LipidXtra by DC

POSSIBLY INEFFECTIVE

• Obesity. Oral guggul does not seem to reduce body weight in patients who are overweight or obese. Details: Several small clinical studies in overweight or obese individuals shows that taking guggul 1.5-4 grams daily for 4-12 weeks or standardized tablets containing guggul (Medohar) 1.5-3 grams daily for 4 weeks does not reduce body weight when compared with no treatment or placebo (54447,54502,54511). Another clinical study in patients with hypercholesterolemia shows that taking a standardized guggul extract 1-2 grams three times daily for 8 weeks does not improve body weight when compared with placebo (10371). Guggul has also been evaluated in combination with other ingredients. One small clinical study in overweight individuals shows that taking guggul 250 mg in combination with phosphate 550 mg, garcinia 250 mg, and L-tyrosine 250 mg three times daily for 6 weeks, along with exercise and calorie restriction, reduces body weight and body fat percentage when compared to baseline, but not when compared with placebo (8152). It is unclear if these findings are due to guggul, other ingredients, or the combination.

INSUFFICIENT RELIABLE EVIDENCE to RATE

• Acne. It is unclear if oral guggul is beneficial in patients with acne. Details: A very small clinical study in patients with nodulocystic acne shows that taking guggul, providing guggulsterone 25 mg, twice daily for 3 months leads to similar reductions in inflammatory lesions and the risk for relapse when compared with tetracycline (3268).
• Hemorrhoids. Topical guggul has only been evaluated in combination with other ingredients; its effect when used alone is unclear. Details: A small study in adults with symptomatic mild to moderate (first- and second-degree) internal hemorrhoids shows that application of a cream containing sesame oil and aqueous extracts of guggul and Allium ampeloprasum as a thin layer to the anus twice daily for 3 weeks improves anal irritation and itching, bleeding, pain, defecation discomfort, and swelling sense when compared to baseline. In contrast, patients using a placebo cream experienced an improvement only in anal itching (105751). The poor study methodology and lack of statistical comparison to the placebo group limit the validity of these findings.
• Hypercholesterolemia. Several small, low-quality clinical studies in Indian populations suggest that oral guggul may reduce cholesterol levels in patients with hypercholesterolemia; however, more recent evidence in patients on Western diets contradicts these findings. Details: A small clinical study in patients with hypercholesterolemia following a Western diet shows that taking guggul 1-2 grams three times daily for 8 weeks increases low-density lipoprotein (LDL) cholesterol by 9% to 10% with no improvements in total cholesterol, triglycerides, or high-density lipoprotein (HDL) cholesterol when compared with placebo (10371). Another small clinical study in adults with hyperlipidemia and low to moderate cardiovascular risk shows that taking a methanolic extract of guggul 200 mg along with an aqueous extract of Terminalia and Indian gooseberry 450 mg three times daily for 3 months does not improve total, LDL, or HDL cholesterol levels or triglyceride levels when compared with placebo (105741). This is in contrast to several low-quality studies of guggul in Indian populations, which show that taking guggul extract (guggulipid) 1-2.25 grams two to three times daily for up to 16 weeks seems to lower total cholesterol, LDL cholesterol, and triglyceride levels when compared with baseline measures, placebo, or other controls (366,3267,8158,51219,54485,54497,54508). Also, some clinical research shows that taking a specific guggul extract fraction called "Fraction A" 500 mg three times daily for up to 75 weeks can reduce cholesterol and triglycerides in Indian patients with hypercholesterolemia (54492,54501). Most of the studies with positive findings were published in the 1970s and 1980s and may not be generalizable to patients on Western diets or taking conventional antihyperlipidemic agents, most of which were approved after the publication of these findings.
• Osteoarthritis. It is unclear if oral guggul is beneficial in patients with osteoarthritis. Details: Two small clinical studies in patients with osteoarthritis show that taking guggul may improve pain and other symptoms of osteoarthritis, measured using the Western Ontario and McMaster Universities Arthritis Index (WOMAC) assessment, when compared to baseline (54453,111720). One study used guggul (containing 3.5% guggulsterones) 500 mg three times daily for 2 months (54453) and the other used a polyherbal ayurvedic formulation, abha guggulu, 1500 mg two times daily for 1 month (111720). The validity of these findings is limited by the lack of a comparator group.
• Rheumatoid arthritis (RA). It is unclear if oral guggul is beneficial in patients with RA. Details: A small, uncontrolled clinical study in patients with RA shows that taking guggul 1 gram three times daily for 4 months improves symptoms of RA when compared to baseline (54512). The validity of these findings is limited by a lack of placebo group. More evidence is needed to rate guggul for these uses.

