1. Search strategy during the trial. Missing or unpublished data (e.g. monacolin K titration in commercial RYR products) were sought by trying to contact authors The study was designed according to guidelines of the 2009 pre- or sponsors via e-mail; repeated messages were sent in case of no re- ferred reporting items for systematic reviews and meta-analysis sponse. All data extraction and database typing were reviewed by the (PRISMA) statement [16]. Due to the study design (meta-analysis), principal investigator (AFGC) before the final analysis, and doubts were neither Institutional Review Board (IRB) approval, nor patient informed resolved by mutual agreement among the authors. consent were required. PubMed, ResearchGate, SCOPUS, Google Scholar and ISI Web of 2.4. Quality assessment Science by Clarivate databases were searched, with no language re- striction, using the following search terms: (“Red yeast rice” OR “Red- A systematic assessment of bias in the included study was performed

2 .Fgci tal. et Fogacci, F. Table 1 Baseline characteristics of the included clinical studies.

Author Year Study Study design Follow-up Main inclusion criteria Intervention Study group (daily dose) Participants (n) Age (years; location mean ± SD)

Ruscica, M [23] 2019 Italy Randomized, double- 12 weeks - Primary prevention for CVD Nutraceutical RYR, coenzyme Q10 20 mg, vitamin PP 16 57 (48-68)* blind, placebo-controlled, - LDL-C≥ 130 mg/dL and ≤200 mg/dL compound with 16 mg, Bifidobacterium longum BB536 106 parallel-group clinical - 18-70 years of age RYR CFU study - no smoking habit Placebo 16 Derosa, G [24] 2018 Italy Randomized, double- 3 months - Estimated 10-year CV risk < 10% according Nutraceutical RYR 200 mg, phytosterols 400 mg, L- 42 53.9 ± 7.6 blind, placebo-controlled, to Framingham risk scoring compound with tyrosol 2.5 mg parallel-group clinical - ≥18 years of age RYR Placebo 38 52.7 ± 6.9 study -TC≥ 200 mg/dL and ≤240 mg/dL Cicero, AF [25] 2017 Italy Randomized, double- 8 weeks - Primary prevention for CVD RYR / Nutraceutical RYR 100 mg 30 49.9 ± 14.5 blind, parallel-group - 18-70 years of age compound with RYR 100 mg, phytosterols 800 mg 30 53.0 ± 11.2 clinical study - LDL-C≥ 130 mg/dL and ≤190 mg/dL RYR Phytosterols 800 mg 30 53.6 ± 12.3 Cicero, AF [8] 2017 Italy Randomized, double- 2 months - Primary prevention for CVD Nutraceutical RYR 400 mg (monacolins 10 mg), 25 50.4 ± 10.3 blind, placebo-controlled, - polygenic hypercholesterolemia resistant to compound with phytosterols 800 mg, L-tyrosol 5 mg parallel-group clinical Mediterranean diet (LDL-C≥ 115 mg/dL and RYR Placebo 25 50.0 ± 14.9 study ≤160 mg/dL) - 35-69 years of age Cicero, AF [26] 2017 Italy Randomized, double- 6 weeks - Primary prevention for CVD Nutraceutical RYR 200 mg, artichoke extract 500 mg, 40 52.2 ± 7.0 blind, placebo-controlled, - 25-75 years of age compound with banaba extract 75 mg, coenzyme Q10 cross-over clinical study - BMI > 25 Kg/m2 and < 30 Kg/m2 RYR 50 mg, vitamin B3 9 mg, vitamin B6 - LDL-C≥ 130 mg/dL and ≤190 mg/dL 1.4 mg, folic acid 110 mcg, vitamin B12 - TG > 150 mg/dL and < 400 mg/dL 0.83 mcg - other lipid-lowering or antihypertensive Placebo treatment stabilized since at least 6 months D’Addato, S [27] 2017 Italy Multicenter, randomized, 4 weeks - Primary prevention for CVD Nutraceutical RYR 200 mg, berberine 500 mg, 55 52.8 ± 12.4 3 double-blind, placebo- - 18-75 years of age compound with hydroxytyrosol 5 mg, coenzyme Q10 2 mg controlled, parallel-group -TC≥ 200 mg/dL and ≤260 mg/dL RYR RYR 200 mg, berberine 500 mg, 51 53.7 ± 11.6 clinical study - LDL-C≥ 115 mg/dL and ≤180 mg/dL policosanols 10 mg, coenzyme Q10 2 mg, astaxanthin 0.5 mg, folic acid 0.2 mg Placebo 51 49.7 ± 12.3 Derosa, G [28] 2017 Italy Randomized, double- 3 months - Estimated 10-year CV risk < 10% according Nutraceutical RYR, berberine 500 mg, silymarin 105 mg 73 50.2 ± 6.2 blind, placebo-controlled, to Framingham risk scoring compound with Placebo 70 47.4 ± 5.3 parallel-group clinical - ≥18 years of age RYR study -TC≥ 200 mg/dL and ≤240 mg/dL Marazzi, G [29] 2017 Italy Randomized, single-blind, 3 months - Documented CAD treated with PCI in the Nutraceutical Low-dose statin, RYR 200 mg, berberine 50 69 ± 10 parallel-group clinical previous 12 months compound with 500 mg, policosanols 10 mg, coenzyme study - high-dose statin intolerance RYR Q10 2 mg, astaxanthin 0.5 mg, folic acid - LDL-C > 100 mg/dL 0.2 mg - < 50% reduction in LDL-C with low-dose Low-dose statin 50 67 ± 12 statin treatment Spigoni, V [30] 2017 Italy Randomized, double- 12 weeks - non-HDL-C≥ 160 mg/dL Nutraceutical RYR 100 mg, berberine 200 mg, chitosan 30 52 ± 12

blind, placebo-controlled, compound with 100 mg, coenzyme Q10 10 mg, Pharmacological Resea parallel-group clinical RYR Placebo 9 52 ± 6 study Xue, Y [31] 2017 China Randomized, double- 4 weeks - SCORE estimated 10-year risk of fatal RYR RYR 1200 mg 27 47.0 ± 5.8 blind, parallel-group CVD<5% Simvastatin 20 mg 33 46.0 ± 7.0 clinical study - LDL-C≥ 115 mg/dL and ≤190 mg/dL Zheng, J [32] 2017 China Randomized, single-blind, 6 months - Primary prevention for CVD RYR RYR 1200 mg 50 58.4 ± 10.0

placebo-controlled, - essential hypertension Placebo 50 57.1 ± 10.4 rch 143(2019)1–16 parallel-group clinical - 45-55 years of age study - TC < 240 mg/dL - LDL-C < 159 mg/dL (continued on next page) .Fgci tal. et Fogacci, F. Table 1 (continued)

Author Year Study Study design Follow-up Main inclusion criteria Intervention Study group (daily dose) Participants (n) Age (years; location mean ± SD)

Cicero, AF [11] 2016 Italy Randomized, single-blind, 4 weeks - Primary prevention for CVD Nutraceutical RYR, coenzyme Q10 30 mg 40 53.8 ± 7.3 placebo-controlled, - 18-70 years of age compound with Placebo 39 54.6 ± 7.7 parallel-group clinical - LDL-C≥ 130 mg/dL and ≤190 mg/dL RYR study Cicero, AF [33] 2016 Italy Randomized, double- 4 weeks - Primary prevention for CVD Nutraceutical RYR 200 mg, dry green tea extract 25 53.2 ± 8.5 blind, placebo-controlled, - 18-70 years of age compound with 1000 mg, quercetin 50 mg, coenzyme Q10 cross-over clinical study - LDL-C≥ 130 mg/dL and ≤190 mg/dL RYR 20 mg, resveratrol 20 mg, astaxanthin 2 mg, folic acid 0.2 mg Placebo Cicero, AF [34] 2016 Italy Randomized, double- 8 weeks - Primary prevention for CVD Nutraceutical RYR 200 mg, silymarin 150 mg, 40 49.5 ± 7.7 blind, placebo-controlled, - 18-70 years of age compound with policosanols 30 mg, guggulipids 10 mg, parallel-group clinical - LDL-C≥ 130 mg/dL and ≤190 mg/dL RYR guggulsterols 2.5 mg study Placebo 40 49.8 ± 7.2 Cicero, AF [35] 2016 Italy Randomized, double- 16 weeks - Primary prevention for CVD RYR RYR 200 mg 30 56 ± 9 blind, placebo-controlled, - stage 1 hypertension Placebo cross-over clinical study - LDL-C > 115 mg/dL Heinz, T [36] 2016 Germany Randomized, double- 12 weeks - 18-70 years of age Nutraceutical RYR 200 mg, coenzyme Q10 2 mg, 73 57.5 ± 7.2 blind, placebo-controlled, - LDL-C≥ 160 mg/dL and ≤220 mg/dL compound with astaxanthin 0.5 mg, folic acid 0.2 mg parallel-group clinical - BMI≤ 35 Kg/m2 RYR Placebo 78 57.0 ± 6.8 study Kasliwal, RR [37] 2016 India Multicenter, randomized, 12 weeks - Primary prevention for CVD RYR RYR 800 mg, grape seed extract 70 mg, 96 47.0 ± 9.7 double-blind, placebo- - 18-65 years of age black pepper 20 mg, vitamin B3 14 mg, controlled, parallel-group - LDL-C > 120 mg/dL vitamin B9 0.2 mg clinical study Placebo 95 47.4 ± 10.4

