Are there any natural bile acid sequestrants?

Natural Bile Acid Sequestrants: Options and Evidence

Psyllium (Metamucil) is the most effective natural bile acid sequestrant, with documented ability to bind bile acids and reduce cholesterol levels, making it a viable natural alternative to synthetic sequestrants like cholestyramine.

Natural Bile Acid Sequestrants

Bile acid sequestrants are compounds that bind bile acids in the intestine, preventing their reabsorption and promoting their excretion. While pharmaceutical options like cholestyramine, colestipol, and colesevelam are well-established, several natural alternatives exist:

Evidence-Based Natural Options

1. Psyllium (Metamucil)

   • Most well-documented natural bile acid sequestrant
   • Soluble fiber that effectively binds bile acids 1
   • Demonstrated ability to reduce cholesterol levels
   • Recommended in clinical guidelines for hypercholesterolemia 2

2. Other Plant-Based Fibers

   • Guar gum: Soluble fiber shown to reduce bacterial conversion of primary bile acids 1
   • Wheat bran: Insoluble fiber that increases fecal mass and dilutes fecal steroids 1
   • Alfalfa: Insoluble fiber with bile acid binding properties 1

3. Biopolymer-Based Options

   • Natural polymers including cellulose, dextran, pullulan, and methylan can function as bile acid sequestrants 3
   • These natural polymers have shown potential in laboratory studies but have less clinical evidence than psyllium

Clinical Applications

Bile acid sequestrants are used primarily for:

1. Hypercholesterolemia management

   • Natural sequestrants like psyllium can lower LDL cholesterol by 5-15% 2
   • Often used as adjuncts to statins or in statin-intolerant patients 2

2. Bile acid diarrhea treatment

   • Bile acid sequestrants are first-line therapy for bile acid diarrhea 4
   • Natural options like psyllium may help manage symptoms but have less evidence than pharmaceutical options

Comparative Efficacy

Sequestrant Type	Bile Acid Binding Capacity	LDL Reduction	GI Side Effects
Cholestyramine (synthetic)	High	15-26%	Moderate-High
Psyllium (natural)	Moderate	5-15%	Low-Moderate
Other natural fibers	Low-Moderate	Variable	Low

Important Considerations

• Medication Interactions: All bile acid sequestrants (natural and synthetic) can interfere with absorption of medications 2

  • Take other medications at least 2 hours before or 4-6 hours after bile acid sequestrants

• Dosing: Higher doses of natural sequestrants are typically needed compared to synthetic options

• Contraindications:

  • Bowel obstruction
  • Complete biliary obstruction
  • Severe constipation

• Monitoring: When using any bile acid sequestrant, monitor for:

  • Constipation (most common side effect)
  • Fat-soluble vitamin deficiencies with long-term use
  • Triglyceride levels (may increase with some sequestrants) 2

Clinical Decision Making

For patients seeking natural bile acid sequestrants:

1. First choice: Psyllium (Metamucil) - best evidence among natural options
2. Alternative options: Guar gum, wheat bran, or mixed fiber supplements
3. For severe bile acid diarrhea: Consider starting with a pharmaceutical option like cholestyramine or colesevelam, as these have stronger evidence for efficacy 4

Remember that natural bile acid sequestrants generally have weaker binding capacity than pharmaceutical options, so higher doses may be needed to achieve similar effects.