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LIKELY EFFECTIVE

• Intermittent claudication. Oral use of policosanol can increase walking distance in patients with intermittent claudication. Details: Multiple, small, randomized controlled trials show that taking policosanol 10 mg orally once to twice daily for up to 2 years moderately improves walking distance when compared with placebo, lovastatin, or aspirin, and has similar effects to ticlopidine, in patients with intermittent claudication (2931,65359,65372,65378,69114).

INSUFFICIENT RELIABLE EVIDENCE to RATE

• Angioplasty. It is unclear if oral policosanol is beneficial for patients after angioplasty. Details: Preliminary clinical research has evaluated the addition of policosanol to dual antiplatelet therapy in Chinese patients with high on-treatment platelet reactivity (HPR) who underwent percutaneous coronary intervention with a drug-eluting stent for an acute coronary syndrome. The addition of policosanol 40 mg orally daily with clopidogrel 75 mg daily and aspirin 300 mg daily for 30 days does not further reduce HPR when compared with taking clopidogrel and aspirin alone (100684).
• Coronary heart disease (CHD). It is unclear if oral policosanol is beneficial for patients with CHD. Details: One small clinical study in adults with CHD shows that taking policosanol 5 mg twice daily, alone or in combination with aspirin 125 mg for 20 months, can reduce cardiac events and improve maximum oxygen uptake during a treadmill exercise electrocardiogram (ECG) when compared with pretreatment (2941). Policosanol has also been evaluated as part of combination products for CHD. Clinical research in statin-intolerant patients with CHD treated with a percutaneous intervention (PCI) shows that taking a specific combination product (Armolipid Plus, Rottapharm S.p.A.) containing policosanol, berberine, red yeast rice, folic acid, coenzyme Q10, and astaxanthin daily for 3 months reduces total cholesterol, low-density lipoprotein (LDL) cholesterol, and triglycerides, and increases high-density lipoprotein (HDL) cholesterol, to a greater extent than ezetimibe 10 mg daily. Combining this specific product with ezetimibe produces additional improvements after 1 year of treatment when compared with either agent alone (97232). Other clinical research in patients with CHD treated with PCI shows that taking the same product in combination with a low-dose statin for 3 months reduces total cholesterol and LDL cholesterol and increases HDL cholesterol when compared with low-dose statin treatment alone (97233). It is unclear if the benefits of this combination product are due to policosanol, other ingredients, or the combination.
• Familial hypercholesterolemia. It is unclear if oral policosanol is beneficial for patients with familial hypercholesterolemia. Details: Preliminary clinical research shows that taking a specific form of policosanol (Lesstanol Octa-60, Garuda International) 20 mg orally daily for 12 weeks does not significantly decrease total or low-density lipoprotein (LDL) cholesterol in patients with familial hypercholesterolemia (14404).
• Hypercholesterolemia. It is unclear if oral policosanol is beneficial for patients with hypercholesterolemia. Details: Current clinical research on the use of policosanol for hyperchloremia is conflicting. The reasons for these discrepant findings are unclear but may be explained by differences in doses, treatment durations, patient populations, and specific policosanol products studied. Clinical research in subjects with hypercholesterolemia, largely conducted by researchers in Cuba, shows that taking policosanol orally 5-20 mg daily for 8-24 weeks lowers total cholesterol by 9% to 29% and low-density lipoprotein (LDL) cholesterol by 11% to 42% and increases high-density lipoprotein (HDL) cholesterol by 7% to 34% when compared with placebo or other controls (2927,2928,2929,2930,2943,2944,14298,14411,65348,65354)(65355,65356,65361,65363,65365,65369,65375,65380,65383,69104)(69105,69106,65362,65351,100178). When compared to conventional drugs, some research also shows that policosanol 10 mg daily lowers total and LDL cholesterol by a similar amount as fluvastatin 20 mg daily and simvastatin 10 mg daily (8147,12190). Atorvastatin 10 mg daily appears to be more effective than policosanol 10 mg daily for lowering total and LDL cholesterol (14411). However, the majority of research conducted outside of Cuba has been contradictory. Research in subjects with hypercholesterolemia, conducted by German, Canadian, Croatia, South African, Netherlands, U.S., and Italian researchers, shows that taking policosanol 10-80 mg daily for 4-12 weeks does not significantly decrease total or LDL cholesterol when compared with placebo (14336,15062,69111,69119,69107,69109,69110,12166,14404). These studies included policosanol derived from Cuban sugar cane, U.S. sugar cane, wheat germ, and red yeast rice and specific policosanol products (Lesstanol Octa-60, Garuda International; Cholesstor, Pharmed Group) (69107,69109,69110,12166,14404). Policosanol has also been studied in combination with other ingredients. Taking a product containing policosanol 10 mg, berberine 500 mg, and red yeast rice 200 mg daily for up to 12 months seems to reduce total cholesterol and LDL cholesterol levels in hypercholesterolemic patients when compared with placebo or ezetimibe 10 mg (34262,34283,34301). Taking a specific combination product (Armolipid Plus, Rottapharm S.p.A.) containing policosanol, berberine, red yeast rice, folic acid, coenzyme Q10, and astaxanthin daily for 8 weeks appears to reduce total cholesterol by 13% and LDL cholesterol by 21%, as well as increasing HDL cholesterol by 5% when compared with baseline in patients with metabolic syndrome and dyslipidemia (89438). A meta-analysis also shows that taking this combination product for up to 1 year reduces total cholesterol by 10%, LDL cholesterol by 14%, and triglycerides by 7%, and increases HDL cholesterol by 4%, when compared with baseline in patients with hypercholesterolemia (92142). It is unclear if the benefits of this combination product are due to policosanol, red yeast rice (which contains monacolin K, a chemical similar to lovastatin), other ingredients, or the combination.
• Hypertension. It is unclear if oral policosanol is beneficial for patients with hypertension. Details: Clinical research in adults with prehypertension shows that taking policosanol 20 mg orally daily for 12 weeks reduces both systolic and diastolic blood pressure by about 7%, compared to non-significant changes with placebo. A lower dose of policosanol 10 mg daily did not improve blood pressure when compared with placebo (100177).
• Metabolic syndrome. Oral policosanol has only been evaluated in combination with other ingredients; its effect when used alone is unclear. Details: Preliminary clinical research shows that taking a specific combination product (Armolipid Plus, Rottapharm S.p.A.) containing policosanol, berberine, red yeast rice, folic acid, coenzyme Q10, and astaxanthin daily for 18 weeks improves systolic blood pressure, left ventricular mass, and flow-mediated dilation in patients with metabolic syndrome when compared with control (34289). It is unclear if these effects are due to policosanol, other ingredients, or the combination. More evidence is needed to rate policosanol for these uses.