4 Gentile, M [38] 2015 Italy Randomized, double- 8 weeks - Familial combined hyperlipidemia Nutraceutical RYR 200 mg, berberine 500 mg, 15 44.1 ± 13.0 blind, placebo-controlled, compound with policosanols 10 mg, coenzyme Q10 2 mg, parallel-group clinical RYR astaxanthin 0.5 mg, folic acid 0.2 mg study Placebo 15 Verhoeven, V [39] 2015 Belgium Randomized, double- 8 weeks - Metabolic syndrome as defined by the ATPIII Nutraceutical RYR, hydroxytyrosol 9.3 mg 26 53.6 ± 8.4 blind, placebo-controlled, criteria compound with Placebo 24 49.9 ± 13.3 parallel-group clinical --≥18 years of age RYR study Derosa, G [40] 2014 Italy Randomized, double- 3 months - Estimated 10-year CV risk < 10% according Nutraceutical RYR 200 mg, silymarin 150 mg, 68 55.6 ± 8.4 blind, placebo-controlled, to Framingham risk scoring compound with policosanols 30 mg, guggulipids 10 mg, parallel-group clinical - ≥18 years of age RYR guggulsterols 2.5 mg study -TC≥ 200 mg/dL and ≤250 mg/dL Placebo 66 53.8 ± 7.7 - BMI≥ 25 Kg/m2 and ≤29.9 Kg/m2 Gonnelli, S [41] 2014 Italy Randomized, double- 24 weeks - Estimated 10-year CV risk < 20% according Nutraceutical RYR 200 mg, berberine 500 mg, 30 46.4 ± 9.7 blind, placebo-controlled, to Framingham risk scoring compound with policosanols 10 mg, coenzyme Q10 2 mg, parallel-group clinical - 18-60 years of age RYR astaxanthin 0.5 mg, folic acid 0.2 mg study - BMI≥19 Kg/m2 and < 30 Kg/m2 Placebo 30 46.4 ± 10.1 - LDL-C > 150 mg/dL Pharmacological Resea Moriarty, PM [42] 2014 China / Multicenter, randomized, 12 weeks - Primary prevention for CVD RYR RYR 2400 mg 42 56.3 ± 10.8 USA double-blind, placebo- - ≥18 years of age RYR 1200 mg 36 57.8 ± 9.0 controlled, parallel-group -TC≥ 240 mg/dL Placebo 38 56.0 ± 12.5 clinical study - LDL-C≥ 160 mg/dL and < 220 mg/dL Ruscica, M [43] 2014 Italy Randomized, double- 8 weeks - Primary prevention for CVD Nutraceutical RYR 200 mg, berberine 500 mg, 30 55.4 ± 9.7 blind, cross-over clinical - metabolic syndrome compound with policosanols 10 mg, coenzyme Q10 2 mg,

study - > 18 years of age RYR astaxanthin 0.5 mg, folic acid 0.2 mg rch 143(2019)1–16 - LDL-C≥ 130 mg/dL and ≤170 mg/dL Pravastatin 10 mg Placebo (continued on next page) .Fgci tal. et Fogacci, F. Table 1 (continued)

Author Year Study Study design Follow-up Main inclusion criteria Intervention Study group (daily dose) Participants (n) Age (years; location mean ± SD)

Solà, R [44] 2014 Spain Randomized, double- 12 weeks - Primary prevention for CVD Nutraceutical RYR 200 mg, berberine 500 mg, 51 49.9 ± 11.6 blind, placebo-controlled, - ≥18 years of age compound with policosanols 10 mg, coenzyme Q10 2 mg, parallel-group clinical - LDL-C≥ 130 mg/dL and < 190 mg/dL RYR astaxanthin 0.5 mg, folic acid 0.2 mg study Placebo 51 52.4 ± 11.2 Barrat, E [45] 2013 France Randomized, double- 4 weeks - 18-65 years of age Nutraceutical RYR 1000 mg, dry artichoke leaf extract 15 50.8 ± 10.8 blind, placebo-controlled, - BMI≥ 18.1 Kg/m2 and < 28.1 Kg/m2 compound with 1200 mg, vitamin E 77.2 mg, dry garlic parallel-group clinical - LDL-C≥ 127 mg/dL and ≤224 mg/dL RYR extract 60 mg, pine bark extract 40, study policosanols 19.8 mg, vitamin B3 17.5 mg, vitamin B2 9.6 mg RYR 500 mg, dry artichoke leaf extract 15 53.4 ± 9.0 600 mg, vitamin E 38.6 mg, dry garlic extract 30 mg, pine bark extract 20 mg, policosanols 9.9 mg, vitamin B3 8.8 mg, vitamin B2 4.8 mg Placebo 15 49.1 ± 9.5 Barrat, E [46] 2013 France Randomized, double- 16 weeks - 18-65 years of age Nutraceutical RYR 500 mg, dry artichoke leaf extract 50 47.9 ± 9.6 blind, placebo-controlled, - LDL-C≥ 127 mg/dL and ≤224 mg/dL compound with 600 mg, vitamin E 38.6 mg, dry garlic parallel-group clinical - HDL-C≥ 40 mg/dL RYR extract 30 mg, pine bark extract 20 mg, study - BMI≥ 18.1 Kg/m2 and < 28.1 Kg/m2 policosanols 9.9 mg, vitamin B3 8.8 mg, vitamin B2 4.8 mg Placebo 50 46.5 ± 11.0 Cicero, AF [47] 2013 Italy Randomized, double- 8 weeks - Primary prevention for CVD Nutraceutical RYR 200 mg, coenzyme Q10 10 mg 25 52.4 ± 7.8 blind, placebo-controlled, - 18-70 years of age compound with Placebo cross-over clinical study - LDL-C≥ 130 mg/dL and ≤190 mg/dL RYR

5 Ogier, N [48] 2013 France Randomized, double- 16 weeks - 18-55 years of age Nutraceutical RYR 500 mg, dry artichoke leaf extract 19 50.3 ± 4.8 blind, placebo-controlled, - TC > 220 mg/dL compound with 600 mg, vitamin E 38.6 mg, dry garlic parallel-group clinical - BMI≥ 18.5 Kg/m2 and < 27.5 Kg/m2 RYR extract 30 mg, pine bark extract 20 mg, study policosanols 9.9 mg, vitamin B3 8.8 mg, vitamin B2 4.8 mg Placebo 20 45.7 ± 9.2 Verhoeven, V [49] 2013 Belgium Randomized, double- 8 weeks - Medical doctors or their partners Nutraceutical RYR 670 mg, lecithin 200 mg. coenzyme 31 55 ± 7 blind, placebo-controlled, - ≥18 years of age compound with Q10 60 mg, procyanidins 40 mg parallel-group clinical - TC > 200 mg/dL RYR Placebo 23 55 ± 11 study Affuso, F [50] 2012 Italy Randomized, double- 18 weeks - Metabolic syndrome Nutraceutical RYR 200 mg, berberine 500 mg, 31 53 ± 7 blind, placebo-controlled, - 18-65 years of age compound with policosanols 10 mg, coenzyme Q10 2 mg, parallel-group clinical RYR astaxanthin 0.5 mg, folic acid 0.2 mg study Placebo 31 50 ± 12 Cicero, AF [51] 2012 Italy Randomized, double- 12 months - Primary prevention for CVD Nutraceutical RYR 200 mg, berberine 500 mg, 71 53 ± 4 blind, placebo-controlled, - overweight compound with policosanols 10 mg, coenzyme Q10 2 mg, parallel-group clinical RYR astaxanthin 0.5 mg, folic acid 0.2 mg study Placebo 64 56 ± 5 Pharmacological Resea Karl, M [52] 2012 USA Randomized, double- 8 weeks - Male subjects aged 20-80 years or post- Nutraceutical RYR 1200 mg, phytosterols 1300 mg, 28 60 ± 13 blind, placebo-controlled, menopausal women aged 55-80 years compound with vitamin C 1000 mg, L-carnitine 300 mg, parallel-group clinical - primary prevention for CVD RYR coenzyme Q10 50 mg, niacin 25 mg study Placebo 25 63 ± 9 Lee, IT [53] 2012 Taiwan Randomized, double- 12 weeks - Metabolic syndrome according to NCEP Nutraceutical Red yeast rice 1110 mg, fresh bitter gourd 54 52 ± 10 blind, placebo-controlled, definition compound with 1200 mg, licorice 660 mg, chlorella

parallel-group clinical RYR 450 mg, soybean 330 mg rch 143(2019)1–16 study Placebo 52 51 ± 10 Guardamagna, O 2011 Italy Randomized, double- 8 weeks - Primary hypercholesterolemia Nutraceutical RYR 200 mg, berberine 500 mg, 40 11.5 ± 2 [54] blind, placebo-controlled, - 8-16 years of age compound with policosanols 10 mg, coenzyme Q10 2 mg, cross-over clinical study - TC > 200 mg/dL RYR astaxanthin 0.5 mg, folic acid 0.2 mg - LDL-C > 130 mg/dL Placebo (continued on next page) .Fgci tal. et Fogacci, F. Table 1 (continued)

Author Year Study Study design Follow-up Main inclusion criteria Intervention Study group (daily dose) Participants (n) Age (years; location mean ± SD)

Marazzi, G [55] 2011 Italy Randomized, single-blind, 12 months - > 75 years of age Nutraceutical RYR 200 mg, berberine 500 mg, 40 82.5 ± 4.4 parallel-group clinical - TC > 200 mg/dL compound with policosanols 10 mg, coenzyme Q10 2 mg, study - LDL-C > 160 mg/dL RYR astaxanthin 0.5 mg, folic acid 0.2 mg - statin intolerance and refusal other treatments Placebo 40 82.5 ± 4.9 for hypercholesterolemia Affuso, F [10] 2010 Italy Randomized, double- 6 weeks - 18-70 years of age Nutraceutical RYR 200 mg, berberine 500 mg, 25 55 ± 8 blind, placebo-controlled, - TC > 120 mg/dL compound with policosanols 10 mg, coenzyme Q10 2 mg, parallel-group clinical - LDL-C > 130 mg/dL RYR astaxanthin 0.5 mg, folic acid 0.2 mg study Placebo 25 55 ± 7 Bogsrud, MP [56] 2010 Norway Randomized, double- 16 weeks - 18-75 years of age RYR RYR 22 NA blind, placebo-controlled, Placebo 20 NA parallel-group clinical study Halbert, SC [57] 2010 USA Randomized, double- 12 weeks - Documented statin-associated myalgia leading RYR RYR 4800 mg 21 62.4 ± 8.9 blind, parallel-group to discontinuation of at least one statin other Pravastatin 40 mg 22 62.9 ± 6.6 clinical trial than pravastatin, with resolution of myalgia after discontinuation Becker, DJ [58] 2009 USA Randomized, double- 24 weeks - Primary polygenic hypercholesterolemia RYR RYR 1800 mg 31 60.5 ± 9.3 blind, placebo-controlled, - 21-80 years of age Placebo 32 61.5 ± 8.2 parallel-group clinical - documented statin-associated myalgia leading study to discontinuation of at least one statin Yang, NC [59] 2009 Taiwan Randomized, double- 6 months - Primary prevention for CVD Nutraceutical RYR 1200 mg, nattokinase 200 mg 19 54.4 ± 10.4 blind, placebo-controlled, -TC≥ 200 mg/dL and ≤300 mg/dL compound Placebo 10 56.3 ± 11.8 parallel-group clinical -TG≥ 200 mg/dL and ≤500 mg/dL ≥ ≤ 6 study - LDL-C 130 mg/dL and 200 mg/dL - HDL-C < 40 mg/dL for men or < 50 mg/dL for women Ye, P [60] 2009 China Randomized, single-blind, 72 weeks - High BP RYR RYR 1200 mg 28 56.3 ± 8.1 placebo-controlled, - LDL-C≤ 130 mg/dL Placebo 27 56.4 ± 9.3 parallel-group clinical study Gheith, O [61] 2008 Egypt Randomized, double- 6 months - Steroid-resistant, steroid-dependent and RYR RYR 600 mg 20 21.4 ± 14 blind, placebo-controlled, frequently relapsing idiopathic nephrotic Fluvastatin 20 mg 30 17.6 ± 7 parallel-group clinical syndrome Placebo 22 19.7 ± 7 study - diet-resistant hypercholesterolemia - Cr < 2 mg/dL - renal biopsy with either FSGS or MNGN lesions Lu, Z [62] 2008 China Randomized, double- 4.5 years - Documented myocardial infarction occurred RYR RYR 1200 mg 2429 M: 58.1 ± 9.9 blind, placebo-controlled, in the previous 60 months W: 62.9 ± 6.7 parallel-group clinical - 18-70 years of age Placebo 2441 M: 58.0 ± 9.7 study -TC≥ 170 mg/dL and ≤ 250 mg/dL W: 62.6 ± 7.4 Pharmacological Resea Cicero, AF [63] 2007 Italy Randomized, single-blind, 4 weeks - Primary prevention for CVD Nutraceutical RYR 200 mg (monacolin k 3 mg), 20 61.0 ± 15.5 parallel-group clinical - estimated 10-year CV risk > 10% and compound with berberine 500 mg, policosanols 10 mg, study < 20% according to Framingham risk scoring RYR coenzyme Q10 2 mg, astaxanthin 0.5 mg, -TC≥ 200 mg/dL and ≤300 mg/dL folic acid 0.2 mg Berberine 500 mg 20 60.4 ± 14.0 Huang, CF [64] 2007 Taiwan Randomized, double- 8 weeks - 18-65 years of age RYR RYR 1200 mg 39 46.3 ± 10.1

