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Niacin
I want to get back to discussing lipid modulating drugs. I have been getting many questions regarding niacin on my message board and what it exactly does. I know there is a lot of information out there that it is some kind of wonder drug that raises your HDL-C (good cholesterol) and keeps you from having heart attacks. This is only partly true. As I have said many times before, there is no way to measure how well HDL-C functions. We only measure a number. In other words there is no qualitative test to measure how well the HDL-C works in our bodies, but only a quantitative test. There has never been a prospective randomized study done to correlate an HDL-C level with an outcome. I am not sure that following the HDL-C in patients on niacin tells us anything. Let's talk about what niacin really does.
First of all, niacin is a member of the B-vitamin family and is sometimes referred to as vitamin B3. It is a soluble B vitamin that impacts all lipid subfractions but is not widely used because of the associated side effects. Niacin-induced flushing, which is the result of vasodilatation of the blood vessels, is the most common side effect and usually occurs within 20 minutes following ingestion and may last for up to 60 minutes.
The way niacin works is rather complicated, but in addition to its antiatherogenic activity, the primary use of niacin is to lower triglyceride levels. Niacin reduces the mobilization of free fatty acids from fatty tissue resulting in reduced secretion of VLDL-P from the liver which is a precursor of LDL-P. While it does lower LDL-C, LDL-P, and apoB, this occurs through its triglyceride lowering abilities. Niacin also increases HDL-C. Although niacin does lower Lp(a), in my previous posting I stated that the goal is to lower LDL-P and statins are the primary to drug to perform this function.
Niacin has been associated with abnormal liver tests and causes significant liver toxicity. It should be discontinued if the liver enzymes (ALT/AST) exceed 3X the upper limit of normal. The use of over-the-counter niacin should be discouraged. Many of these preparations are not labeled as sustained release and when combined with a fiber (an example would be oat bran) can become sustained release and adversely affect the liver enzymes. Food maximizes the availability of niacin. It can raise uric acid levels and should be used cautiously in patients with gout.
As I stated earlier, the most common complaint is flushing and this occurs in all patients treated with therapeutic doses of niacin. This is also the most common reason patients stop using the medication. This can be minimized by pretreatment with aspirin or Motrin. Flushing is increased when taken with hot beverages. Gastritis and peptic ulcer disease are also some of the most common reasons for inability to tolerate niacin. Hyperglycemia occurs in patients taking niacin. Patients who are borderline diabetics can become overtly diabetic although data from the ADMIT trial indicate that it can be used safely in diabetics.
Although we still await serious outcome data with niacin, there is good data from very small trials that adding niacin to a statin lessens the thickness of the carotid arteries (CIMT), improves findings on angiograms, and reduces clinical events (the FATS and HATS trials). We await confirmation of this in the much larger AIM HIGH trial which is currently underway. They are not seeing the 90% reduction in clinical events in the AIM HIGH trial that occurred in HATS or the trial would have been stopped for ethical reasons.
In conclusion, while niacin is a drug that should be kept in the armamentarium of a physician that practices lipidology, it should not be used as a first line drug to lower LDL-C or LDL-P. I primarily use it in patients with high triglycerides with known coronary artery disease - in addition to a statin. As I write about in every posting, the name of the game to ensure cardioprotection is to lower LDL-P or apoB and this is now recommended by the American Diabetic Association and American College of Cardiology as a standard of care in patients with moderately high, high, or very high cardiometabolic risk. The full text can be found on my website at www.lipidcenter.com.
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First of all, niacin is a member of the B-vitamin family and is sometimes referred to as vitamin B3. It is a soluble B vitamin that impacts all lipid subfractions but is not widely used because of the associated side effects. Niacin-induced flushing, which is the result of vasodilatation of the blood vessels, is the most common side effect and usually occurs within 20 minutes following ingestion and may last for up to 60 minutes.
The way niacin works is rather complicated, but in addition to its antiatherogenic activity, the primary use of niacin is to lower triglyceride levels. Niacin reduces the mobilization of free fatty acids from fatty tissue resulting in reduced secretion of VLDL-P from the liver which is a precursor of LDL-P. While it does lower LDL-C, LDL-P, and apoB, this occurs through its triglyceride lowering abilities. Niacin also increases HDL-C. Although niacin does lower Lp(a), in my previous posting I stated that the goal is to lower LDL-P and statins are the primary to drug to perform this function.
Niacin has been associated with abnormal liver tests and causes significant liver toxicity. It should be discontinued if the liver enzymes (ALT/AST) exceed 3X the upper limit of normal. The use of over-the-counter niacin should be discouraged. Many of these preparations are not labeled as sustained release and when combined with a fiber (an example would be oat bran) can become sustained release and adversely affect the liver enzymes. Food maximizes the availability of niacin. It can raise uric acid levels and should be used cautiously in patients with gout.
