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COMPLEMENTARY THERAPIES FOR CHOLESTEROL MANAGEMENT: EVIDENCE FOR OUTCOMES CPD ACTIVITY 73 Craig Dowdy Craig Dowdy has been a pharmacist for more than 30 years, working most of his career in the community pharmacy setting as both an owner and manager, practising in Adelaide, Darwin and Canberra. He also has experience in hospital pharmacy and has worked as a pharmaceutical adviser in the PBS section of Medicare Australia. He is enthusiastic about being involved in the production of interesting and relevant CPD activities suitable for pharmacists working in all areas of the profession. LEARNING OJECTIVES After completing this CPD activity, pharmacists should be able to: • Describe the evidence for the use of plant sterol, psyllium husk, omega 3 fatty acid, and probiotic supplementation in the management of cholesterol. 2016 Competency Standards: 3.2, 3.5, 3.6. Accreditation Number: A2008RP3 (exp: 31/07/2022). Introduction Hypercholesterolaemia (high plasma cholesterol) is a well-known, modifiable risk factor for cardiovascular disease (CVD), and collectively dyslipidaemia accounts for most of the population-attributed risk for myocardial infarction worldwide.1 Hypercholesterolaemia is defined as an excess of cholesterol transported in atherogenic apolipoprotein containing lipoproteins, among which low density lipoproteins (LDL) predominate relative to non-atherogenic apoA-I-containing high- density lipoproteins (HDL).1 A 10 per cent increase in total cholesterol (TC) is associated with a 27 per cent increase in the incidence of coronary heart disease (CHD), and this risk remains despite the presence or absence of other risk factors (eg, smoking status or elevated BP).1 Multiple meta-analyses confirm that a reduction in LDL cholesterol (LDL-C) must be of primary concern in the prevention of CVD. In addition, hypertriglyceridemia (HTG) is associated with the development of early onset CVD and significantly increases the risk of acute pancreatitis.1 Hypercholesterolaemia is often associated with dietary causes, including excessive alcohol or sugar consumption found in metabolic syndrome. The mainstay of treatment for hypercholesterolaemia are the statins, which, compared with placebo, reduce the risk of death or cardiovascular events in populations without a history of CVD, irrespective of age and gender, across a wide range of cholesterol levels.1 These benefits exist without any evidence of harm on quality of life1. Fibrates effectively lower triglycerides (TG) and increase HDL-C, and their addition to statin therapy has been shown to more effectively lower LDL-C and TC than statins alone. The complementary medicine industry in Australia represents a significant proportion of individual spend on healthcare. It’s important to consider the evidence on outcomes of various complementary approaches touted to assist in the management of cholesterol. Omega-3 (fish oil) supplements, foods and supplements containing plant sterols, and fibre supplementation with psyllium husk are commonly recommended for the management of cholesterol, or to improve heart health. This article will review current evidence for efficacy of supplements, relevant doses, and the outcomes associated with these interventions to determine if there are benefits, as well as examining safety considerations. Plant sterols The liver and intestines are key players in cholesterol homeostasis. The liver rapidly clears circulating chylomicron remnants, which carry cholesterol that was absorbed TO PAGE 74 RETAIL PHARMACY • AUG 2020 2 CPD CREDITS