blind, placebo-controlled, - LDL-C≥ 160 mg/dL Placebo 40 46.5 ± 9.5 rch 143(2019)1–16 parallel-group clinical study (continued on next page) .Fgci tal. et Fogacci, F. Table 1 (continued)

Author Year Study Study design Follow-up Main inclusion criteria Intervention Study group (daily dose) Participants (n) Age (years; location mean ± SD)

Li, JJ [65] 2007 China Randomized, single-blind, 3 months - Cardiac syndrome X RYR RYR 1200 mg 18 NA placebo-controlled, Placebo 18 NA parallel-group clinical study Shang, XB [66] 2007 China Randomized, double- 2 months - Stable angina RYR RYR 1200 mg 65 51 ± 10 blind, parallel group Atorvastatin 10 mg 65 55 ± 10 clinical study Hu, CL [67] 2006 China Randomized, double- 8 weeks - Documented CHD RYR RYR 1200 mg 25 55.3 ± 3.4 blind, placebo-controlled, - NYHA class I or II Placebo 25 54.1 ± 5.1 parallel-group clinical study Zhao, SP [9] 2004 China Randomized, single-blind, 6 weeks - Documented CHD RYR RYR 1200 mg 25 58.2 ± 4.2 placebo-controlled, Placebo 25 59.1 ± 6.3 parallel-group clinical study Liu, L [68] 2003 China Randomized, single-blind, 6 weeks - Documented CHD RYR RYR 1200 mg 30 57.6 ± 5.2 placebo-controlled, Placebo 30 58.0 ± 4.3 parallel-group clinical study Keithley, JK [69] 2002 USA Randomized, double- 8 weeks - Documented HIV-1 infection RYR RYR 6 40.8 ± 23 blind, placebo-controlled, - 18-60 years of age Placebo 6 44.2 ± 18.6 parallel-group clinical - plasma HIV-RNA < 10,000 copies/mL study - CD4+ cell counts > 200 cells mm3 - LDL-C > 130 mg/dL

7 Yu, H [70] 2002 China Randomized, double- 8 weeks - Documented CHD RYR RYR 1200 mg 32 53.5 ± 10.8 blind, placebo-controlled, -TC≥ 180 mg/dL Placebo 30 50.6 ± 6.7 parallel-group clinical - LDL-C≥ 100 mg/dL study Heber, D [71] 1999 USA Randomized, double- 12 weeks - LDL-C > 160 mg/dL RYR RYR 2400 mg 42 62 ± 8 blind, placebo-controlled, - TG < 114 mg/dL Placebo 42 61 ± 10 parallel-group clinical study

ATP = Adult treatment panel; BMI = Body mass index; BP = Blood pressure; CAD = Coronary artery disease; CFU = Colony-forming unit; CHD = Coronary heart disease; Cr = Creatinine; CV = Cardiovascular; CVD = Cardiovascular disease; FSGS = Focal segmental glomerulosclerosis; HDL-C= High-density lipoprotein cholesterol; LDL-C = Low-density lipoprotein cholesterol; MPGN = Membranoproliferative glomerulone- phritis; NA = Not available; RYR = Red yeast rice; SD = Standard deviation; TC = Total cholesterol; TG = Triglycerides; USA = United States of America. * expressed as median and interquartile range. Pharmacological Resea rch 143(2019)1–16 F. Fogacci, et al. Pharmacological Research 143 (2019) 1–16 using the Cochrane criteria [17]. The items utilized for the assessment or stiffness, cramps, myalgia, myopathy, back pain and creatine kinase of each study were as follows: adequacy of sequence generation, allo- (CK) elevation ≥4 times the upper limit of normal (ULN), even in ab- cation concealment, blinding addressing of dropouts (incomplete out- sence of muscle-related symptoms). Secondary outcomes were non- come data], selective outcome reporting, and other probable sources of musculoskeletal adverse events (Non-MuD) (i.e. adverse cardiovascular bias [18]. Risk-of-bias assessment was performed independently by 2 events, gastrointestinal disorders, urinary tract infections, erectile reviewers (FF and AFGC); disagreements were resolved by a consensus- dysfunction, ear pain, rash and flash, pruritus, alopecia, pneumonia, based discussion. influence, general discomfort, arthralgia, jaw pain, loss of coordination, tingling, dizziness, headache, numbness, insomnia and other sleeping disorders, depression, pricking sensation, tactile hypersensitivity, dys- 2.5. Data synthesis geusia, mild elevation in biomarkers targeting liver, renal or bile duct function) and serious adverse events (SAE) (i.e. requiring urgent med- Meta-analysis was conducted using Comprehensive Meta-Analysis ical procedures and/or hospitalization, life-threatening or leading to (CMA) V3 software (Biostat, NJ) [19]. Primary outcomes were mus- death). If one or more outcomes could not be extracted from a study, culoskeletal disorders (MuD) (defined as body aches, muscle weakness

Table 2 Quality of bias assessment of the included studies according to Cochrane guidelines.

SEQUENCE ALLOCATION BLINDING OF PARTICIPANTS, INCOMPLETE SELECTIVE OTHER POTENTIAL GENERATION CONCEALMENT PERSONNEL AND OUTCOME OUTCOME DATA OUTCOME THREATS TO ASSESSMENT REPORTING VALIDITY

Ruscica, M [23] 2019 L L L L L U Derosa, G [24] 2018 L L L L L U Cicero, AF [25] 2017 L L L L L L Cicero, AF [8] 2017 L L L L L L Cicero, AF [26] 2017 L L L L L L D’Addato, S [27] 2017 L L L L L L Derosa, G [28] 2017 U U L L L U Marazzi, G [29] 2017 H H H U U U Spigoni, V [30] 2017 L L L L L L Xue, Y [31] 2017 U U L L L H Zheng, J [32] 2017 U U H L L U Cicero, AF [11] 2016 L L H L L L Cicero, AF [33] 2016 L L L L L L Cicero, AF [34] 2016 L L L L L L Cicero, AF [35] 2016 L L L U U L Heinz, T [36] 2016 L L L L L L Kasliwal, RR [37] 2016 L L L L L H Gentile, M [38] 2015 L L L U U U Verhoeven, V [39] 2015 L L L L L L Derosa, G [40] 2014 L L L L L H Gonnelli, S [41] 2014 L L L L L L Moriarty, PM [42] 2014 L L L L L U Ruscica, M [43] 2014 L L L L L L Solà, R [44] 2014 L L L L L L Barrat, E [45] 2013 L U L L L L Barrat, E [46] 2013 L U L L L L Cicero, AF [47] 2013 L L L L L L Ogier, N [48] 2013 L L L L L L Verhoeven, V [49] 2013 L L L L L U AF[ffuso, 50] 2012 L L L L L L Cicero, AF [51] 2012 U U U L L U Karl, M [52] 2012 L L L L L L Lee, IT [53] 2012 U U H L L H Guardamagna, O 2011 L L L L L L [54] Marazzi, G [55] 2011 H H H L L U Affuso, F [10] 2010 L L L L L L Bogsrud, MP [56] 2010 L L L L L L Halbert, SC [57] 2010 L L L L L L Becker, DJ [58] 2009 L U L L L L Yang, NC [59] 2009 U U L L L H Ye, P [60] 2009 U U H U L U Geith, O [61] 2008 L U L L L H Lu, Z [62] 2008 L L L H H L Cicero, AF [63] 2007 L L H L L U Huang, CF [64] 2007 U L U U U U Li, JJ [65] 2007 L U U U U U Shang, XB [66] 2007 U U U L L U Hu, [67] 2006 L L L U H U Zhao, SP [9] 2004 U L H L L L Liu, L [68] 2003 U L H L L U Keithley, JK [69] 2002 L L L L L L Yu, H [70] 2002 U U U L L U Heber, D [71] 1999 L L L L L L

L = Low risk of bias; H= High risk of bias; U = Unclear risk of bias.

