Comprehensive Guide to Policosanol
(Saccharum officinarum)

Policosanol (Saccharum officinarum)Dr. James Meschino DC, MS, ND
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General Features
Policosanol is a natural compound derived from sugar cane wax, which has been shown to significantly reduce high cholesterol in human and animal studies. It also has been shown to reduce platelet stickiness, improving blood flow and aiding patients with intermittent claudication and non-insulin dependent diabetes mellitus. The efficacy, safety and lack of toxicity of this natural health product makes it a very desirable supplement in the management of high cholesterol as it has been shown to reduce cholesterol levels equally as well as many prescription medications, without producing significant side effects.

Principle Active Constituents Policosanol is a mixture of higher primary aliphatic alcohols isolated from sugar cane wax, whose main component is octacosanol. Octacosanol is a long chain fatty alcohol (similar in structure to cholesterol, which is also an alcohol ). Policosanol is a combination of octacosanol and several other long chain alcohols — hence the name poli-cosanol. Keeping octacosanol together with other naturally occurring fatty alcohols makes it more stable and seems to enhance the efficacy of this supplement
Clinical Application and Mechanism of Action
1. Cholesterol Lowering - Policosanol has been shown to reduce high levels of blood cholesterol to a significant degree (LDL-cholesterol reduction ~ 20%) in human and animal studies. Its mechanism of action is not completely understood, but it is known to suppress cholesterol synthesis in the liver. This effect appears to be related to its modulation of the HMG-CoA reductase enzyme, a rate-limiting enzyme in cholesterol synthesis. However, it is not officially considered to be an HMG-CoA reductase inhibitor, as are statin drugs. Nor does it produce the side effects associated with the use of statin drugs, which include potential liver damage, muscle pain, fatigue, dizziness, skin rash, diarrhea, heartburn, skin rash and male impotence. 4,6,30 Large trials over long periods have demonstrated that Policosanol supplementation can lower and maintain blood cholesterol levels as well as most conventional drugs, without producing untoward side effects. 1,4,7,8,9
Human Trials
A review of the clinical trials using Policosanol to lower cholesterol levels in humans appeared in the American Heart Journal in 2002. A review of the available peer-reviewed journal publications revealed that Policosanol, at doses of 10 to 20 mg per day lowers total cholesterol by 17% to 21% and low-density lipoprotein (LDL) cholesterol by 21% to 29%, and raises high-density lipoprotein (HDL, the good cholesterol) cholesterol by 8% to 15%. The researchers state that because higher doses have not been tested up to now, it can not be excluded that effectiveness may be even greater. Daily doses of 10 mg of Policosanol have been shown to be equally effective in lowering total and LDL cholesterol as the same dose of simvastatin or pravastatin (two widely prescribed cholesterol-lowering statin drugs). Triglyceride levels are not influenced by Policosanol supplementation. At doses of up to 20 mg per day, Policosanol is safe and well tolerated, as studies of greater than three years of therapy indicate. 1
Postmenopausal Women - Policosanol has been shown to reduce elevated total and LDL-cholesterol levels in postmenopausal women by 17.3% and 26.7%, respectively, in 56 women who showed no cholesterol lowering to a 6-week standard lipid-lowering diet that has been followed prior to the administration of Policosanol. This is of great clinical significance as heart disease is the number one cause of death in postmenopausal women. After menopause the decline in estrogen levels is associated with a decrease in LDL-cholesterol receptors on the cell surface. In turn, this reduces clearance of cholesterol from the bloodstream permitting blood levels of LDL-cholesterol to rise, predisposing women to heart attack and ischemic stroke. 9
- Patients with type II hypercholesterolemia are known to have a genetically based defect that encourages lifelong elevation of blood cholesterol- a condition that is difficult to manage through diet and exercise alone. Studies have shown in a convincing manner that Policosanol supplementation significantly lowers cholesterol levels even in these more challenging patients. Total and LDL-cholesterol can be expected to drop by up to 17.4% and 25.6%, respectively. HDL-cholesterol levels have been shown to rise by 15.5% to 28.4% in these patients, which is a remarkable finding due to the fact that it is difficult to raise HDL levels and that higher HDL levels are known to significantly reduce risk of heart attack. HDL-cholesterol collects the cholesterol that has been deposited in the artery wall and transports it back to the liver where it can be cleared from the blood stream and eliminated from the body via its conversion to bile acids. 10
Even in older patients with type II hypercholesterolemia presenting with more than one concomitant atherosclerotic risk factor, the administration of Policosanol at 5 mg or 10 mg per day was shown to significantly reduce total and LDL-cholesterol levels and raise HDL- levels by up to 29.1%. The 10 mg dose produced better results in all cholesterol parameters compared to the 5 mg dose. 11
