Red Yeast Rice for the Improvement of Lipid Profiles in Mild-to-Moderate Hypercholesterolemia: A Narrative Review

Abstract

Reducing low-density lipoprotein cholesterol (LDL-C) levels is a key target for lowering cardiovascular risk and preventing atherosclerotic cardiovascular disease (ASCVD). Red yeast rice (RYR) is a nutraceutical widely used as a lipid-lowering dietary supplement. The main cholesterol-lowering components of RYR are monacolins, particularly monacolin K, which is structurally identical to lovastatin and targets the same key enzyme of cholesterol biosynthesis. RYR supplementation reduces LDL-C levels by approximately 15-34% versus placebo, with a similar effect to low-dose, first-generation statins in subjects with mild-to-moderate dyslipidemia. RYR has also demonstrated beneficial reductions of up to 45% versus placebo in the risk of ASCVD events in secondary prevention studies. RYR at a dose that provides about 3 mg/d of monacolin K is well tolerated, with an adverse event profile similar to that of low-dose statins. RYR is therefore a treatment option for lowering LDL-C levels and ASCVD risk for people with mild-to-moderate hypercholesterolemia who are ineligible for statin therapy, particularly those who are unable to implement lifestyle modifications, and also for people who are eligible for statin therapy but who are unwilling to take a pharmacologic therapy.

Keywords: Monascus purpureus; efficacy; endothelial function; inflammatory markers; safety; vascular remodeling.

Figure 1

Main cholesterol-lowering mechanism of action of RYR [28]. RYR = red yeast rice. HMG-CoA = β-hydroxy β-methylglutaryl coenzyme A; HMG-CoAR = β-hydroxy β-methylglutaryl coenzyme A reductase; PP = pyrophosphate.

Figure 2

Actions of RYR on cholesterol synthesis, transport, and gene expression [35]. Apo-A1 = apolipoprotein A1; HDL-C = high-density lipoprotein cholesterol; HMG-CoA = β-hydroxy β-methylglutaryl coenzyme A; HMG-CoAR = β-hydroxy β-methylglutaryl coenzyme A reductase; PP = pyrophosphate.