Meta-Analysis of Usefulness of Psyllium Fiber as Adjuvant Antilipid Therapy to Enhance Cholesterol Lowering Efficacy of Statins

      Statins are usually well-tolerated drugs with a clear dose-dependent efficacy. However, manifestation of statin's side effects also bears a direct relation to higher doses necessary to achieve high impact cholesterol-lowering effects. Nevertheless, the reliance on statin efficacy alone has often left dietary intervention underutilized even though studies have shown a reduction in serum cholesterol levels when dietary fiber intake is increased. In this meta-analysis, we investigated whether the concomitant use of psyllium, a gel-forming viscous soluble fiber, would cause further overall cholesterol lowering in subjects already receiving statins. A systematic review of the medical literature was performed and identified three randomized, controlled clinical studies that evaluated the cholesterol lowering efficacy of statins when given concomitantly with psyllium as a fiber supplement. The duration of the studies ranged from 4 weeks to 12 weeks. The objective of the meta-analysis was to estimate the overall effect of psyllium plus statin versus statin alone. The results of the meta-analysis showed a clinically and statistically significant (p = 0.001) cholesterol lowering advantage for psyllium plus statin combination treatment over a statin alone. Adding psyllium fiber resulted in reductions in low-density lipoprotein-cholesterol equivalent to doubling the statin dose. In conclusion, the data support that psyllium fiber taken before meals adds to the efficacy of statins, providing an easy to implement dietary intervention for those who cannot tolerate side effects associated with higher-dose statins.
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        • Stone NJ
        • Robinson J
        • Lichtenstein AH
        • Merz CNB
        • Blum CB
        • Eckel RH
        • Goldberg AC
        • Gordon D
        • Levy D
        • Lloyd-Jones DM
        • McBride P
        • Schwartz JS
        • Shero ST
        • Smith SC
        • Watson K
        • Wilson PWF
        2013 ACC/ AHA Guideline on the treatment of blood cholesterol to reduce atherosclerotic cardiovascular risk in adults; A report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines.
        Circulation. 2014; 129: S1-S45
        • Lloyd-Jones DM
        • Morris PB
        • Ballantyne CM
        • Birtcher KK
        • Daly Jr., DD
        • DePalma SM
        • Minissian MB
        • Orringer CE
        • Smith Jr., SC
        2016 ACC expert consensus decision pathway on the role of non-statin therapies for LDL-cholesterol lowering in the management of atherosclerotic cardiovascular disease risk: a report of the American College of Cardiology Task Force on Clinical Expert Consensus Documents.
        J Am Coll Cardiol. 2016; 68: 92-125
        • Naci H
        • Brugts J
        • Ades T
        Comparative tolerability and harms of individual statins: a study-level network meta-analysis of 246 955 participants from 135 randomized, controlled trials.
        Circ Cardiovasc Qual Outcomes. 2013; 6: 390-399
        • Miettinen TA
        • Gylling H
        • Lindbohm N
        • Miettinen TE
        • Rajaratnam RA
        • Relas H
        • Finnish Treat-to-Target Study I
        Serum noncholesterol sterols during inhibition of cholesterol synthesis by statins.
        J Lab Clin Med. 2003; 141: 131-137
        • Miettinen TA
        • Gylling H
        • Hallikainen M
        • Juonala M
        • Rasanen L
        • Viikari J
        • Raitakari OT
        Relation of non-cholesterol sterols to coronary risk factors and carotid intima-media thickness: the Cardiovascular Risk in Young Finns Study.
        Atherosclerosis. 2010; 209: 592-597
        • Ramos SC
        • Fonseca FA
        • Kasmas SH
        • Moreira FT
        • Helfenstein T
        • Borges NC
        • Moreno RA
        • Rezende VM
        • Silva FC
        • Izar MC
        The role of soluble fiber intake in patients under highly effective lipid-lowering therapy.
        Nutr J. 2011; 10: 80
        • McRorie Jr., JW
        • McKeown NM
        Understanding the physics of functional fibers in the gastrointestinal tract: an evidence-based approach to resolving enduring misconceptions about insoluble and soluble fiber.
        J Acad Nutr Diet. 2017; 117: 251-264
        • Anderson JW
        • Floore TL
        • Geil PB
        • O'Neal DS
        • Balm TK
        Hypocholesterolemic effects of different bulk-forming hydrophilic fibers as adjuncts to dietary therapy in mild to moderate hypercholesterolemia.
        Arch Intern Med. 1991; 151: 1597-1602
        • Anderson JW
        • Zettwoch N
        • Feldman T
        • Tietyen-Clark J
        • Oeltgen P
        • Bishop CW
        Cholesterol-lowering effects of psyllium hydrophilic mucilloid for hypercholesterolemic men.
        Arch Intern Med. 1988; 148: 292-296
        • Rodriguez-Moran M
        • Guerrero-Romero F
        • Lazcano-Burciaga G
        Lipid- and glucose-lowering efficacy of Plantago Psyllium in type II diabetes.
        J Diabetes Complications. 1998; 12: 273-278
        • Jenkins DJ
        • Wolever TM
        • Vidgen E
        • Kendall CW
        • Ransom TP
        • Mehling CC
        • Mueller S
        • Cunnane SC
        • O'Connell NC
        • Setchell KD
        • Lau H
        • Teitel JM
        • Garvey MB
        • Fulgoni 3rd, V
        • Connelly PW
        • Patten R
        • Corey PN
        Effect of psyllium in hypercholesterolemia at two monounsaturated fatty acid intakes.