Head-To-Head Trials Against Statin Drugs - A study involving older patients with type II hypercholesterolemia tested the efficacy of the statin drug Pravastain against Policosanol, in a randomized, double-blind study. The results showed that Policosanol was more effective than Pravastatin in reducing total and LDL-cholesterol and was able to raise HDL-cholesterol by 18.4%, whereas Pravastatin showed no effect on HDL-cholesterol levels. Policosanol also more effectively reduced platelet aggregation than did Pravastatin, another important risk factor in cardiovascular disease. Patients receiving Pravastatin over the 6-week trial period experienced a rise in their serum levels of alanine amine transferase enzyme, which indicates potential damage to liver cells. This did not occur in the Policosanol group. Two patients dropped out of the Pravastatin group due to adverse side effects (myocardial infarction and jaundice, likely due to liver damage). The researchers conclude “the effects of Policosanol (10 mg per day) on lipid profile, platelet aggregation and endothelemia in older patients with type II hypercholesterolemia and high coronary risk are more favorable than those induced by the same doses of Pravastatin.” 12
A second study tested the efficacy of Policosanol against Lovastatin and Simvastatin (two popular statin drugs). The results showed that Policosanol reduced LDL-cholesterol by 24% on average compared to a 22% and 15% reduction with Lovastatin and Simvastatin, respectively. HDL levels rose significantly in the Policosanol group and no change was seen in the patients receiving Lovastain or Simvastatin. This was a 6- week trial involving patients with an LDL-cholesterol level of over 160 mg/dl. 13
Used In Conjunction With Fibrate Drugs - A study combining the use of Bezafibrate and Policaosanol demonstrated that these cholesterol and triglyceride-lowering agents can be used together to produce a positive outcome on blood lipids with no untoward side effects. Fibrate drugs are often used to help lower triglyceride levels, an effect that is not produced to a substantial degree by Policosanol. Thus, in patients with high cholesterol and high triglycerides, the combination of both agents has been shown to be effective and safe. 14
Intermittent Claudication - Sixty-two patients with intermittent claudication were given either 10 mg of Policosanol, twice per day or a placebo for 6 weeks. The Policaosanol group realized a significant improvement on treadmill walking distance during the course of the study. No change was seen in the placebo group. 15
Improved Exercise ECG Results in Coronary Patients - Policosanol supplementation was tested in patients with myocardial ischemia (severe blood flow restriction to the heart muscle) versus placebo. The results showed thatafter 20 months the Policosanol group experienced an incremental improvement in ECG exercise testing (aerobic functional capacity percent) and a decline in blood cholesterol levels. The researchers state that Policosanol treated patients with coronary heart disease showed improved clinical evolution, and exercise-ECG responses, owing to the amelioration of myocardial ischemia. These results were even better when Policosanol was combined with 125 mg of aspirin per day, indicating that the use of aspirin in conjunction with Policosanol may be of greater benefit to certain heart patients than is aspirin alone. 16
Coronary Heart Disease Patients - A randomized single-blinded, placebo-controlled trial was conducted on 23 middle-aged outpatients with established coronary heart disease. The 12 patients given the Policosanol demonstrated a significant reduction in blood cholesterol levels and exhibited a clinical tendency to improvement of their coronary heart disease, in comparison to no improvement in these parameters in the placebo group. “ These findings show the effectiveness of low dose of Policosanol lowering total cholesterol and LDL-cholesterol and suggest a coronary heart disease improvement in middle-aged patients with primary or marginal hyperlipidemia.” 17
Diabetic Patients With High Cholesterol - In a study of non-insulin dependent diabetic patients with high cholesterol levels, Policosanol supplementation at 10 mg per day was shown to reduce total cholesterol by 17.5% and LDL-cholesterol by 21.8% compared with baseline and placebo. HDL-cholesterol levels rose by 11.3% and triglyceride levels fell by 6.6% in the Policosanol group. None of these changes occurred in the placebo group. Moreover, Policosanol did not adversely affect glucose levels or glycemic control. The researchers conclude “ Policosanol is effective and safe in patients with non-insulin dependent diabetes mellitus and hypercholesterolemia.” 2. Anti-Coagulant Effects
Policosanol has been shown to exert anti-coagulant effects on platelet function. However, this does not seem to be the case when administered at 5 or 10 mg per day. Anti-coagulant effects appear to start at a dose of 20 mg per day, with increasing anti-coagulant effects at 40 mg per day. Thus, patients taking other anti-coagulants (warfarin, coumadin, aspirin ) appear to be able to safely take up to 10 mg per day of Policosanol to lower cholesterol without risk of potentiating the action of anti-coagulant drugs. 19 A dose of 20 mg per day of Policosanol has been shown to provide the same degree of anti-coagulant activity as 100 mg of aspirin per day in human subjects. 20 This implies that if an anti-coagulant effect is desired along with a cholesterol lowering effect, then Policosanol can be used alone at a dose of 20 or 40 mg per day. If the patient is already on anti-coagulant therapy, then it is wise to limit the dose of Policosanol to 10 mg per day, where a cholesterol lowering effect is desirable.