As I stated earlier, the most common complaint is flushing and this occurs in all patients treated with therapeutic doses of niacin. This is also the most common reason patients stop using the medication. This can be minimized by pretreatment with aspirin or Motrin. Flushing is increased when taken with hot beverages. Gastritis and peptic ulcer disease are also some of the most common reasons for inability to tolerate niacin. Hyperglycemia occurs in patients taking niacin. Patients who are borderline diabetics can become overtly diabetic although data from the ADMIT trial indicate that it can be used safely in diabetics.
Although we still await serious outcome data with niacin, there is good data from very small trials that adding niacin to a statin lessens the thickness of the carotid arteries (CIMT), improves findings on angiograms, and reduces clinical events (the FATS and HATS trials). We await confirmation of this in the much larger AIM HIGH trial which is currently underway. They are not seeing the 90% reduction in clinical events in the AIM HIGH trial that occurred in HATS or the trial would have been stopped for ethical reasons.
In conclusion, while niacin is a drug that should be kept in the armamentarium of a physician that practices lipidology, it should not be used as a first line drug to lower LDL-C or LDL-P. I primarily use it in patients with high triglycerides with known coronary artery disease - in addition to a statin. As I write about in every posting, the name of the game to ensure cardioprotection is to lower LDL-P or apoB and this is now recommended by the American Diabetic Association and American College of Cardiology as a standard of care in patients with moderately high, high, or very high cardiometabolic risk. The full text can be found on my website at www.lipidcenter.com.
Related Topics:
28 Comments:
Thank you for the excellent posting Dr. Richman! I have been waiting to hear what the facts are about Niacin. There is so much garbage on the internet about cholesterol medications and I get confused. Thanks you for giving me the medical facts. I am tired of everybody's own opinion which has no basis in scientific fact.
I second anonymous's post! Thank you Dr. Richman. My question is there a "safer" statin? I'm diong all I can to battle high cholesterol, I work out religously, eat very well my weight is perfect for my size & age, but my cholesterol is high due to bad genes. Both my pasrents have high cholesterol as did their pearents. I had to get off them due to my muscles being attacked to where it hindered mny daily walking. Isn't there a "safer"statin? I just wish the drug companies could put out a safe drug for once! One that doesnt't treat one thing but degrades every organ in your body!
the flushing actually feels like a bad sunburn being carried by the blood its itchy and lasts about 30-60 min
Thank you for kind words. Niacin is not a statin. Statins are extremely safe and I think that by reading all my postings on the safety of statins I think you will understand this. These postings are available on this blog as well as in the educational resource section of my website at www.lipidcenter.com
Dr. Richman, Can you please post a blog about how an individual should go about finding a doctor who is trained in the techniques you mention, such as the NMR Lipoprofile? I live in a large city, and it is really hard to tell if a cardiologist is a specialist in preventative cardiology, let alone if they are trained to even run the NMR test and properly assess and treat based on the results. I would hate to be in a small rural town and have to muddle through all of this.
I would like to know about a test called a VAP panel for checking cholestrol? What does it check, and what is the difference between it and getting an NMR profile done?
Dr. Richman, thank you for the information on Niacin. I have just started taking it. 500mg. in the evening. I have not had any flushing or other side effects that I can feel, but it has only been two nights. Can I expect side effects as I continue taking Niacin? Is the Niacin suppose to increase HDL levels also?
Thank you for the cogent comments on Niacin. I participated in a Merck drug study--Niacin + X drug (to prevent the flushing side effect), and continued to take the available SR Niacin after the studies, as statins that I tried were intolerable to my system (muscle pain, fatigue). Whatever the study drug was, it was partially effective in eliminating the flushing effect, but during the study I had a number of episodes of "lightheadedness" to the point where I needed to sit down for a while feeling as if I may faint. I wouldn't take it for that reason if it were available. The flushing effect really isn't that bothersome once you are used to it, if it occurs--only occasionally in my case.
I am new to taking niacin and I am on TWO 500 mg tabs at bedtime. The flushing was horrible... I did not take the aspirin 30 minutes ahead of time. A few things concerned me about this article. Gout... I have it and take Allopurinol daily to prevent outbreaks. Will that be a problem or not? Second, how long does the lightheadedness remain. This morning I am very lightheaded and have the beginnings of a splitting headache. Is this from the niacin? Last, I can not take statins; my liver enzymes were in bad shape after a few months on the meds. Should I ask for something other than a statin and NOT NIACIN???
What I'm trying to find out is "What foods are high in niacin. My problem is low good cholesterol.
I was wondering, my doctor told me to take niacin because of my higher lipid count. It was recommended I take a baby aspirin 30 to 45 minutes before taking the niacin which I did. The flushing occured almost five hours later. I looked like I had been trapped in a tanning bed for a very long time and it was to the point of being almost painful.
