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Chinese Red Rice and Myopathy

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  • Chinese Red Rice and Myopathy

    A recent report in one of my medical journals references the potential dangers of Chinese red rice, because it contains a chemical that not only lowers cholesterol, but can cause liver and muscle damage. The report is as follows:

    A middle-aged man presented with joint pain and muscle weakness that had begun 2 months before presentation. Three months before presentation, he had begun to take the herbal preparation Chinese red rice. Laboratory testing revealed a moderately elevated creatine phosphokinase level. Symptoms and laboratory abnormalities resolved with discontinuation of the Chinese red rice. Eight months later, he resumed the product and his creatine phosphokinase level rose again. Lovastatin is a naturally occurring component of Chinese red rice and was the probable cause of his myopathy.


    Herbal product use is increasing in popularity in the United States. Herbal remedies are used to prevent and to alleviate symptoms of disease. In 1999, the Centers for Disease Control and Prevention reported that 10% of adults used herbal preparations and 29% used some form of complementary or alternative medicine. Herbal preparations are easily obtainable by the general public at most health food stores. Information regarding their use is widespread on the Internet. Herbal preparations are not required to meet the standards of other proprietary drugs, because they are marketed as dietary supplements. It is a challenge for most medical professionals to maintain a working knowledge of contents and adverse effects of the various herbal preparations on the market today. However, some herbal preparations can have clinically significant adverse effects. For example, the Chinese herb Aristolochia fangchi has been reported to increase urothelial carcinoma among patients with end-stage Chinese herb nephropathy. One case report described proximal muscle weakness associated with the ingestion of an herb purchased in Mexico that contained triamcinolone. We report a case of symptomatic myopathy associated with the use of Chinese red rice.

    A 50-year-old white man presented to his primary care physician with a complaint of joint pain and muscle weakness. The patient had been well until approximately 2 months earlier, when he had developed pain in his left wrist and muscle discomfort in his left forearm. The muscle discomfort subsequently involved the right upper extremity. At presentation, the patient complained of diffuse body aching, upper-extremity weakness, and stiffness in his lower back. He denied acute injuries, insect bite, rashes, or recent travel. Cold weather exacerbated the symptoms, and a nonsteroidal agent helped minimally. The patient denied any infectious symptoms such as fever, chills, cough, or dysuria. There were no complaints of nausea, vomiting, or diarrhea.

    His pertinent medical and social history included hypertension, mild hypercholesterolemia, anxiety, tobacco abuse, and occasional alcohol use. The patient had no family history of muscle diseases or problems. At the time of presentation, the patient was taking quinapril, clonazepam, rofecoxib, paroxetine, ginseng, and Chinese red rice. He had been taking quinapril and clonazepam for years, the rofecoxib for approximately 1 month, and the herbal supplements for 3 months.

    The physical examination revealed a healthy-appearing man in no distress. His vital signs were normal. There was minimal edema of the metacarpophalangeal joint of the first digit of his left hand. During range-of-motion testing, the patient had difficulty in extending his upper extremities. His muscle strength in his hands was decreased to 4/5 bilaterally. He had normal strength testing with his upper arms, forearms, and lower extremities. There was no edema, erythema, or reproducible muscle tenderness with palpation of the upper and lower extremities. No pain was elicited with percussion of his spine. The upper- and lower-extremity pulses were normal, and he had good capillary refill. Crepitus was noted in his knees bilaterally with extension.

    All laboratory tests (complete blood count, basic metabolic panel, liver function studies, thyroid-stimulating hormone, erythrocyte sedimentation rate, antinuclear antibody, rheumatoid factor, and creatinine phosphokinase [CPK]) were normal, except for a CPK level of 358 IU/L (normal range, 30-160 IU/L). According to the patient, the only new medications in his regimen were the over-the-counter herbal preparations, which he had started taking approximately 4 weeks before developing his symptoms, and rofecoxib, which he had started taking after the onset of symptoms. He was instructed to stop taking both ginseng and Chinese red rice. At the 3-week follow-up visit, his complaints of muscle weakness and joint pain had resolved completely. The CPK was rechecked and had decreased to 179 IU/L. Eight months later, the patient resumed Chinese red rice, and his CPK increased again, to 212 IU/L.

    Chinese red rice was first used to make rice wine and as a food preservative during the Tang Dynasty in ad 800. It is used to help improve blood circulation and decrease cholesterol and triglycerides. The main active ingredients in Chinese red rice are hydroxymethylglutaryl coenzyme reductase inhibitors, primarily lovastatin (also referred to as monacolin K or mevinolin). Some studies have shown a significant decrease in total cholesterol and reductions in low-density lipoprotein and triglycerides after 8 weeks of treatment with Chinese red rice compared with placebo. During and after the 8-week trial, there were no reported adverse events using the Chinese red rice.

