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lactic acid-producing bacteria of which Lactobacillus plantarum (L. plantarum) is the predominant Lactobacillus species found on oral and intestinal human mucosa. It has been shown to survive passage through the human gastrointestinal tract and to establish itself in the intestine after consumption.17 Three L. plantarum strains (CECT 7527, 7528, and 7529) were isolated from human faeces and shown to have the capacity to deconjugate bile acids, assimilate cholesterol, and produce short- chain fatty acids.17 This ability to modify lipids was optimal as a mixed culture, and this mixed culture is patented as a hypocholesterolaemic agent.17 Fuentes et al17 conducted a randomised clinical trial evaluating the ability of L. plantarum to lower LDL-C and other lipoprotein lipid variables in adults with hypercholesterolaemia. The study enrolled 60 adult patients with TC of 5.2–7.8 mmol/lt and LDL-C 3.4–4.9 mmol/ lt. Patients with TG of >3.95 mmol/L were excluded. Lipid-altering medications and any other treatment for hypercholesterolemia was not allowed. The patients were randomised to a proprietary formulation of three L. plantarum strains (CECT 7527, 7528, and 7529) or placebo. At 12 weeks the probiotic group had significantly larger reductions in LDL-C, TC, LDL-C/HDL-C ratio and triglycerides, and increases in HDL-C. The authors concluded that the L. plantarum combination reduced LDL-C and improved other lipid parameters. It’s important to note that this study was funded by AB-BIOTICS, owner of the patent and provider of the proprietary probiotic preparation. A recent meta-analysis concluded that evidence indicates probiotic supplements can significantly reduce serum TC. Importantly, not all probiotic interventions are effective against dyslipidaemia. A meta-analysis conducted by Wang et al16 included studies of between one week and 24 weeks’ duration. Six studies used supplementation with strains of L. plantarum for the intervention. Analysis of the results of the long intervention cycle, defined as greater than six weeks, showed a pooled mean net change in TC of −22.18mg/dL (1.23 mmol/lt) \\\\\\\\\\\\\\\[MD = −22.18, 95% CI (−28.73, −15.63), P < .05\\\\\\\\\\\\\\\]. This indicated that longer-term probiotic intervention could significantly reduce the level of TC. The meta- analysis indicated that the efficacy of the probiotic intervention on reducing total cholesterol was impacted by baseline TC and intervention duration. The higher the baseline TC the more efficacious the intervention seemed to be.16 There were significant limitations in the meta-analysis and randomised clinical trials assessing the impact of probiotics on cholesterol.16 The authors of this meta-analysis16 cite deficiencies in the quality of literature, small sample sizes and heterogeneity in analysis.16 L. plantarum may have a role in the management of cardiovascular risk in patients through modulating serum lipids. But larger sample-sized and randomised multicentre studies are needed to make confident recommendations on this intervention. In Australia, the only proprietary preparation of the mixed culture L. plantarum formulation: CECT 7527,7528,7529 is ENLIVA. The recommended dose is one capsule daily. Conclusions Hypercholesterolaemia is a significant independent risk factor for cardiovascular disease. There is evidence to show the benefit of some complementary interventions in modifying blood lipids, notably reducing total serum cholesterol, LDL-C or triglycerides. Consuming foods enriched with plant sterols and supplementation with psyllium husk can significantly reduce LDL cholesterol. Consuming omega-3 PUFAs from fish oil can significantly reduce triglycerides, with higher pharmacological doses (4g daily) offering the most efficacious reduction. Reversible secondary causes of HTG, such as hypothyroidism or poorly controlled type 2 diabetes mellitus, should be identified and treated prior to initiation of any pharmacotherapy or supplementary interventions, and dietary causes including excessive alcohol or sugar intake should be addressed. There is no evidence that these complementary medicine inventions, despite efficacy in modifying lipid parameters, improve cardiovascular outcomes. The most recent Australian guidelines for the management of absolute cardiovascular disease risk indicate that further high-quality trials are needed to confirm suggestions of a protective effect of omega-3 PUFAs on cardiovascular health to prevent CVD, although increasing consumption of fish generally is recommended. The guidelines also state that while phytosterols and soluble fibre may have modest hypocholesterolaemic effects, there is insufficient evidence to make clear recommendations on the impact of these interventions. Pharmacists are often asked for advice on the efficacy of complementary medicines in lowering cholesterol. By understanding the strength and limitations of the evidence for the use of these products, pharmacists are better able to assist patients in making informed choices. References 1. Lalor E, Boyden A, Cadilhac D, Colagiur S, Doust J, Fraser D, Harris M, Huang N, Johnson D, Johnson G, Lusis N. ‘Guidelines for the management of absolute cardiovascular disease risk’. The National Vascular Disease Prevention Alliance, Australia, 2012. TO PAGE 78 CPD ACTIVITY 77 RETAIL PHARMACY • AUG 2020