Dosage and Standardized Grade
Cholesterol Lowering - To lower cholesterol in patients not taking anti-coagulant therapy (including aspirin) doses of Policosanol from 5 mg per day to 40 mg per day have been used. Most typically, 10 mg, twice per day is the most common daily dosage of Policosanol used to treat hypercholesterolemia. In patients using anti-coagulant drugs, it is best to limit the dose of Policosanol to 5 mg, twice per day.
Adverse Side Effects, Toxicity and Contraindications
Long term studies with Policosanol in humans has not shown any significant side effects and appears to have a safer profile than statin drugs (HMG-CoA reductase inhibitor drugs) that are commonly prescribed to lower cholesterol. 1,4,7,8,9 A case of erthyma was reported in one trial with diabetics. 18 Animal studies reveal that Policosanol is extremely safe even when administered to beagle dogs at 180 mg/kg for 52 weeks, which is 620 times higher than the therapeutic dose of 20 mg per day. 22 Studies in mice showed no adverse effects or carcinogenicity at doses of 50-500 mg/kg administered orally for 18 months. 23 Overall Policosanol is considered to be an extremely safe therapeutic agent for cholesterol lowering.

Drug-Nutrient Interactions
1. Anti-coagulant Drugs - Policosanol has been shown to inhibit platelet aggregation and therefore, may potentiate the effects of anti-coagulant drugs such as warfarin, coumadin and aspirin. Studies on humans and animals have not shown a significant enhancement of anti-platelet activity when Policoasanol has been combined with warfarin or aspirin. Nevertheless, in the interest of patient safety, it is best not to recommend a daily dosage of more than 5 mg, twice per day in patients on concomitant anti-coagulant therapy, and even then, their prothrombin time should be properly monitored.
2. Beta-Blocker, Anti-Hypertensive Drugs - Human and animal studies reveal that Policosanol can potentiate the effects of beta-blockers used to lower high blood pressure. Thus, blood pressure should be monitored in order to see if a dose reduction in beta-blocker medication is required once Policosanol supplementation has been implemented.
Pregnancy and Lactation
During pregnancy and lactation, the only supplements that are considered safe include standard prenatal vitamin and mineral supplements. All other supplements or dose alterations may pose a threat to the developing fetus and there is generally insufficient evidence at this time to determine an absolute level of safety for most dietary supplements other than a prenatal supplement. Any supplementation practices beyond a prenatal supplement should involve the cooperation of the attending physician (e.g., magnesium and the treatment of preeclampsia.)

References: Pregnancy and Lactation
1. Encyclopedia of Nutritional Supplements. Murray M. Prima Publishing 1998.
2. Reavley NM. The New Encyclopedia of Vitamins, Minerals, Supplements, and Herbs. Evans and Company Inc. 1998.
3. The Healing Power of Herbs (2nd edition). Murray M. Prima Publishing 1995.
4. Boon H and Smith M. Health Care Professional Training Program in Complementary Medicine. Institute of Applied Complementary Medicine Inc. 1997.
References
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2. Torres O, Agramonte AJ, Illnait J, Más Ferreiro R, Fernández L, Fernández JC. Treatment of hypercholesterolemia in NIDDM with policosanol. Diabetes Care 1995Mar;18(3):393-7
3. Castaño G, Más R, Roca J, Fernández L, Illnait J, Fernández JC, Selman E. A double-blind, placebo-controlled studyof the effects of policosanol in patients with intermittent claudication. Angiology 1999Feb;50(2):123-30
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5. Prat H, et al. Comparative effects of policosanol and two HMG-CoA Reductase inhibitors on type II hypercholesterolemia. Rev Med Chil Mar1999;127(3):286-94
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