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POSSIBLY SAFE ...when the prepared gum resin is used orally and appropriately. It has been used with apparent safety in clinical trials for up to 24 weeks (3267,3268,10371). There is insufficient reliable information available about the safety of guggul when used topically.

PREGNANCY: LIKELY UNSAFE
when used orally; avoid using. Guggul gum resin appears to stimulate menstrual flow and the uterus (12).

LACTATION:
Insufficient reliable information available; avoid using.

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LIKELY SAFE ...when used orally and appropriately in medicinal amounts. Policosanol seems to be safe when used in doses of 5-80 mg daily for up to 3 years (2927,2928,2929,2930,2931,2943,2944,12166,14298,14336)(14404,14411,65383,89438,89454,89451,100178,103832).

PREGNANCY AND LACTATION:
Insufficient reliable information available; avoid using.

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ANTICOAGULANT/ANTIPLATELET DRUGS Interaction Rating = Moderate Be cautious with this combination. Severity = High •  Occurrence = Possible •  Level of Evidence = B Theoretically, guggul might increase the risk of bleeding when taken with anticoagulant/antiplatelet drugs.  Details In vitro research and preliminary clinical studies suggest that guggul might have antiplatelet and anticoagulant effects (3267,9557,54503,54505).

CONTRACEPTIVE DRUGS Interaction Rating = Moderate Be cautious with this combination. Severity = High •  Occurrence = Possible •  Level of Evidence = D Theoretically, guggul might increase the risk of adverse effects when taken with contraceptive drugs.  Details In vitro research shows that guggul has estrogen-alpha receptor agonist activity (12444).

CYTOCHROME P450 3A4 (CYP3A4) SUBSTRATES Interaction Rating = Moderate Be cautious with this combination. Severity = Moderate •  Occurrence = Probable •  Level of Evidence = D Theoretically, guggul might reduce the effects of CYP3A4 substrates.  Details In vitro research shows that guggul constituents known as guggulsterones can induce CYP3A4 (12444).

DILTIAZEM (Cardizem, others) Interaction Rating = Moderate Be cautious with this combination. Severity = Moderate •  Occurrence = Probable •  Level of Evidence = B Guggul might reduce the effects of diltiazem.  Details A small pharmacokinetic study shows that concomitant use of guggul with diltiazem reduces the bioavailability of diltiazem (383).

