Statins are the most common drugs administered for patients with cardiovascular disease. However, due to statin-associated muscle symptoms, adherence to statin therapy is challenging in clinical practice. Certain nutraceuticals, such as red yeast rice, bergamot, berberine, artichoke, soluble fiber, and plant sterols and stanols alone or in combination with each other, as well as with ezetimibe, might be considered as an alternative or add-on therapy to statins, although there is still insufficient evidence available with respect to long-term safety and effectiveness on cardiovascular disease prevention and treatment. These nutraceuticals could exert significant lipid-lowering activity and might present multiple non-lipid-lowering actions, including improvement of endothelial dysfunction and arterial stiffness, as well as anti-inflammatory and antioxidative properties. The aim of this expert opinion paper is to provide the first attempt at recommendation on the management of statin intolerance through the use of nutraceuticals with particular attention on those with effective low-density lipoprotein cholesterol reduction.

1st Department of Internal Medicine Faculty of Medicine Pavol Jozef Safarik University Košice Slovakia

1st Department of Internal Medicine Paracelsus Private Medical University Salzburg Austria

2nd Propaedeutic Department of Internal Medicine Medical School Aristotle University of Thessaloniki Hippocration Hospital Thessaloniki Greece

3rd Department of Internal Medicine 1st Medical Faculty Charles University Prague Czech Republic

Biomedical Department of Internal Medicine and Medical Specialties University of Palermo Palermo Italy

Biotechnology Research Center Pharmaceutical Technology Institute and Neurogenic Inflammation Research Center Mashhad University of Medical Sciences Mashhad Iran

Cardiology Clinic School of Medicine University of Athens Athens Greece

Cardiometabolic Service Department of Cardiology Royal Perth Hospital and School of Medicine University of Western Australia Perth Western Australia Australia

Cardiovascular Clinical Academic Group St George's Hospitals NHS Trust University of London London United Kingdom; IRCCS San Raffaele Roma Rome Italy

Clinic of Cardiology University Clinical Centre of Kosovo and the Medical Faculty University of Prishtina Prishtina Kosovo

Department of Cardiology and Pneumology University of Göttingen Medical Center Göttingen Germany

Department of Clinical Biochemistry Royal Free Campus University College London Medical School University College London London United Kingdom

Department of Epidemiology University of Alabama Birmingham Birmingham Alabama

Department of Functional Sciences Discipline of Pathophysiology Victor Babes University of Medicine and Pharmacy Timisoara Romania

Department of Hypertension Medical University of Lodz and the Polish Mother's Memorial Hospital Research Institute Lodz Poland; Cardiovascular Research Centre University of Zielona Gora Zielona Gora Poland

Department of Internal Medicine Centres Hospitaliers Jolimont Haine Saint Paul Belgium; Department of Cardiology Cliniques Universitaires Saint Luc Bruxells Belgium

Department of Internal Medicine Faculty of Medicine University of Debrecen Debrecen Hungary

Department of Laboratory Medicine AZ Sint Jan Hospital Bruges Belgium

Department of Medicine and Surgery Sciences University of Bologna Bologna Italy

Department of Medicine Division of Cardiology University of British Columbia Vancouver British Columbia Canada

Division of Clinical Pharmacology Division of Internal Medicine University of Kansas Medical Center Kansas City Kansas

Dyslipidaemia Department Institute of Cardiology AMS of Ukraine Kiev Ukraine

Faculty of Medicine and Institute of Cardiology and Regenerative Medicine University of Latvia Riga Latvia

Heart Disease Prevention Program Division of Cardiology University of California Irvine California

Institute of Cardiometabolism and Nutrition Endocrinology Department Hopital Pitié Salpetrière Paris France

Institute of Genetics and Animal Breeding of the Polish Academy of Sciences Jastrzebiec Poland; Department of Pharmacognosy University of Vienna Vienna Austria

Institute of Medical Physiology Richard Burian Faculty of Medicine University of Belgrade Belgrade Serbia

Mount Sinai Heart Icahn School of Medicine at Mount Sinai New York New York

National Cardiology Research Center Moscow Russia

Preventive Cardiology Unit Department of Vascular Medicine Division of Internal Medicine University Medical Centre Ljubljana and Faculty of Medicine University of Ljubljana Ljubljana Slovenia

School of Health Science and Education Department of Nutrition and Dietetics Harokopio University of Athens Athens Greece

University Hospital Centre Zagreb School of Medicine University of Zagreb Department of Internal Medicine Zagreb Croatia

University of Medicine and Pharmacy Carol Davila and Department of Cardiology University and Emergency Hospital Bucharest Romania

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