    Chinese red rice has been documented to cause anaphylactic reactions, gastritis, abdominal discomfort, and elevated liver enzymes. Because Chinese red rice does contain the ingredient lovastatin, it may pose the risk of rhabdomyolysis, liver damage, and kidney toxicity. Patients who take this herbal supplement could develop symptoms of weakness, muscle pain, and illnesses similar to those caused by viruses. However, none of those adverse reactions caused by hydroxymethylglutaryl coenzyme reductase inhibitors have been reported in association with Chinese red rice ingestion.

    Because the patient was also taking ginseng, its role in his symptoms must be considered. Ginseng is used in the United States to increase resistance to daily stress. The main constituents of ginseng marketed in the United States are the ginsenosides or panoxosides. Ginsenoside Rb-1 is found primarily in U.S. ginseng and reportedly decreases blood pressure, helps enhance gastrointestinal motility, and has an ulcer-protective effect.

    Although ginseng seems to have broad medicinal uses, there have been reported adverse reactions, including amenorrhea, mastalgia, and postmenopausal bleeding in women. One small French study showed an increase in the CPK levels of guinea pigs that were administered ginseng in comparison with those administered placebo. No human cases of myopathy have been reported.

    The present case provides strong anecdotal evidence for a cause-and-effect relationship between the ingestion of Chinese red rice and the development of myopathy. The patient developed symptoms and laboratory findings of a myopathy after beginning to ingest Chinese red rice. These symptoms completely resolved after discontinuation. With resumption of Chinese red rice consumption, the patient's CPK level increased again. Although we cannot entirely exclude the possibility that his symptoms were related to the use of ginseng, ginseng-related myopathy has not been reported in humans. Furthermore, it is biologically plausible that Chinese red rice could cause myopathy, because it contains lovastatin.
    Italics mine.
    Experienced Community organizer. Yeah, let's choose him to run the free world. It will be historic. What could possibly go wrong...

    "You're just a jaded cynical mother****er...." Jeffpeg

    (more comments in my User Profile)

  • #2
    A synopsis on Red Yeast Rice, and the dangers inherent thereof:

    Red yeast rice is a traditional Chinese medicinal agent prepared by culturing the yeast Monascus purpureus with rice. This process produces a group of compounds called monacolins. Monacolin K is lovastatin, the first commercially available statin on the market. Some of the other monacolins may have HMG-CoA reductase inhibitory effects also. In addition, some of the red yeast rice preparations contain phytosterols. The red yeast rice preparations that are available may contain different amounts of monacolin K ranging from nearly undetectable levels to the equivalent of approximately 10 mg of lovastatin. A recent survey of 12 commercially available products indicated that the mean dose of lovastatin was approximately 6 mg/day. A randomized controlled trial using one particular formulation of red yeast rice for 12 weeks achieved a 22% reduction in LDL-C.

    Red yeast rice has been used as an alternative to statins in statin-intolerant patients. A small survey of 25 patients unable to tolerate statins due to myalgias, gastrointestinal symptoms and liver enzyme abnormalities showed that red yeast rice was well tolerated, and that 92% were able to remain on therapy. The mean reduction in LDL-C in patients unable to tolerate statins was 19%. A randomized trial of 62 patients who discontinued statins due to myalgias compared red yeast rice with placebo over a 24-week period. There was a 21% reduction in LDL-C at 24 weeks. There was no difference in pain severity scores between the placebo or red yeast rice groups. Red yeast rice was compared with pravastatin in 43 patients with a history of statin discontinuation because of myalgias. LCL-C decreased by 30% in the red yeast rice group and 27% in the pravastatin group. Withdrawal from medication due to myalgias occurred in 5% (one patient) of the red yeast rice group and 9% (two patients) in the pravastatin group after 12 weeks. Although red yeast rice has a natural statin as its main lipid-lowering agent, it seems to be tolerated, probably because only low doses of the statin are present. The lipid-lowering effect may be enhanced by phytosterols that are present in many of the products. Because red yeast rice does contain a statin, however, there have been reports of myalgias and one case of rhabdomyolysis attributed to red yeast rice.

    There are major concerns about red yeast rice as a long-term medicinal agent. Red yeast rice is considered a food or dietary supplement, but because it contains lovastatin, the US FDA has taken action against several of the products. Some of these products have been reformulated and no longer contain appreciable amounts of lovastatin. In addition, if the red yeast rice is not fermented correctly, the contaminant citrinin can be present. Citrinin is potentially nephrotoxic and may be cancer causing. In a recent survey of 12 commercially available red yeast rice products, one-third contained the potentially toxic citrinin. Because of the lack of standardization and concern about the presence of mycotoxins, caution will need to be used when considering the use of these products.

    Matthew J Sorrentino
    Experienced Community organizer. Yeah, let's choose him to run the free world. It will be historic. What could possibly go wrong...

    "You're just a jaded cynical mother****er...." Jeffpeg

    (more comments in my User Profile)


    • #3
      I hear it delicious when coupled with River Pig.


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