8 F. Fogacci, et al. Pharmacological Research 143 (2019) 1–16 the study was removed only from the analysis involving those out- 2.8. Publication biases comes. To avoid a double-counting problem, in trials comparing multiple Potential publication biases were explored using visual inspection of treatment arms versus a single control group, the number of subjects in Begg’s funnel plot asymmetry, Begg’s rank correlation test and Egger’s the control group was divided by the number of the treatment arms. weighted regression test [21]. The Duval & Tweedie “trim and fill” Study findings were combined using the generic inverse variance method was used to adjust the analysis for the effects of publication method and a fixed-effect model due to the low (< 40%) heterogeneity, biases [22]. Two-sided p values ≤0.05 were considered significant. which was quantitatively assessed using Higgins index (I2). Results were expressed as odds-ratios (OR) with 95%CI. Finally, sensitivity 3. Results analyses were conducted to account for the risk of bias. A leave-one-out method was used (i.e. one study was removed at a time and the analysis 3.1. Flow and characteristics of the included studies repeated) [20]. Meta-analysis was performed by excluding studies with ≤ zero events in both arms. Two-sided p values 0.05 were considered After database searches performed strictly according to inclusion fi signi cant. and exclusion criteria, 459 published articles were identified and the abstracts reviewed. Of these, 261 were excluded because they were non-original articles. Another 82 were eliminated because they did not 2.6. Additional analyses meet the inclusion criteria. Thus, 116 articles were carefully assessed and reviewed. An additional 63 studies were excluded because of: ob- Subgroup analyses were carried out considering the intervention servational design (n = 7), single arm trials (n = 5), case reports or (RYR alone or in association with other nutraceutical compounds), case series (n = 6), lacking blinding (n = 29), lacking of a control ≤ – monacolin K administered daily dose ( 3, 3 5 and > 5 mg/day), group receiving placebo or statin treatment (n = 8), lacking of rando- ≤ follow-up (> 12 or 12 weeks), with statin therapy or statin-intoler- mization (n = 1), substantial sample overlap (n = 7) (Appendix 1). ance and type of control treatment (placebo or statin treatment). Finally, 53 studies were eligible and included in the meta-analysis Subgroup analyses were performed excluding studies with zero events [8–11,24–71]. The study selection process is shown in Supplementary ≤ fi in both arms. Two-sided p values 0.05 were considered signi cant. Fig. 1. Data were pooled from 53 RCTs comprising 112 treatment arms, which included 8535 subjects, with 4437 in the RYR arm and 4303 in 2.7. Meta-regression analyses the control one. For reasons largely independent of the tested nu- traceuticals (i.e. withdrawal of informed consent and personal pro- ff Fixed e ects meta-regression analyses including some potential in- blems), 144 subjects prematurely terminated the trials in which they dependent moderator variables (i.e. age at baseline and monacolin K were enrolled. Therefore, the meta-analysis was performed on the other daily dose) were planned to explore heterogeneity. Meta-regression subjects (per-protocol (PP) population). analyses were performed excluding studies with zero events in both Eligible studies were published between 1999 and 2019, and were ≤ fi arms. Two-sided p values 0.05 were considered signi cant. conducted in Italy (n = 24), China (n = 11), USA (n = 6), France

Fig. 1. Forest plot comparing the RYR associated risk of MuD in the entire population. RYR: Red yeast rice, MuD: Musculoskeletal disorders (For interpretation of the references to colour in this figure legend, the reader is referred to the web version of this article).

9 F. Fogacci, et al. Pharmacological Research 143 (2019) 1–16

(n = 3), Taiwan (n = 3), Belgium (n = 2), Egypt (n = 1), Germany (slope: -0.005; 95%CI: -0.06, 0.05; two-tailed p = 0.86; Supplementary (n = 1), India (n = 1), Norway (n = 1) and Spain (n = 1). Follow-up Fig. 3) and monacolin K daily dose (slope: 0.001; 95%CI: -0.16, 0.17; periods ranged between 4 weeks and 4.5 years and several daily doses two-tailed p = 0.99; Supplementary Fig. 4). The funnel plot of standard of monacolin K were tested. Selected trials were designed with cross- error by log OR was asymmetric, suggesting potential publication bias over [26,33,35,43,47,54] or parallel groups in the meta-analysis. However, the results of Egger’s linear regression [8,10,11,23–25,27–32,34,36–42,44–46,48–53,55–71]. Enrolled sub- (intercept = 0.14; standard error = 0.63; 95%CI: -1.22, 1.49; t = 0.21, jects were adults and children without any major disease df = 14; two-tailed p = 0.83) and Begg’s rank correlation (Kendall’s [8,10,11,23–28,30–61,63,64,69,71], individuals with documented CVD Tau with continuity correction= 0; z = 0; two-tailed p = 1) did not [9,29,62,65–68,70], statin intolerant patients [55,57,58] patients with suggest potential publication bias. An attempt was made to address HIV-1 infection [69] or idiopathic nephrotic syndrome [61]. The publication bias using “trim and fill” correction. Correction of the characteristics of the evaluated studies are summarized in Table 1. asymmetry using the Duval & Tweedie “trim and fill” method yielded only 1 potentially missing study on the left-side of the funnel plot, which lowered the estimated effect to 0.88 (95%CI: 0.50, 1.54) (Sup- 3.2. Risk of bias assessment plementary Fig. 5). Almost all of the included studies were characterized by sufficient information regarding sequence generation, allocation concealment 3.4. Non-musculoskeletal adverse events and personnel and outcome assessments, and showed low risk of bias because of incomplete outcome data and selective outcome reporting. No Non-MuD was experienced by subjects enrolled in 34 studies Details of the quality of bias assessment are reported in Table 2. among those selected. In the others, meta-analysis showed reduced risk of Non-MuD vs. control (OR 0.59, 95%CI 0.50,0.69; Supplementary 3.3. Musculoskeletal disorders Fig. 6). Subgroup analyses confirmed the high tolerability profile of monacolin K at the tested doses (Supplementary Figure 11). No MuD was experienced by subjects enrolled in 37 studies among Considering the entire population, meta-regression analyses did not those selected for the meta-analysis. In the others, monacolin K ad- suggest an increased risk for RYR associated Non-MuD depending on ministration was neither associated with increased risk of MuD in the age (slope: -0.03; 95%CI: -0.06, 0.003; two-tailed p = 0.08; entire sample (OR = 0.94, 95%CI 0.53,1.65; Fig. 1) nor in subsets of Supplementary Figure 12). Increasing daily doses of monacolin K were studies categorized according to administrated daily dose (besides do- negatively associated with increasing risk of Non-MuD (slope: -0.10; sage ranged 3.1–5 mg/day which was based only on a single study; 95%CI: -0.17, -0.03; two-tailed p < 0.01; Supplementary Figure 13). Fig. 2), treatment duration (Fig. 3), intervention type (Fig. 4), presence The funnel plots of standard error by log OR were asymmetric, sug- of statin therapy or statin-intolerance (Fig. 5) and type of control gesting potential publication biases in the meta-analysis. The presence treatment (Fig. 6). The result was robust in the leave-one-out sensitivity of publication biases was confirmed by Egger’s linear regression (in- analysis (Supplementary Fig. 2). tercept= 0.63; standard error= 0.23; 95%CI: 0.16, 1.11; t= 2.79, df= Considering the entire population, meta-regression analyses did not 20; two-tailed p = 0.01). Contrary to what was visibly detectable, suggest an increased risk for RYR associated MuD depending on age Begg’s rank correlation did not highlight any publication bias (Kendall’s

Fig. 2. Forest plot comparing the RYR associated risk of MuD. Subgroup analysis stratified by monacolin k administrated daily dose. RYR: Red yeast rice, MuD: Musculoskeletal disorders (For interpretation of the references to colour in this figure legend, the reader is referred to the web version of this article).

10 F. Fogacci, et al. Pharmacological Research 143 (2019) 1–16

Fig. 3. Forest plot comparing the RYR associated risk of MuD. Subgroup analysis stratified by treatment duration. RYR: Red yeast rice, MuD: Musculoskeletal disorders (For interpretation of the references to colour in this figure legend, the reader is referred to the web version of this article).

Tau with continuity correction= 0.02; z= 0.14; two-tailed p = 0.89). 3.5. Serious adverse events Correction of the asymmetries using Duval & Tweedie “trim and fill” method yielded 7 potentially missing studies on the left-side of the No SAE was experienced by subjects enrolled in 48 studies among funnel plot which lowered the estimated effect to 0.56 (95%CI: 0.48, those selected. In the others, meta-analysis showed reduced risk of SAE 0.66) (Supplementary Figure 14). vs. control (OR 0.54, 95%CI 0.46,0.64; Supplementary Figure 19). Considering the entire population, meta-regression analyses did not

Fig. 4. Forest plot comparing the RYR associated risk of MuD. Subgroup analysis stratified by intervention type. RYR: Red yeast rice, MuD: Musculoskeletal disorders (For interpretation of the references to colour in this figure legend, the reader is referred to the web version of this article).

11 F. Fogacci, et al. Pharmacological Research 143 (2019) 1–16

Fig. 5. Forest plot comparing the RYR associated risk of MuD. Subgroup analysis stratified by presence of statin intolerance or statin therapy. RYR: Red yeast rice, MuD: Musculoskeletal disorders (For interpretation of the references to colour in this figure legend, the reader is referred to the web version of this article). suggest an increased risk for RYR associated SAE depending on age standard error = 0.42; 95%CI: -1.27, 1.42; t = 0.18, df = 3; two-tailed (slope: -0.15; 95%CI: -0.49, 0.19; two-tailed p = 0.39; Supplementary p = 0.87) and Begg’s rank correlation (Kendall’s Tau with continuity Figure 20) or monacolin daily dose (slope: -0.02; 95%CI: -0.24, 0.20; correction= -0.1; z= 0.24; two-tailed p = 0.81) did not suggest any two-tailed p = 0.86; Supplementary Figure 21). publication bias. Visual inspection of Begg’s funnel plot did not reveal any asymmetry in the meta-analysis requiring “trim and fill” correction (Supplementary Figure 22). Likewise, Egger’s linear regression (intercept = 0.08;

Fig. 6. Forest plot comparing the RYR associated risk of MuD. Subgroup analysis stratified by control treatment. RYR: Red yeast rice, MuD: Musculoskeletal disorders (For interpretation of the references to colour in this figure legend, the reader is referred to the web version of this article).

