Supplements, Placebo, or Rosuvastatin Study

Few well-controlled trials have studied the LDL-lowering effects of dozens of marketed "cholesterol health" dietary supplements. Prior research suggests most U.S. consumers believe cholesterol health supplements are safer than statins, and a majority of the public also believe supplements are as effective, or more effective, than prescription statins. Approximately one third of US adults who have been told they have elevated cholesterol are using a supplement to provide heart health protection rather than a statin. This represents a significant public health concern.

The purpose of this study is to evaluate the effect of select dietary supplements on cholesterol health compared with a low dose of a statin.

The study is comparing their effect on LDL and HDL cholesterol and inflammatory markers.

A randomized, single blind study design will be used to evaluate rosuvastatin 5 mg. vs. placebo and 6 commercially available over the counter supplements in a hierarchical testing order. Each participant will take study medication/supplement for a total of 4 weeks.

The study will randomize primary prevention patients who are considered borderline and intermediate risk for ASCVD based upon the 2018 Cholesterol Treatment Guidelines7 and are not taking any of the studied medication/supplements at the time of randomization.

Participants must have a documented elevated LDL cholesterol level between 70-189mg/dL, must not currently be taking a statin or one of the dietary supplements included in the trial. Participants willing to discontinue a prohibited supplement for 4 weeks prior to enrollment will be allowed to participate. Study medication will be provided at no charge. There will be 2 visits which include a lab draw at any Cleveland Clinic laboratory. Participants will be randomized (like a coin flip) to be in one of 8 possible groups: Rosuvastatin, Fish oil, Cinnamon, Garlic, Turmeric, Plant sterol, Red yeast rice, or placebo. The study will enroll 200 participants.

• Fish Oil, Cinnamon, Garlique,Turmeric, Plant Sterol, Red Yeast Rice (Dietary supplement): Subjects will be randomized to a Statin (Rosuvastatin 5 mg), a placebo, or a dietary supplement (Fish oil, Cinnamon, Garlic, Turmeric, Plant sterol, Red yeast rice).
• Rosuvastatin (Drug), also known as Crestor: Subjects will be randomized to a Statin (Rosuvastatin 5 mg), a placebo, or a dietary supplement (Fish oil, Cinnamon, Garlic, Turmeric, Plant sterol, Red yeast rice).
• Placebo (Other): Subjects will be randomized to a Statin (Rosuvastatin 5 mg), a placebo, or a dietary supplement (Fish oil, Cinnamon, Garlic, Turmeric, Plant sterol, Red yeast rice).

Primary outcomes

• Percent Change in LDL-C From Baseline for Rosuvastatin 5mg Daily Compared With Placebo and Each Dietary Supplement. [The percent change in LDL-C for rosuvastatin 5 mg compared with dietary supplements after 4 weeks]: The primary objective of this study is to compare the LDL lowering of rosuvastatin with the effect of six commonly used dietary supplements on cholesterol health.

Secondary outcomes

• Percent Change in hsCRP for Rosuvastatin vs Dietary Supplements. [The percent change in high sensitivity C reactive protein (hsCRP) for rosuvastatin 5 mg and dietary supplements compared with placebo after 4 weeks.]: Assess the effect of each supplement on inflammatory markers compared with rosuvastatin 5 mg.
• Percent Change in HDL-C, Total Cholesterol, and Triglycerides for Rosuvastatin vs Dietary Supplements. [After 4 weeks]: The percent change in HDL-C, total cholesterol, and triglycerides for each supplement compared with rosuvastatin. The percent change in HDL-C, total cholesterol, and triglycerides for each supplement compared with rosuvastatin. The percent change in HDL-C, total cholesterol, and triglycerides for each supplement compared with placebo.
• The Percent Change in HDL-C, Total Cholesterol, and Triglycerides for Placebo vs the Dietary Supplements. [After 4 weeks]: The percent change in HDL-C, total cholesterol, and triglycerides for each supplement compared with placebo.

Sex: All, ages: 40 Years to 75 Years

Inclusion Criteria:

1. Written informed consent must be obtained before any assessment is performed.
2. U.S. adults with primary hypercholesterolemia, 40-75 years of age.
3. Not currently taking statins or one of the dietary supplements included in the trial. Patients willing to discontinue a prohibited supplement for 4 weeks prior to enrollment will be allowed to participate.
4. LDL-cholesterol between 70 and 189 mg/dL.
5. Patients without diabetes mellitus and a 10-year risk of ASCVD between 5 and <20% using the pooled cohort risk equation. * Or Patients with diabetes mellitus in females 50-60 years of age or males 40-50 years of age with an LDL-C between 70-189 mg/dL and with an ASCVD risk below 20%.