I took my first Niacin (500 mg) last night. I took it with my statin & baby aspirin at bedtime. A little over an hour later, I thought I was being tortured. The "flushing" was unbearable. I felt like I took my worst sunburn ever, and multiplied it by 10. My skin hurt to touch. This lasted about 1 hour. I'm not sure I have the courage to try it again tonight, but if I do, I'll take the aspirin earlier...
I'm interested in knowing if anyone has success increasing HDL with Niaspan. I started on this road about 2 years ago after a heart attack. In my case, I took increasing dosages (500-1,500 mg)of slo-niacin over 1 1/2 years and had increase of HDL from 40 to 48. Then started 2000 mg of niaspan and over 6 months, HDL decreased to 42. Over this time my "heart habits" have been getting better (1 hour of exercise per day and low fat diet), and I've been taking Crestor for good LDL result. SO.. I'm very puzzled.
What is the reason that aspirin or motrin is suggested with niacin? Do their blood thinning capabilities help prevent or reduce the flushing?
Thank you.
I have been taking 1500mg of non flush niacin over the counter for almost two years and my HDL increased significantly but my LDL (bad) has not decreased much.
My Cardiologist recommended it after a angiogram.
I have taken the flush type in the past but why go through that if I don't have to.
All systems are good and I am 67 year old male.
I started OTC plain niacin at 100 mg to build up another 100 mg four days later in 4-day steps until I reached 1 gm. over a month. The effect raised my HDL to over 40, while zocor, vitorin, nor crestor would get it higher than 38. Triglycerides went from 200 to 85 with Vytorin, but it caused plantar fasciitis and shoulder pains plus debilitation. Niacin did the same to bring Trigs from 200 to 85 with NO pains. All readings are now borderline, better than both my doctor and cardiologist. Doctor recommended taking the full shot of 1500 mg niacin at night now to get the full effect. Male, 68
Do you have any comments on no flush Niacin.I have been taking 1500 mg and my blood test was pretty normal with the the exception of border line high LDL>
I am also curious about the non-flushing niacin. I began taking it recently to try and combat high cholesterol. Is it as effective as the "flushing" kind?
I'm not quite a month into taking Niaspan (500mg) and just had a second flushing which made me feel as if I was on fire plus extreme itching. I know I can't go through this again. Next week I'm to increase the dose. I could use a solution?
Dr. Richman,
Which is better slo niacin or immediate release and which has the least impact on the liver? Also, the heahaches,nausea side effects are they temporary or they stay with the usuage? how does wine effect the body if you are on niacin? if you go gradual increase from 50- 500 mg what is the best schedule? and can you just take the dosage in the morning and nothing during the day? please advice.
can you skip a day and give your body a break from niacin? how long of time frame is good to increase dosage?
I have been on Niacin therapy for a couple of years. I can tell you that there is a specific way to reduce the side affects. First of all take at least an 81mg aspirin 30 minutes before you take the Niacin. Two hours before you know you are going to take the Niacin, do not consume foods in high sugar. If you want a sncak before you take the Niacin at bedtime, eat a piece of cheese or something low in sugar and fat. I take 1000 mg at bedtime. It has helped.
If you are flushing, then you are not drinking enough water. Drinking a full glass of water when you flush relieves it immediately. Once I figured this out, have not had any issues. I also take a mini aspirin with my night dose.
I am very concerned about the levels of Niacin in the popular over the counter "Extreme Energy 6-hour Shot". This is the little bottle advertised all over the place to boost your engery without any crashing. I admit, I have used it and really like the effects, but I am very concerned about the 33mg level of Niacin. I have talked to my doctor about Niacin, but how much is too much.
I have high cholestrol my dad and brother died from heart attacks does this put me more at risk? If you are married does this better your chance to not have a heart attack?
If you have a comment about this blog post, you are in the right place. However, if you have a question for Dr. Richman, please visit him on the Cholesterol Management message board.
I would like to know Dr. Richman's thoughts on taking Niaspan when you have very low cholesterol and triglyceride levels (overall cholesterol 100, trigliycerid 66-72). I do have other risk factors, obesity, blood pressure(controlled) and diabetes(controlled).
Dear Sir, My Dr. put me on a 500 mg of Slo-Niain about a month ago, I have a headache every day at the base of my skull on my left side. I take 2 asprin plus an 800 mg of ibuprofen to ease the headache. my cholesterol runs about 125 and my triglicerides run about 350, it has ran high in my family for years. do I need to see my Dr. about my headaches or just push thru the medciation and hope that it gets better later ? I am on a 400 mg of time release high-blood psi pill ea day. I also take lopid and lovaza(just started about 1 month ago w / slo-niacin). I am curious to what I need to do ? Headache has been ongoing for about 3 weeks. Thanks Brian
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