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Steroids, Smoking, and Niacin: The Importance of Outcomes

Two big health news stories came out this week. The first is that “cell phones might cause cancer.” Not going to go there… But I was impressed to hear about the new data suggesting that increasing your HDL with niacin may not be such a great idea after all.

Niacin, also known as vitamin B3, has been demonstrated previously to increase HDL (good cholesterol). And we already know that having a higher HDL cholesterol is associated with a lower risk of cardiovascular disease. So that means that we should all be taking niacin to improve our HDL, right?

Not so fast. The purpose of this research trial was to demonstrate what has been assumed to be a beneficial impact from taking niacin on heart attacks and strokes. But it didn’t quite work out as planned. The study was halted prematurely because niacin didn’t help reduce risk. In fact, there was some concern that there could be a slightly increased risk of stroke related to taking niacin. This is still under some debate, given that several of the strokes in the individuals who were in the niacin group had actually stopped taking niacin for at least two months and up to four years before their stroke occurred. So no benefit, and possibly a small risk. We may never know, as I doubt that Abbott (the drug’s manufacturer) will be likely to put millions of dollars toward a future niacin research study, as they did for this one.

Today I saw a patient on both a statin and long-acting niacin, and he asked me, “How can this happen?” Why didn’t niacin improve cardiovascular outcomes, if (a) higher HDL cholesterol is associated with better outcomes, and (b) niacin improves HDL cholesterol?

It’s the link between (a) and (b) where you get into trouble. Let’s think about an entirely different example – body composition. We know that being leaner and more muscular is not only associated with better fitness, but also with lower risks of diabetes and heart disease. Let’s call that (a). So you might argue that becoming leaner and developing more muscle should be associated with lower cardiac risk. There are many ways to accomplish that. There’s exercise… and then there are steroids. Steroids may make you leaner. Steroids may increase your muscle mass. There’s your (b).

But steroids don’t lower your risk of heart disease. They increase it. There are other examples too – like the impact of cigarette smoking on body weight. No one is recommending that we start smoking to fight the obesity epidemic, right? But the challenge for lots of patients (and their cardiologists) is that lots of people are taking niacin right now. In a sense, they are already taking their figurative steroids and smoking their figurative cigarettes – on their doctors’ recommendations.

The moral of the story is that we should prescribe medications and perform procedures that have been proven to actually help people, not just make their laboratory tests look better.

If you are taking niacin, please talk to your doctor about the best game plan for you.

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