12 F. Fogacci, et al. Pharmacological Research 143 (2019) 1–16

4. Discussion metabolite derived from the fermentation of Monascus [84]. Citrinin is nephrotoxic for various animal species and long-term exposure can Based on the overall high tolerability and safety profile of RYR, a gradually cause renal tubular epithelial hyperplasia, renal adenomas, number of official statements have recently suggested its use as a lipid- and sometimes renal tumours (in particular, at dose of 50 mg/kg b.w. lowering dietary supplement in the general population as well as in citrinin has been shown to cause tumours in 100% of the tested ani- statin-intolerant patients [72–76]. Our meta-analysis of 53 RCTs mals) [85]. Moreover, citrinin induces reproductive toxicity, and in with > 8500 patients confirmed that RYR-based therapy is safe and vitro and in vivo malformations and embryo-toxicity [86]. Although the very well tolerated independent of dose and duration of therapy and EFSA has expressed as 0.2 ug/kg b.w. per day as the highest quantity of populations investigated. To the best of our knowledge, the current citrinin which can be taken by humans without nephrotoxic sequelae. systematic review and meta-analysis is the first one to comprehensively However, genotoxic and carcinogenic effects have been observed even analyse evidence from RCTs on the short- and longer-term safety of RYR at these doses [87]. However, this concern is not so strictly related to supplementation in mildly hypercholesterolemic patients. RYR, as to the production quality because citrinin-free RYR is available These results and conclusions are contrary to the recent European on the market. Hence, the best way to avoid adverse health sequelae is Food Safety Authority (EFSA) opinion on the safety of monacolins in to force industries to market only certified citrinin-free products. For RYR [77]. In fact, based on data from 30 single cases and uncertainty on instance, most of the RCTs included in our meta-analysis tested certified the possible increased bioavailability of RYR when taken with a stan- products. What is more, in the recent ILEP position papers on nu- dard meal (only two studies with opposite results), EFSA concludes that traceuticals [72,74], we strongly emphasized the need for quality it is difficult to identify a dietary intake of monacolins that does not control of all natural products to ensure credibility and reproducibility give rise to concerns about harmful effects [77]. However, it needs to be of efficacy and safety findings from RCTs. emphasized that most case reports were not followed by a rechallenge nor was it investigated whether the observed adverse effects were in- 5. Study limitations deed related to monacolins (lack of confirmed causality), to other components possibly contained in low-quality products, or due to a Our present meta-analysis has some limitations. Firstly, some of the drug interaction. included studies were single-blinded and most had relatively short Concerning the RYR safety profile, previous meta-analyses of RCTs follow-up. On the other hand, one of our subgroup analyses did not showed that the incidence of cases of liver enzymes abnormality and suggest any differences in the incidence of adverse events among the kidney injury ranged between 0 and 5% in both groups (RYR and studies categorized according to treatment duration. We were also able control). In addition, the recorded incidence of muscle symptoms was to find only one study with monacolin K dose 3.1–5 mg; however, meta- lower in RYR group (0–23.8%) compared with the control one (0–36%), analysis of studies with doses both ≤3 and > 5 showed no sign of and there were no cases of either rhabdomyolysis or myopathy [5,6]. It adverse effects. Secondly, the concomitant therapies were not clearly is worth emphasizing that for RYR, which contains natural lovastatin, reported in all the RCTs, and there was only one study on children and as well as for statin therapy, care should be taken to establish causality no studies on pregnant or lactating women, whom RYR supplementa- between the observed symptoms and the therapy itself [78]. That is tion is not to be advised. Although the analysis consisted of differently why the International Lipid Expert Panel (ILEP) [72,79] published a characterized samples, we found a low heterogeneity level among the position paper defining statin intolerance and presented the manage- effect sizes of the studies, indicating that safety data are similar across ment of the most common risk factors/conditions that increase the risk the targeted samples. of statin-associated muscle symptoms (SAMS). In a recent paper, Ba- nach also presented 4 step diagnostic approach to SAMS, including 6. Conclusions application of a SAMS clinical index (SAMS-CI) score, which helps to confirm causality between muscle pain and statin therapy [80,81]. The present meta-analysis, which included more than 8500 subjects, The concomitant administration of RYR and strong inhibitors of demonstrates that RYR supplementation is safe and is not associated CYP3A4 (e.g. cyclosporine, niacin, fibrates, warfarin, verapamil, anti- with increased incidence of muscular adverse effects. On the contrary, fungals, macrolides, nefazodone, HIV protease inhibitors) should in our findings shows reduced risk of Non-MuD and SAE, suggesting this theory increase the level of monacolin K in plasma and could, conse- nutraceutical compound can be used in order to promote health in quently, reduce its safety [82]. However, these drugs are usually pre- general population with mildly increased cardiovascular disease risk scribed in a specialist medical setting, and, thus, potential interaction and in statin-intolerant patients. can be detected and limited. Nevertheless, this supports close mon- itoring of food supplements intake by medical professionals while Funding prescribing medications with acting as strong inhibitors of CYP3A4. Furthermore, the drug-drug interaction risk is dose-related and the This position paper was written independently; no company or in- monacolin K administrated daily dosage is usually low (3–10 mg per stitution supported it financially. No professional writer was involved in day). As a matter of fact, in our meta-analysis of RCTs, no significant the preparation of this meta-analysis. difference in the incidence of side effects have been observed despite the fact that half of the enrolled subjects took other drugs besides RYR: Declaration of interest this is because the patients were strictly monitored according to good clinical practice (GCP) guidelines. Nevertheless, it is possible that high Maciej Banach has served on the speakers bureau of Abbott/Mylan, doses of RYR assumed together with drugs characterized by a very strict Abbott Vascular, Actavis, Akcea, Amgen, Biofarm, KRKA, MSD, Sanofi- therapeutic range (i.e. cyclosporine) can be associated with severe ad- Aventis, Servier and Valeant, and has served as a consultant to Abbott verse events, especially in frail patients [83,84]. Therefore, despite the Vascular, Akcea, Amgen, Daichii Sankyo, Esperion, Lilly, MSD, above-mentioned very low risk of drug-to-drug interactions that might Resverlogix, Sanofi-Aventis; Grants from Sanofi and Valeant; Eric cause adverse effects, these patients should be monitored for the con- Bruckert has received honoraria for consulting/presentations from comitant therapies, especially those that are recognized to increase the AstraZeneca, AMGEN, Genfit, MSD, Sanofi and Regeneron, Unilever, risk of SAMS. Danone, Aegerion, Chiesi, Rottapharm-MEDA, Lilly, Ionis- Recently, some concerns have been raised about the safety of RYR Pharmaceuticals, and AKCEA; Arrigo F.G. Cicero has given talks, furn- when high quality production standards are lacking. In particular, the ished scientific consultancies and/or participated in trials sponsored by greatest attention must be paid to citrinin, which is a mycotoxin Amgen, Angelini, Mylan, and Sanofi; Federica Fogacci has served as a