ESTROGENS Interaction Rating = Moderate Be cautious with this combination. Severity = High •  Occurrence = Possible •  Level of Evidence = D Theoretically, guggul might increase the risk of adverse effects when taken with estrogens.  Details In vitro research shows that guggul constituents known as guggulsterones have estrogen-alpha receptor agonist activity (12444).

PROPRANOLOL (Inderal) Interaction Rating = Moderate Be cautious with this combination. Severity = Moderate •  Occurrence = Probable •  Level of Evidence = B Guggul might reduce the effects of propranolol.  Details A small pharmacokinetic study shows that concomitant use of guggul with propranolol reduces the bioavailability of propranolol (383).

ROSUVASTATIN (Crestor) Interaction Rating = Moderate Be cautious with this combination. Severity = Moderate •  Occurrence = Possible •  Level of Evidence = D Theoretically, guggul might increase the effects and adverse effects of rosuvastatin.  Details Animal research shows that guggul increases the bioavailability and hypolipidemic effects of rosuvastatin (109584). The mechanism of this interaction is unclear.

TAMOXIFEN (Nolvadex) Interaction Rating = Moderate Be cautious with this combination. Severity = High •  Occurrence = Possible •  Level of Evidence = D Theoretically, guggul might interfere with tamoxifen therapy.  Details In vitro research shows that guggul has estrogen-alpha receptor agonist activity (12444).

THYROID HORMONE Interaction Rating = Moderate Be cautious with this combination. Severity = Moderate •  Occurrence = Probable •  Level of Evidence = B Theoretically, guggul might increase the risk for adverse effects when taken with thyroid hormone therapy.  Details Animal research suggests that guggul has thyroid-stimulating effects (8153).

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ANTICOAGULANT/ANTIPLATELET DRUGS Interaction Rating = Moderate Be cautious with this combination. Severity = High •  Occurrence = Possible •  Level of Evidence = B Theoretically, taking policosanol with other antiplatelet or anticoagulant drugs might increase the risk of bruising and bleeding.  Details Some clinical research shows that taking policosanol 10-50 mg daily for 7-15 days can inhibit platelet aggregation in healthy patients (2936,2937,2938,103832). Although, one clinical trial shows that taking policosanol 10 mg twice daily for 2 weeks prior to warfarin dosing does not affect warfarin pharmacokinetics or warfarin response (20083). Furthermore, a study in patients undergoing percutaneous coronary intervention with a drug-eluting stent found that taking policosanol 40 mg plus clopidogrel and aspirin daily for 30 days modestly reduced the risk for minor bleeding events when compared with taking clopidogrel and aspirin alone (100684). Until more is known, use with caution.

ANTIDIABETES DRUGS Interaction Rating = Moderate Be cautious with this combination. Severity = Moderate •  Occurrence = Possible •  Level of Evidence = B Theoretically, policosanol might have additive effects with antidiabetes drugs and increase the risk of hypoglycemia.  Details Clinical research shows that policosanol can lower blood glucose levels (100178).

BETA-BLOCKERS Interaction Rating = Moderate Be cautious with this combination. Severity = Moderate •  Occurrence = Probable •  Level of Evidence = A Concomitant use of policosanol with beta-blockers can cause additive blood pressure-lowering effects.  Details Clinical research shows that policosanol 5 mg daily can have additive blood pressure-lowering effects in patients with hypertension who are taking beta-blockers (65383). Also, animal research shows that policosanol can increase the blood-pressure lowering effects of propranolol (23775).

NITROPRUSSIDE (Nitropress) Interaction Rating = Moderate Be cautious with this combination. Severity = Moderate •  Occurrence = Possible •  Level of Evidence = D Theoretically, concomitant use of policosanol with nitroprusside might cause additive blood pressure-lowering effects.  Details Animal research shows that taking policosanol along with nitroprusside can increase the blood pressure-lowering effects of nitroprusside (65374).

WARFARIN (Coumadin) Interaction Rating = Moderate Be cautious with this combination. Severity = High •  Occurrence = Possible •  Level of Evidence = B Theoretically, taking policosanol with warfarin might increase the risk of bruising and bleeding.  Details Some clinical research shows that taking policosanol 10-50 mg daily for 7-15 days can inhibit platelet aggregation in healthy patients (2936,2937,2938). However, one clinical trial shows that taking policosanol 10 mg twice daily for 2 weeks prior to warfarin dosing does not affect warfarin pharmacokinetics or warfarin response (20083).

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General ...Orally, guggul seems to be generally well tolerated.
Most Common Adverse Effects:
Orally: Belching, bloating, diarrhea, headache, nausea, unpleasant taste, and vomiting. Allergic and non-allergic skin reactions.
Topically: Allergic contact dermatitis in sensitive individuals.
Serious Adverse Effects (Rare):
Orally: Rhabdomyolysis.