Exclusion Criteria:

1. Age < 40 or >75 years of age
2. Women who are pregnant, plan to become pregnant within the next 6 months, or are breastfeeding.
3. Documented liver dysfunction or history of elevated LFTs indicating active liver disease
4. Documented chronic renal dysfunction within the past two years defined as an eGFR<30mL/min/m2.
5. Known hypersensitivity to rosuvastatin or any supplement under investigation (i.e. shellfish allergy, etc.).
6. Currently taking any prescription statin, or other prescription medication/supplements to treat elevated cholesterol or triglycerides.
7. Currently taking a medication/supplement that has known interaction with rosuvastatin, including fenofibrate, gemfibrozil, HIV medications, colchicine, cyclosporine, warfarin, anti-viral medications to treat Hepatitis C, regorafenib, and darolutamide.
8. Are unwilling to discontinue prohibited dietary supplement(s) for 4 weeks prior to participation or during the course of the trial. Other non-prohibited supplements will be permitted if doses have been stable for at least 4 weeks.
9. Known cardiovascular disease including a history of prior MI, stroke/TIA, PAD or prior revascularization procedures of the heart or vasculature (e.g. CABG, stenting, PCI etc.).
10. Fasting Triglycerides >200mg/dl.
11. In the opinion of the investigator, any other condition that will preclude participation in the study.

Participant flow

Outcome results

• Percent Change in LDL-C From Baseline for Rosuvastatin 5mg Daily Compared With Placebo and Each Dietary Supplement. (Primary), Least squares mean, percent change LDL-C: Rosuvastatin -37.86 (-42.13 to -33.59); Placebo -2.63 (-6.99 to 1.73); Fish Oil -3.43 (-7.86 to 1.01); Cinnamon 0.42 (-3.91 to 4.74); Garlique 5.13 (0.97 to 9.29); Turmeric -1.29 (-5.44 to 2.87); Plant Sterol -4.37 (-8.65 to -0.09); Red Yeast Rice -6.55 (-10.94 to -2.16) (p <0.001)
• Percent Change in hsCRP for Rosuvastatin vs Dietary Supplements. (Secondary), Least squares mean, percent change hsCRP: Rosuvastatin -5.70 (-32.52 to 31.78); Placebo -7.12 (-34.06 to 30.83); Fish Oil -1.39 (-30.45 to 39.81); Cinnamon 29.04 (-7.94 to 80.88); Garlique 1.09 (-27.08 to 40.14); Turmeric -4.49 (-31.08 to 32.36); Plant Sterol -13.72 (-38.28 to 20.60); Red Yeast Rice 6.28 (-24.42 to 49.43)
• Percent Change in HDL-C, Total Cholesterol, and Triglycerides for Rosuvastatin vs Dietary Supplements. (Secondary), Least squares mean, % change HDLC,Tot Cholest, Triglycerides: Rosuvastatin 3.44 (-0.73 to 7.62); Placebo 3.08 (-1.16 to 7.32); Fish Oil 2.41 (-1.91 to 6.73); Cinnamon -2.33 (-6.47 to 1.80); Garlique 3.43 (-0.61 to 7.47); Turmeric 1.42 (-2.62 to 5.45); Plant Sterol -4.02 (-8.16 to 0.13); Red Yeast Rice 2.45 (-1.79 to 6.69) (p 0.05)
• The Percent Change in HDL-C, Total Cholesterol, and Triglycerides for Placebo vs the Dietary Supplements. (Secondary), Least squares mean, % change HDLC, tot chole, triglycerides: Rosuvastatin 3.44 (-0.73 to 7.62); Placebo 3.08 (-1.16 to 7.32); Fish Oil 2.41 (-1.91 to 6.73); Cinnamon -2.33 (-6.47 to 1.80); Garlique 3.43 (-0.61 to 7.47); Turmeric 1.42 (-2.62 to 5.45); Plant Sterol -4.02 (-8.16 to 0.13); Red Yeast Rice 2.45 (-1.79 to 6.69)

Adverse events

Time frame: 4 weeks

Serious adverse events by term

Other adverse events by term

• Results publication: Laffin LJ, Bruemmer D, Garcia M, Brennan DM, McErlean E, Jacoby DS, Michos ED, Ridker PM, Wang TY, Watson KE, Hutchinson HG, Nissen SE. Comparative Effects of Low-Dose Rosuvastatin, Placebo, and Dietary Supplements on Lipids and Inflammatory Biomarkers. J Am Coll Cardiol. 2023 Jan 3;81(1):1-12. doi: 10.1016/j.jacc.2022.10.013. Epub 2022 Nov 6. PMID 36351465

• Study Protocol (PDF, 2021-02-23)
• Statistical Analysis Plan (PDF, 2022-01-12)

• Luke Laffin, M.D., Principal investigator, The Cleveland Clinic
• Steven Nissen, M.D., Study chair, The Cleveland Clinic