13 F. Fogacci, et al. Pharmacological Research 143 (2019) 1–16 consultant to Mylan; Zlatko Fras has given talks at conferences spon- [13] R. Russo, L. Gallelli, R. Cannataro, M. Perri, A. Calignano, R. Citraro, E. Russo, sored by Amgen, AstraZeneca, KRKA, Pfizer and Sanofi, and has par- P. Gareri, A. Corsonello, G.D. Sarro, When nutraceuticals reinforce drugs side ef- – fi fects: a case report, Curr. Drug Saf. 11 (2016) 264 266. ticipated in trials sponsored by AstraZeneca and Sano ; John G.B. [14] V.R. Polsani, P.H. Jones, C.M. Ballantyne, V. Nambi, A case report of myopathy Mancini has received honoraria from and/or served on the advisory from consumption of red yeast rice, J. Clin. Lipidol. 2 (2008) 60–62, https://doi. board for Amgen, Sanofi, Merck, AstraZeneca, and Aegerion; Dimitri P. org/10.1016/j.jacl.2007.12.005. [15] E. Raschi, A. Girardi, E. Poluzzi, E. Forcesi, F. Menniti-Ippolito, G. Mazzanti, F. De Mikhailidis has given talks and attended conferences sponsored by Ponti, Adverse events to food supplements containing red yeast rice: comparative Merck Sharp & Dohme, AstraZeneca and Libytec; Željko Reiner has re- analysis of FAERS and CAERS reporting systems, Drug Saf. 41 (2018) 745–752, ceived honoraria from Akcea and Sanofi-Aventis; Manfredi Rizzo has https://doi.org/10.1007/s40264-018-0661-3. ff given lectures, received honoraria and research support, and partici- [16] D. Moher, A. Liberati, J. Tetzla , D.G. Altman, PRISMA Group, Preferred reporting items for systematic reviews and meta-analyses: the PRISMA statement, BMJ 339 pated in conferences, advisory boards, and clinical trials sponsored by (2009) b2535, https://doi.org/10.1136/bmj.b2535. Amgen, AstraZeneca, Boehringer Ingelheim, Kowa, Eli Lilly, Meda [17] J. Higgins, S. Green, Cochrane Handbook for Systematic Reviews of Interventions. Pharma, Merck Sharp & Dohme, Novo Nordisk, Novartis, Roche Version 5.0. 2, John Wiley and Sons Ltd, Chichester, UK, 2009 Ref Type: Report; 2010. Diagnostics, and Servier; Peter P. Toth has served on the speakers bu- [18] L.E. Simental-Mendía, M. Simental-Mendía, A. Sánchez-García, M. Banach, reau of Amarin, Amgen, Kowa, Merck, Novo-Nordisk, Regeneron, S.L. Atkin, A.M. Gotto Jr, A. Sahebkar, Effect of fibrates on glycemic parameters: a Sanofi, and has served as a consultant to Amarin, Amgen, AstraZeneca, systematic review and meta-analysis of randomized placebo-controlled trials, Pharmacol. Res. 132 (June) (2018) 232–241, https://doi.org/10.1016/j.phrs.2017. Kowa, Merck, Nov-Nordisk, and Theravance; Michal Vrablik has re- 12.030. ceived personal fees from Abbott, Actavis, AstraZeneca, Amgen, BMS, [19] M. Borenstein, L. Hedges, J. Higgins, H. Rothstein, Comprehensive Meta-analysis Genzyme, KRKA, MSD, Novartis, Pfizer and Sanofi-Regeneron; Gerald F. Version 3, Biostat, Englewood, NJ, 2005, p. 104. [20] F. Fogacci, D. Grassi, M. Rizzo, A.F.G. Cicero, Metabolic effect of berberine-sily- Watts has received honoraria for lectures and advisory boards for marin association: a meta-analysis of randomized, double-blind, placebo-controlled Sanofi, Regeneron, Kowa, and Amgen; Olena Mitchenko, Daniel Pella and clinical trials, Phytother. Res. (January (10)) (2019), https://doi.org/10.1002/ptr. Amirhossein Sahebkar have no conflict of interest. 6282 [Epub ahead of print]. [21] M. Bała, A. Sahebkar, S. Ursoniu, M.C. Serban, A. Undas, D.P. Mikhailidis, G.Y.H. Lip, J. Rysz, M. Banach, Lipid Blood Pressure Meta-Analysis Collaboration Appendix A. Supplementary data Group, Effects of tibolone on fibrinogen and antithrombin III: a systematic review and meta-analysis of controlled trials, Pharmacol. Res. 124 (October) (2017) 64–73, Supplementary material related to this article can be found, in the https://doi.org/10.1016/j.phrs.2017.07.024. [22] S. Duval, R. Tweedie, Trim and fill: a simple funnel plot–based method of testing online version, at doi:https://doi.org/10.1016/j.phrs.2019.02.028. and adjusting for publication bias in meta-analysis, Biometrics 56 (2000) 455–463. [23] M. Ruscica, C. Pavanello, S. Gandini, C. Macchi, M. Botta, D. Dall’Orto, M. Del References Puppo, M. Bertolotti, R. Bosisio, G. Mombelli, C.R. Sirtori, L. Calabresi, P. Magni, Nutraceutical approach for the management of cardiovascular risk - a combination containing the probiotic Bifidobacterium longum BB536 and red yeast rice extract: [1] A. Sahebkar, M.C. Serban, A. Gluba-Brzózka, D.P. Mikhailidis, A.F. Cicero, J. Rysz, results from a randomized, double-blind, placebo-controlled study, Nutr. J. 18 M. Banach, Lipid-modifying effects of nutraceuticals: an evidence-based approach, (February (1)) (2019) 13, https://doi.org/10.1186/s12937-019-0438-2. Nutrition 32 (2016) 1179–1192, https://doi.org/10.1016/j.nut.2016.04.007. [24] G. Derosa, G. Catena, R. Raddino, G. Gaudio, A. Maggi, A. D’Angelo, P. Maffioli, [2] J. Ma, Y. Li, Q. Ye, J. Li, Y. Hua, D. Ju, D. Zhang, R. Cooper, M. Chang, Constituents E ffects on oral fat load of a nutraceutical combination of fermented red rice, sterol of red yeast rice, a traditional Chinese food and medicine, J. Agric. Food Chem. 48 esters and stanols, curcumin, and olive polyphenols: a randomized, placebo con- (2000) 5220–5225. trolled trial, Phytomedicine. 42 (2018) 75–82, https://doi.org/10.1016/j.phymed. [3] D.W. Lachenmeier, Y.B. Monakhova, T. Kuballa, S. Löbell-Behrends, S. Maixner, 2018.01.014. M. Kohl-Himmelseher, A. Waldner, C. Steffen, NMR evaluation of total statin con- [25] A.F.G. Cicero, F. Fogacci, M. Rosticci, A. Parini, M. Giovannini, M. Veronesi, tent and HMG-CoA reductase inhibition in red yeast rice (Monascus spp.) food S. D’Addato, C. Borghi, Effect of a short-term dietary supplementation with phy- supplements, Chin. Med. 7 (2012) 8, https://doi.org/10.1186/1749-8546-7-8. tosterols, RYR or both on lipid pattern in moderately hypercholesterolemic subjects: [4] A.W. Alberts, Discovery, biochemistry and biology of lovastatin, Am. J. Cardiol. 62 a three-arm, double-blind, randomized clinical trial, Nutr. Metab. (Lond) 14 (2017) (1988) 10J–15J. 61, https://doi.org/10.1186/s12986-017-0214-2. [5] M.C. Gerards, R.J. Terlou, H. Yu, C.H. Koks, V.E. Gerdes, Traditional Chinese lipid- [26] A.F. Cicero, A. Colletti, F. Fogacci, M. Bove, M. Rosticci, C. Borghi, Effects of a lowering agent red yeast rice results in significant LDL reduction but safety is un- combined nutraceutical on lipid pattern, glucose metabolism and inflammatory certain - a systematic review and meta-analysis, Atherosclerosis 240 (2015) parameters in moderately hypercholesterolemic subjects: a double-blind, cross- 415–423, https://doi.org/10.1016/j.atherosclerosis.2015.04.004. over, randomized clinical trial, High Blood Press. Cardiovasc. Prev. 24 (2017) [6] J. Liu, J. Zhang, Y. Shi, S. Grimsgaard, T. Alraek, V. Fønnebø, Chinese red yeast rice 13–18, https://doi.org/10.1007/s40292-016-0163-2. (Monascus purpureus) for primary hyperlipidemia: a meta-analysis of randomized [27] S. D’Addato, L. Scandiani, G. Mombelli, F. Focanti, F. Pelacchi, E. Salvatori, G. Di controlled trials, Chin. Med. 1 (2006) 4, https://doi.org/10.1186/1749-8546-1-4. Loreto, A. Comandini, P. Maffioli, G. Derosa, Effect of a food supplement containing [7] V. Bianconi, M.R. Mannarino, A. Sahebkar, T. Cosentino, M. Pirro, Cholesterol- berberine, monacolin K, hydroxytyrosol and coenzyme Q(10) on lipid levels: a lowering nutraceuticals affecting vascular function and cardiovascular disease risk, randomized, double-blind, placebo controlled study, Drug Des. Dev. Ther. 11 Curr. Cardiol. Rep. 20 (May (7)) (2018) 53, https://doi.org/10.1007/s11886-018- (2017) 1585–1592, https://doi.org/10.2147/DDDT.S128623. 0994-7. [28] G. Derosa, A. D’Angelo, D. Romano, P. Maffioli, Effects of a combination of Berberis [8] A.F. Cicero, M. Morbini, M. Rosticci, S. D’’Addato, E. Grandi, C. Borghi, Short-term aristata, Silybum marianum and monacolin on lipid profile in subjects at low car- effects of a combined nutraceutical on lipid level, fatty liver biomarkers, hemody- diovascular risk; a double-blind, randomized, placebo-controlled trial, Int. J. Mol. namic parameters, and estimated cardiovascular disease risk: a double-blind, pla- Sci. 18 (2017), https://doi.org/10.3390/ijms18020343 pii: E343. cebo-controlled randomized clinical trial, Adv. Ther. 34 (2017) 1966–1975, [29] G. Marazzi, G. Campolongo, F. Pelliccia, S. Quattrino, C. Vitale, L. Cacciotti, https://doi.org/10.1007/s12325-017-0580-1. R. Massaro, M. Volterrani, G. Rosano, Comparison of low-dose statin versus low- [9] S.P. Zhao, L. Liu, Y.C. Cheng, M.H. Shishehbor, M.H. Liu, D.Q. Peng, Y.L. Li, dose statin + armolipid plus in high-intensity statin-intolerant patients with a Xuezhikang, an extract of cholestin, protects endothelial function through anti-in- previous coronary event and percutaneous coronary intervention (ADHERENCE flammatory and lipid-lowering mechanisms in patients with coronary heart disease, trial), Am. J. Cardiol. 120 (2017) 893–897, https://doi.org/10.1016/j.amjcard. Circulation 110 (2004) 915–920, https://doi.org/10.1161/01.CIR.0000139985. 2017.06.015. 81163.CE. [30] V. Spigoni, R. Aldigeri, M. Antonini, M.M. Micheli, F. Fantuzzi, A. Fratter, [10] F. Affuso, A. Ruvolo, F. Micillo, L. Saccà, S. Fazio, Effects of a nutraceutical com- M. Pellizzato, E. Derlindati, I. Zavaroni, R.C. Bonadonna, A. Dei Cas, Effects of a bination (berberine, red yeast rice and policosanols) on lipid levels and endothelial new nutraceutical formulation (Berberine, RYR and chitosan) on Non-HDL cho- function randomized, double-blind, placebo-controlled study, Nutr. Metab. lesterol levels in individuals with dyslipidemia: results from a randomized, double Cardiovasc. Dis. 20 (2010) 656–661, https://doi.org/10.1016/j.numecd.2009.05. blind, placebo-controlled study, Int. J. Mol. Sci. 18 (2017), https://doi.org/10. 017. 3390/ijms18071498 pii: E1498. [11] A.F. Cicero, M. Morbini, M. Rosticci, S. D’’Addato, E. Grandi, C. Borghi, Middle- [31] Y. Xue, L. Tao, S. Wu, G. Wang, L. Qian, J. Li, L. Liao, J. Tang, K. Ji, RYR induces term dietary supplementation with red yeast rice plus coenzyme Q10 improves lipid less muscle fatigue symptom than simvastatin in dyslipidemic patients: a single pattern, endothelial reactivity and arterial stiffness in moderately hypercholester- center randomized pilot trial, BMC Cardiovasc. Disord. 17 (2017) 127, https://doi. olemic subjects, Ann. Nutr. Metab. 68 (2016) 213–219, https://doi.org/10.1159/ org/10.1186/s12872-017-0560-z. 000445359. [32] J. Zheng, T. Xiao, P. Ye, D. Miao, H. Wu, Xuezhikang reduced arterial stiffness in [12] M. Pirro, C. Vetrani, C. Bianchi, M.R. Mannarino, F. Bernini, A.A. Rivellese, Joint patients with essential hypertension: a preliminary study, Braz. J. Med. Biol. Res. 50 position statement on "Nutraceuticals for the treatment of hypercholesterolemia" of (2017) e6363, https://doi.org/10.1590/1414-431X20176363. the Italian Society of Diabetology (SID) and of the Italian Society for the Study of [33] A.F. Cicero, M. Morbini, A. Parini, R. Urso, M. Rosticci, E. Grandi, C. Borghi, Effect Arteriosclerosis (SISA), Nutr. Metab. Cardiovasc. Dis. 27 (January (1)) (2017) 2–17, of RYR combined with antioxidants on lipid pattern, hs-CRP level, and endothelial https://doi.org/10.1016/j.numecd.2016.11.122. function in moderately hypercholesterolemic subjects, Ther. Clin. Risk Manag. 12