Dermatologic ...Orally, guggul can cause hypersensitivity reactions including rash and pruritus (10371,54457). Guggul can also cause nonallergic adverse skin reactions. The risk of skin reactions appears to be dose-dependent. In one study, the incidence of skin reactions was 3% with a dosage of 1000 mg three times daily, compared with 15% with a dosage of 2000 mg three times daily. The severity of the reactions ranged from pruritus to swelling and erythema of the face to bullous lesion on the lower legs associated with headaches, myalgias, and pruritus (13662).
Topically, guggul can cause allergic contact dermatitis (54464,54467). Also, in a small clinical study, one patient using a cream containing aqueous extracts of guggul and Allium ampeloprasum as well as sesame oil complained of rash at the application site (105751). It is unclear if this reaction was due to guggul, other ingredients, or other factors.

Gastrointestinal ...Orally, guggul can cause nausea, vomiting, loose stools, diarrhea, belching, bloating, hiccups, and mild gastrointestinal discomfort (3267,8155,8158,10371,52033,54492).

Hepatic ...A case of severe hypertransaminasemia has been reported for a 63-year-old female who took a specific product (Equisterol) containing guggulsterone and red yeast rice extract daily for 6 months. Liver function normalized after discontinuing the supplement. It is unclear if the adverse effect was due to guggulsterone, red yeast, or the combination. However, the patient had previously developed hepatotoxicity while taking lovastatin, and red yeast contains monacolin K, which is identical to lovastatin (54477). Also, a case of acute liver failure requiring liver transplantation has been reported for a previously healthy young female who used a mixed-ingredient dietary supplement containing extracts of green tea, guggul, and usnic acid. It is unclear if the hepatotoxicity was due to guggul or other ingredients; green tea has been associated with hepatotoxicity (54027).

Immunologic ...Orally, guggul can cause hypersensitivity reactions including rash and pruritus (10371,54457). In a small clinical study, two adults with hyperlipidemia developed a hypersensitivity rash, one with facial edema, within minutes of oral administration of a methanolic extract of guggul, together with Terminalia extract (105741). It is unclear if this reaction was due to guggul, Terminalia, or other factors.
Topically, guggul can cause allergic contact dermatitis (54464,54467).

Musculoskeletal ...There is one case of rhabdomyolysis reported in a patient who took guggul 300 mg three times daily. The patient developed hemoglobinuria within 2 weeks of starting guggul in addition to increased alanine aminotransferase (ALT), aspartate aminotransferase (AST), lactate dehydrogenase, creatine kinase, and myoglobinemia. The patient did not have any muscular symptoms. The patient's condition improved when guggul was discontinued. The patient had a history of developing elevated creatine kinase levels after taking simvastatin; however, the patient was not taking a statin at the time of this episode of rhabdomyolysis (13029).

Neurologic/CNS ...Orally, guggul can cause headaches (3267,8155,8158,10371,42692,49583). Less commonly, guggul may cause restlessness and apprehension (49583,54492).

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General ...Orally, policosanol is usually well-tolerated.
Most Common Adverse Effects:
Orally: Dysuria, headache, insomnia, polyphagia, pruritis, skin rash, somnolence, upset stomach, vertigo, weight loss.

Dermatologic ...Orally, policosanol can cause pruritus or skin rash, but these events appear to be uncommon (65369,95374,100178). In one clinical trial that included over 50 patients, one case of policosanol-associated skin rash was reported (65369). In another study, 1 out of 40 patients treated with policosanol 10 mg daily reported pruritus (95374).

Gastrointestinal ...Orally, policosanol can cause upset stomach or polyphagia (2937).

Genitourinary ...Orally, policosanol can cause dysuria (2937).

Hematologic ...A case gum bleeding has been reported in a patient taking policosanol 20 mg and aspirin 100 mg daily for 7 days (2937).

Neurologic/CNS ...Orally, policosanol may cause headache, mild vertigo, somnolence, irritability, or insomnia but these events are uncommon. In one clinical study, 1 out of 44 subjects receiving policosanol 20 mg daily 12 weeks experienced mild vertigo and 2 out of 44 experienced mild headache (14404). In another study, 2 out of 70 patients taking policosanol 10 mg daily for 8 weeks experienced headache (69119). In another study, 1 out of 40 patients taking policosanol 10 mg daily reported insomnia (95374).

Other ...Orally, policosanol has been associated with weight loss. However, evidence from a post-market surveillance study of patients taking policosanol 5-15 mg daily shows that this adverse event is uncommon (95375).

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