Red yeast rice (RYR) is a Chinese herbal supplement produced by fermenting white rice with the yeast, Monascus purpureus. The Chinese have used RYR to flavor, color, and preserve foods and as a traditional medicine for many years. In the USA, RYR has been used as an alternative to statin therapy in treating patients with mild to moderate hypercholesterolemia. RYR contains a variety of monacolins, which inhibit hydroxymethylglutaryl-coenzyme A (HMG CoA) reductase, the rate-limiting step in cholesterol synthesis. Consumption of RYR has increased recently especially among patients who might be intolerant to standardized therapy due to statin-associated myalgia (SAM). Several clinical trials have shown RYR to be safe, effective, and well tolerated; however, the studies are small and of short duration. The US Food and Drug Administration has prohibited the sale of all RYR products containing monacolin K, which is chemically identical to lovastatin, because it is considered an unapproved drug. However, many RYR supplements continue to remain on the market and lack standardization and quality control.