14 F. Fogacci, et al. Pharmacological Research 143 (2019) 1–16

(2016) 281–286, https://doi.org/10.2147/TCRM.S91817. red yeast rice, bitter gourd, chlorella, soy protein, and licorice improve total cho- [34] A.F. Cicero, A. Colletti, M. Rosticci, E. Grandi, C. Borghi, Efficacy and tolerability of lesterol, low-density lipoprotein cholesterol, and triglyceride in subjects with me- a combined lipid-lowering nutraceutical on cholesterolemia, hs-CRP level and en- tabolic syndrome, Nutr. Res. 32 (2012) 85–92, https://doi.org/10.1016/j.nutres. dothelial function in moderately hypercholesterolemic subjects, J. Biol. Regul. 2011.12.011. Homeost. Agents 30 (2016) 593–598. [54] O. Guardamagna, F. Abello, V. Baracco, B. Stasiowska, F. Martino, The treatment of [35] A.F. Cicero, F. Fogacci, M. Bove, M. Giovannini, S. D’Addato, Effetto di un nu- hypercholesterolemic children: efficacy and safety of a combination of RYR extract traceutico combinato a medio termine su controllo pressorio, ottimizzazione della and policosanols, Nutr. Metab. Cardiovasc. Dis. 21 (2011) 424–429, https://doi. colesterolemia LDL e rischio cardiovascolare stimato: follow-up di uno studio pilota, org/10.1016/j.numecd.2009.10.015. Pharmanutr. Funct. Foods 3 (2016) 39–42 [Italian]. [55] G. Marazzi, L. Cacciotti, F. Pelliccia, L. Iaia, M. Volterrani, G. Caminiti, B. Sposato, [36] T. Heinz, J.P. Schuchardt, K. Möller, P. Hadji, A. Hahn, Low daily dose of 3 mg R. Massaro, F. Grieco, G. Rosano, Long-term effects of nutraceuticals (berberine, monacolin K from RYR reduces the concentration of LDL-C in a randomized, pla- RYR, policosanol) in elderly hypercholesterolemic patients, Adv. Ther. 28 (2011) cebo-controlled intervention, Nutr. Res. 36 (2016) 1162–1170, https://doi.org/10. 1105–1113, https://doi.org/10.1007/s12325-011-0082-5. 1016/j.nutres.2016.07.005. [56] M.P. Bogsrud, L. Ose, G. Langslet, I. Ottestad, E.C. Strøm, T.A. Hagve, K. Retterstøl, [37] R.R. Kasliwal, M. Bansal, R. Gupta, S. Shah, S. Dani, A. Oomman, V. Pai, HypoCol (RYR) lowers plasma cholesterol - a randomized placebo controlled study, G.M. Prasad, S. Singhvi, J. Patel, S. Sivam, N. Trehan, ESSENS dyslipidemia: a Scand. Cardiovasc. J. 44 (2010) 197–200, https://doi.org/10.3109/ placebo -controlled, randomized study of a nutritional supplement containing RYR 14017431003624123. in subjects with newly diagnosed dyslipidemia, Nutrition 32 (2016) 767–776, [57] S.C. Halbert, B. French, R.Y. Gordon, J.T. Farrar, K. Schmitz, P.B. Morris, https://doi.org/10.1016/j.nut.2016.01.012. P.D. Thompson, D.J. Rader, D.J. Becker, Tolerability of RYR (2,400 mg twice daily) [38] M. Gentile, I. Calcaterra, A. Strazzullo, C. Pagano, D. Pacioni, E. Speranza, P. Rubba, versus pravastatin (20 mg twice daily) in patients with previous statin intolerance, G. Marotta, Effects of Armolipid Plus on small dense LDL particles in a sample of Am. J. Cardiol. 105 (2010) 198–204, https://doi.org/10.1016/j.amjcard.2009.08. patients affected by familial combined hyperlipidemia, Clin. Lipidol. 10 (2015) 672. 475–480. [58] D.J. Becker, R.Y. Gordon, S.C. Halbert, B. French, P.B. Morris, D.J. Rader, Red yeast [39] V. Verhoeven, A. Van der Auwera, L. Van Gaal, R. Remmen, S. Apers, M. Stalpaert, rice for dyslipidemia in statin-intolerant patients: a randomized trial, Ann. Intern. J. Wens, N. Hermans, Can RYR and olive extract improve lipid profile and cardi- Med. 150 (2009) 830-9, W147-9. ovascular risk in metabolic syndrome?: a double blind, placebo controlled rando- [59] N.C. Yang, C.W. Chou, C.Y. Chen, K.L. Hwang, Y.C. Yang, Combined nattokinase mized trial, BMC Complement. Altern. Med. 15 (2015) 52, https://doi.org/10. with RYR but not nattokinase alone has potent effects on blood lipids in human 1186/s12906-015-0576-9. subjects with hyperlipidemia, Asia Pac. J. Clin. Nutr. 18 (2009) 310–317. [40] G. Derosa, A. Bonaventura, L. Bianchi, D. Romano, A. D’Angelo, E. Fogari, [60] P. Ye, C.E. Wu, L. Sheng, H. Li, Potential protective effect of long-term therapy with P. Maffioli, A randomized, placebo-controlled study on the effects of a nutraceutical Xuezhikang on left ventricular diastolic function in patients with essential hy- combination of RYR, silybum marianum and octasonol on lipid profile, endothelial pertension, J. Altern. Complement. Med. 15 (2009) 719–725, https://doi.org/10. and inflammatory parameters, J. Biol. Regul. Homeost. Agents 28 (2014) 317–324. 1089/acm.2008.0599.-. [41] S. Gonnelli, C. Caffarelli, K. Stolakis, C. Cuda, N. Giordano, R. Nuti, Efficacy and [61] O. Gheith, H. Sheashaa, M. Abdelsalam, Z. Shoeir, M. Sobh, Efficacy and safety of tolerability of a nutraceutical combination (Red yeast rice, policosanols, and ber- Monascus purpureus went rice in subjects with secondary hyperlipidemia, Clin. berine) in patients with low-moderate risk hypercholesterolemia: a double-blind, Exp. Nephrol. 12 (2008) 189–194, https://doi.org/10.1007/s10157-008-0033-x. placebo-controlled study, Curr. Ther. Res. Clin. Exp. 77 (2014) 1–6, https://doi. [62] Z. Lu, W. Kou, B. Du, Y. Wu, S. Zhao, O.A. Brusco, J.M. Morgan, D.M. Capuzzi, org/10.1016/j.curtheres.2014.07.003. Chinese Coronary Secondary Prevention Study Group, Li S. Effect of Xuezhikang, an [42] P.M. Moriarty, E.M. Roth, A. Karns, P. Ye, S.P. Zhao, Y. Liao, D.M. Capuzzi, extract from red yeast Chinese rice, on coronary events in a Chinese population with H.E. Bays, F. Zhang, S. Liu, A.J. Reichman, O.A. Brusco, G. Lu, S. Lerman, Z. Duan, previous myocardial infarction, Am. J. Cardiol. 101 (2008) 1689–1693, https://doi. S. Guo, P.L. Liu, J. Zhao, Y. Zhang, S. Li, Effects of Xuezhikang in patients with org/10.1016/j.amjcard.2008.02.056. dyslipidemia: a multicenter, randomized, placebo-controlled study, J. Clin. Lipidol. [63] A.F. Cicero, L.C. Rovati, I. Setnikar, Eulipidemic effects of berberine administered 8 (2014) 568–575, https://doi.org/10.1016/j.jacl.2014.09.002. alone or in combination with other natural cholesterol-lowering agents. A single- [43] M. Ruscica, M. Gomaraschi, G. Mombelli, C. Macchi, R. Bosisio, F. Pazzucconi, blind clinical investigation, Arzneimittelforschung 57 (2007) 26–30. C. Pavanello, L. Calabresi, A. Arnoldi, C.R. Sirtori, P. Magni, Nutraceutical approach [64] C.F. Huang, T.C. Li, C.C. Lin, C.S. Liu, H.C. Shih, M.M. Lai, Efficacy of Monascus to moderate cardiometabolic risk: results of a randomized, double-blind and purpureus went rice on lowering lipid ratios in hypercholesterolemic patients, Eur. crossover study with Armolipid Plus, J. Clin. Lipidol. 8 (2014) 61–68, https://doi. J. Cardiovasc. Prev. Rehabil. 14 (2007) 438–440. org/10.1016/j.jacl.2013.11.003. [65] J.J. Li, Y. Wang, S.P. Nie, Q. Li, Y.S. Li, Y. Huang, R.T. Hui, Xuezhikang, an extract [44] R. Solà, R.M. Valls, J. Puzo, J.R. Calabuig, A. Brea, A. Pedret, D. Moriña, J. Villar, of cholestin, decreases plasma inflammatory markers and endothelin-1, improve J. Millán, A. Anguera, Effects of poly-bioactive compounds on lipid profile and body exercise-induced ischemia and subjective feelings in patients with cardiac syndrome weight in a moderately hypercholesterolemic population with low cardiovascular X, Int. J. Cardiol. 122 (2007) 82–84. disease risk: a multicenter randomized trial, PLoS One 9 (2014) e101978, , https:// [66] X.B. Shang, Clinical observation of Xuezhikang and atorvastatin for patients with doi.org/10.1371/journal.pone.0101978. coronary heart disease complicated with dyslipidemia on serum lipid and he- [45] E. Barrat, Y. Zaïr, P. Sirvent, P. Chauveau, C. Maudet, B. Housez, E. Derbord, morheology, Guangxi Med. J. 29 (2007) 1158–1159. J.F. Lescuyer, J.M. Bard, M. Cazaubiel, S.L. Peltier, Effect on LDL-cholesterol of a [67] C.L. Hu, Y.B. Li, Y.H. Tang, J.B. Chen, J. Liu, Q.Z. Tang, Q.H. Zhang, C.X. Huang, large dose of a dietary supplement with plant extracts in subjects with untreated Effects of withdrawal of Xuezhikang, an extract of cholestin, on lipid profile and C- moderate hypercholesterolaemia: a randomised, double-blind, placebo-controlled reactive protein: a short-term time course study in patients with coronary artery study, Eur. J. Nutr. 52 (2013) 1843–1852, https://doi.org/10.1007/s00394-012- disease, Cardiovasc. Drugs Ther. 20 (2006) 185–191. 0486-2. [68] L. Liu, S.P. Zhao, Y.C. Cheng, Y.L. Li, Xuezhikang decreases serum lipoprotein(a) [46] E. Barrat, Y. Zaïr, N. Ogier, B. Housez, C. Vergara, C. Maudet, J.F. Lescuyer, and C-reactive protein concentrations in patients with coronary heart disease, Clin. J.M. Bard, Y.A. Carpentier, M. Cazaubiel, S.L. Peltier, A combined natural supple- Chem. 49 (2003) 1347–1352. ment lowers LDL cholesterol in subjects with moderate untreated hypercholester- [69] J.K. Keithley, B. Swanson, B.E. Sha, J.M. Zeller, H.A. Kessler, K.Y. Smith, A pilot olemia: a randomized placebo-controlled trial, Int. J. Food Sci. Nutr. 64 (2013) study of the safety and efficacy of cholestin in treating HIV-related dyslipidemia, 882–889, https://doi.org/10.3109/09637486.2013.809405. Nutrition 18 (2002) 201–204. [47] A.F. Cicero, G. Derosa, A. Parini, P. Maffioli, S. D’Addato, A. Reggi, M. Giovannini, [70] H. Yu, Y.L. Cui, S.Y. Wang, B. Han, Effect of Xuezhikang for patients with coronary C. Borghi, RYR improves lipid pattern, high-sensitivity C-reactive protein, and heart disease complicated with hyperlipidemia on fibrinolytic function, Chin. J. vascular remodeling parameters in moderately hypercholesterolemic Italian sub- Coal Ind. Med. 5 (2002) 61–62. jects, Nutr. Res. 33 (2013) 622–628, https://doi.org/10.1016/j.nutres.2013.05. [71] D. Heber, I. Yip, J.M. Ashley, D.A. Elashoff, R.M. Elashoff, V.L. Go, Cholesterol- 015. lowering effects of a proprietary Chinese red-yeast-rice dietary supplement, Am. J. [48] N. Ogier, M.J. Amiot, S. Georgé, M. Maillot, C. Mallmann, M. Maraninchi, Clin. Nutr. 69 (1999) 231–236. S. Morange, J.F. Lescuyer, S.L. Peltier, Cardinault N. Eur J Nutr 52 (2013) 547–557, [72] M. Banach, A.M. Patti, R.V. Giglio, A.F.G. Cicero, A.G. Atanasov, G. Bajraktari, https://doi.org/10.1007/s00394-012-0357-x. E. Bruckert, O. Descamps, D.M. Djuric, M. Ezhov, Z. Fras, S. von Haehling, [49] V. Verhoeven, M. Lopez Hartmann, R. Remmen, J. Wens, S. Apers, P. Van Royen, N. Katsiki, M. Langlois, G. Latkovskis, G.B.J. Mancini, D.P. Mikhailidis, RYR lowers cholesterol in physicians - a double blind, placebo controlled rando- O. Mitchenko, P.M. Moriarty, P. Muntner, D. Nikolic, D.B. Panagiotakos, G. Paragh, mized trial, BMC Complement. Altern. Med. 13 (2013) 178, https://doi.org/10. B. Paulweber, D. Pella, C. Pitsavos, Ž Reiner, G.M.C. Rosano, R.S. Rosenson, J. Rysz, 1186/1472-6882-13-178. A. Sahebkar, M.C. Serban, D. Vinereanu, M. Vrablík, G.F. Watts, N.D. Wong, [50] F. Affuso, V. Mercurio, A. Ruvolo, C. Pirozzi, F. Micillo, G. Carlomagno, F. Grieco, M. Rizzo, International lipid expert panel (ILEP). The role of nutraceuticals in statin S. Fazio, A nutraceutical combination improves insulin sensitivity in patients with intolerant patients, J. Am. Coll. Cardiol. 72 (2018) 96–118, https://doi.org/10. metabolic syndrome, World J. Cardiol. 4 (2012) 77–83, https://doi.org/10.4330/ 1016/j.jacc.2018.04.040. wjc.v4.i3.77. [73] M.M. Gulizia, F. Colivicchi, G. Ricciardi, S. Giampaoli, A.P. Maggioni, M. Averna, [51] A.F. Cicero, V. De Sando, D. Benedetto, M. Cevenini, E. Grandi, C. Borghi, Long- M.S. Graziani, F. Ceriotti, A. Mugelli, F. Rossi, G. Medea, D. Parretti, term efficacy and tolerability of a multicomponent lipid-lowering nutraceutical in M.G. Abrignani, M. Arca, P. Perrone Filardi, F. Perticone, A. Catapano, R. Griffo, overweight and normoweight patients, Nutrafoods 11 (2012) 55–61, https://doi. F. Nardi, C. Riccio, A. Di Lenarda, M. Scherillo, N. Musacchio, A.V. Panno, G.B. Zito, org/10.1007/s13749-012-0018-y. M. Campanini, L. Bolognese, P.M. Faggiano, G. Musumeci, E. Pusineri, M. Ciaccio, [52] M. Karl, M. Rubenstein, C. Rudnick, J. Brejda, A multicenter study of nutraceutical E. Bonora, G. Cantelli Forti, M.P. Ruggieri, C. Cricelli, F. Romeo, R. Ferrari, drinks for cholesterol (evaluating effectiveness and tolerability), J. Clin. Lipidol. 6 A. Maseri, ANMCO/ISS/AMD/ANCE/ARCA/FADOI/GICR-IACPR/SICI-GISE/ (2012) 150–158, https://doi.org/10.1016/j.jacl.2011.09.004. SIBioC/SIC/SICOA/SID/SIF/SIMEU /SIMG/SIMI/SISA Joint ConsensusDocument [53] I.T. Lee, W.J. Lee, C.M. Tsai, I.J. Su, H.T. Yen, W.H. Sheu, Combined extractives of on cholesterol and cardiovascular risk: diagnostic-therapeutic pathway in Italy, Eur.