        Am J Clin Nutr. 1997; 65: 1524-1533
        • Everson GT
        • Daggy BP
        • McKinley C
        • Story JA
        Effects of psyllium hydrophilic mucilloid on LDL-cholesterol and bile acid synthesis in hypercholesterolemic men.
        J Lipid Res. 1992; 33: 1183-1192
        • Stoy DB
        • LaRosa JC
        • Brewer BK
        • Mackey M
        • Meusing RA
        Cholesterol-lowering effects of ready-to-eat cereal containing psyllium.
        J Am Diet Assoc. 1993; 93: 910-912
        • Sprecher DL
        • Harris BV
        • Goldberg AC
        • Anderson EC
        • Bayuk LM
        • Russell BS
        • Crone DS
        • Quinn C
        • Bateman J
        • Kuzmak BR
        • Allgood LD
        Efficacy of psyllium in reducing serum cholesterol levels in hypercholesterolemic patients on high- or low-fat diets.
        Ann Intern Med. 1993; 119: 545-554
        • Weingand K
        • Le N
        • Kuzmak B
        • Brown WV
        • Daggy BP
        • Miettinen TA
        • Howard BV
        • Howard WJ
        Effects of psyllium on cholesterol and low-density lipoprotein.
        Endocrinol Metab. 1997; 4: 141-150
        • Garvin JE
        • Forman DT
        • Eiseman WR
        • Phillips CR
        Lowering of human serum cholesterol by an oral hydrophilic colloid.
        Proc Soc Exp Biol Med. 1965; 120: 744-746
        • de Bock M
        • Derraik JG
        • Brennan CM
        • Biggs JB
        • Smith GC
        • Cameron-Smith D
        • Wall CR
        • Cutfield WS
        Psyllium supplementation in adolescents improves fat distribution & lipid profile: a randomized, participant-blinded, placebo-controlled, crossover trial.
        PLoS One. 2012; 7: e41735
        • Shrestha S
        • Freake HC
        • McGrane MM
        • Volek JS
        • Fernandez ML
        A combination of psyllium and plant sterols alters lipoprotein metabolism in hypercholesterolemic subjects by modifying the intravascular processing of lipoproteins and increasing LDL uptake.
        J Nutr. 2007; 137: 1165-1170
        • Moreyra AE
        • Wilson AC
        • Koraym A
        Effect of combining psyllium fiber with simvastatin in lowering cholesterol.
        Arch Intern Med. 2005; 165: 1161-1166
        • Maciejko JJ
        • Brazg R
        • Shah A
        • Patil S
        • Rubenfire M
        Psyllium for the reduction of cholestyramine-associated gastrointestinal symptoms in the treatment of primary hypercholesterolemia.
        Arch Fam Med. 1994; 3: 955-960
        • Spence JD
        • Huff MW
        • Heidenheim P
        • Viswanatha A
        • Munoz C
        • Lindsay R
        • Wolfe B
        • Mills D
        Combination therapy with colestipol and psyllium mucilloid in patients with hyperlipidemia.
        Ann Intern Med. 1995; 123: 493-499
        • Agrawal AR
        • Tandon M
        • Sharma PL
        Effect of combining viscous fibre with lovastatin on serum lipids in normal human subjects.
        Int J Clin Pract. 2007; 61: 1812-1818
        • Jayaram S
        • Prasad HB
        • Sovani VB
        • Langade DG
        • Mane PR
        Randomised study to compare the efficacy and safety of isapgol plus atorvastatin versus atorvastatin alone in subjects with hypercholesterolaemia.
        J Indian Med Assoc. 2007; 105 (150): 142-145
        • Sola R
        • Bruckert E
        • Valls RM
        • Narejos S
        • Luque X
        • Castro-Cabezas M
        • Domenech G
        • Torres F
        • Heras M
        • Farres X
        • Vaquer JV
        • Martinez JM
        • Almaraz MC
        • Anguera A
        Soluble fibre (Plantago ovata husk) reduces plasma low-density lipoprotein (LDL) cholesterol, triglycerides, insulin, oxidised LDL and systolic blood pressure in hypercholesterolaemic patients: a randomised trial.
        Atherosclerosis. 2010; 211: 630-637
      1. The Cochrane Collaboration, West Sussex, England2011 (Available from)
      2. Institute of Medicine, Food and Nutrition Board, Washington, DC2002
        • Wang H
        • Lichtenstein AH
        • Lamon-Fava S
        • Jacques PF
        Association between statin use and serum cholesterol concentrations is modified by whole-grain consumption: NHANES 2003-2006.
        Am J Clin Nutr. 2014; 100: 1149-1157
        • Van Rosendaal GM
        • Shaffer EA
        • Edwards AL
        • Brant R
        Effect of time of administration on cholesterol-lowering by psyllium: a randomized cross-over study in normocholesterolemic or slightly hypercholesterolemic subjects.
        Nutr J. 2004; 3: 17
        • Vergara-Jimenez M
        • Conde K
        • Erickson SK
        • Fernandez ML
        Hypolipidemic mechanisms of pectin and psyllium in guinea pigs fed high fat-sucrose diets: alterations on hepatic cholesterol metabolism.
        J Lipid Res. 1998; 39: 1455-1465
        • Davis Jr., HR
        • Altmann SW
        Niemann-Pick C1 Like 1 (NPC1L1) an intestinal sterol transporter.
        Biochim Biophys Acta. 2009; 1791: 679-683