15 F. Fogacci, et al. Pharmacological Research 143 (2019) 1–16

Heart J. Suppl. 19 (Suppl D) (2017) D3–D54, https://doi.org/10.1093/eurheartj/ R. Ceska, S.J. Nicholls, M. Broncel, D. Nikolic, D. Pella, R. Puri, J. Rysz, N.D. Wong, sux029. L. Bajnok, S.R. Jones, K.K. Ray, D.P. Mikhailidis, Statin intolerance - an attempt at a [74] A.F.G. Cicero, A. Colletti, G. Bajraktari, O. Descamps, D.M. Djuric, M. Ezhov, unified definition. Position paper from an International Lipid Expert Panel, Arch. Z. Fras, N. Katsiki, M. Langlois, G. Latkovskis, D.B. Panagiotakos, G. Paragh, Med. Sci. 11 (2015) 1–23, https://doi.org/10.5114/aoms.2015.49807. D.P. Mikhailidis, O. Mitchenko, B. Paulweber, D. Pella, C. Pitsavos, Ž Reiner, [80] M. Banach, D.P. Mikhailidis, Statin intolerance: some practical hints, Cardiol. Clin. K.K. Ray, M. Rizzo, A. Sahebkar, M.C. Serban, L.S. Sperling, P.P. Toth, 36 (2018) 225–231, https://doi.org/10.1016/j.ccl.2017.12.004. D. Vinereanu, M. Vrablík, N.D. Wong, M. Banach, Lipid-lowering nutraceuticals in [81] R.S. Rosenson, K. Miller, M. Bayliss, R.J. Sanchez, M.T. Baccara-Dinet, D. Chibedi- clinical practice: position paper from an International Lipid Expert Panel, Nutr. Rev. De-Roche, B. Taylor, I. Khan, G. Manvelian, M. White, T.A. Jacobson, The statin- 75 (2017) 731–767, https://doi.org/10.1093/nutrit/nux047. associated muscle symptom clinical index (SAMS-CI): revision for clinical use, [75] Authors/Task Force Members, A.L. Catapano, I. Graham, G. De Backer, O. Wiklund, content validation, and inter-rater reliability, Cardiovasc. Drugs Ther. 31 (2017) M.J. Chapman, H. Drexel, A.W. Hoes, C.S. Jennings, U. Landmesser, T.R. Pedersen, 179–186, https://doi.org/10.1007/s10557-017-6723-4. Ž Reiner, G. Riccardi, M.R. Taskinen, L. Tokgozoglu, W.M. Verschuren, [82] DFG permanent senate commission on food safety, Toxicological Evaluation of Red C. Vlachopoulos, D.A. Wood, J.L. Zamorano, ESC/EAS Guidelines for the Mould Rice: An Update, (2012). Management of Dyslipidaemias: The Task Force for the Management of [83] G.V. Prasad, T. Wong, G. Meliton, S. Bhaloo, Rhabdomyolysis due to red yeast rice Dyslipidaemias of the European Society of Cardiology (ESC) and European (Monascus purpureus) in a renal transplant recipient, Transplantation 74 (2002) Atherosclerosis Society (EAS) Developed with the special contribution of the 1200–1201. European Assocciation for Cardiovascular Prevention & Rehabilitation (EACPR), [84] A.F. Cicero, A. Colletti, An update on the safety of nutraceuticals and effects on lipid Atherosclerosis 2016 (253) (2016) 281–344, https://doi.org/10.1016/j. parameters, Expert Opin. Drug Saf. 17 (3) (2018) 303–313, https://doi.org/10. atherosclerosis.2016.08.018. 1080/14740338.2018.1429404. [76] EFSA Panel on Dietetic Products, Nutrition and Allergies (NDA), Scientific Opinion [85] B. Avula, P.A. Cohen, Y.H. Wang, S. Sagi, W. Feng, M. Wang, J. Zweigenbaum, on the substantiation of health claims related to monacolin K from red yeast rice M. Shuangcheng, I.A. Khan, Chemical profiling and quantification of monacolins and maintenance of normal blood LDL-cholesterol concentrations (ID 1648, 1700) and citrinin in red yeast rice commercial raw materials and dietary supplements pursuant to Article 13(1) of Regulation (EC) No 1924/2006, EFSA J. (9) (2011) using liquid chromatography-accurate QToF mass spectrometry: chemometrics 2304. application, J. Pharm. Biomed. Anal. 100 (2014) 243–253, https://doi.org/10. [77] EFSA, Scientific opinion on the safety of monacolins in red yeast rice, EFSA Panel on 1016/j.jpba.2014.07.039. Food Additives and Nutrient Sources added to Food (ANS). European Food Safety [86] W.H. Chan, Effects of citrinin on maturation of mouse oocytes, fertilization, and Authority (EFSA), Parma, Italy, EFSA J. 16 (2018) 5368, https://doi.org/10.2903/j. fetal development in vitro and in vivo, Toxicol. Lett. 180 (1) (2008) 28–32, https:// efsa.2018.5368. doi.org/10.1016/j.toxlet.2008.05.011. [78] Z. Reiner, Resistance and intolerance to statins, Nutr. Metab. Cardiovasc. Dis. 24 [87] EFSA, Scientific Opinion on the risks for public and animal health related to the (2014) 1057–1066, https://doi.org/10.1016/j.numecd.2014.05.009. presence of citrinin in food and feed. EFSA Panel on Contaminants in the Food [79] M. Banach, M. Rizzo, P.P. Toth, M. Farnier, M.H. Davidson, K. Al-Rasadi, Chain (CONTAM). European Food Safety Authority (EFSA), Parma, italy, EFSA J. 10 W.S. Aronow, V. Athyros, D.M. Djuric, M.V. Ezhov, R.S. Greenfield, G.K. Hovingh, (2012) 2605. K. Kostner, C. Serban, D. Lighezan, Z. Fras, P.M. Moriarty, P. Muntner, A. Goudev,

16