Baltimore Health Examiner

Another option for improving your cholesterol: have you heard of niacin?

I’m sure you’ve heard of ‘statins’ like Lipitor ™, Zocor ™, and Pravachol ™.   These powerful cholesterol-lowering medicines are widely used – some people make jokes about adding them to the water supply.  If you aren’t taking one of them yourself, you certainly know someone who is.  

I have prescribed many statins myself and have been impressed with their powerful cholesterol-lowering powers, however I realize that some people worry about side effects.  If you choose not to take a statin, you have some other options.  One of those options is niacin.

Niacin has gotten a bad rap.  Many doctors, myself included, were taught that niacin is made essentially useless by its unbearable side effects.  Statins were touted as wonder-drugs and step-brother niacin was relegated to the musty basement.  

Niacin is having a comeback.

It turns out that while statins are good at lowering LDL (the ‘bad’ cholesterol), they are not so great at raising HDL (the ‘good’ cholesterol).  Having enough HDL is protective against cardiovascular disease.  This is where niacin shines.

HDL appears to have anti-inflammatory, antioxidant, and antithrombotic properties.  Thus, aggressively raising HDL as you lower LDL is thought to be important to maximally lower cardiac risk.  Lifestyle changes, particularly weight loss and exercise, can raise HDL but if that doesn’t work, niacin is your man.

A large research study, called the OCEANS study, looked at the safety and efficacy of niacin combined with simvastatin (a statin drug).  Not surprisingly, niacin did have the pesky side effect that I learned about in medical school – 71% of the patients experienced flushing.  However, most people rated the symptom as mild or moderate and it usually decreased over time.  Only 7% were bothered enough to discontinue the drug.  

The OCEANS study confirmed that the combination of niacin and a statin was safe and effective --  both LDL and triglycerides were decreased by approximately 50% and HDL was raised by about 25%.  

So if you are only on a statin, but not niacin, does that mean that your doctor is bad?  No, because the science is still evolving.  There have been some concerns about liver problems and elevated blood sugar caused by niacin, but recent studies have put some of those fears to rest.  To my knowledge, there has not been a large randomized study that evaluates how niacin alone, niacin plus a statin, and statins alone affect cardiovascular illness and mortality.  Once that happens we will have a clearer vision of how to best use medicines to protect you from a heart attack.  But until then, we are stumbling a bit in the dark.

If you are at significant risk of a heart attack and you have a low HDL (<40 in men or <50 in women), consider asking your doctor about niacin -- either alone or combined with a statin.  Remember that the flushing often goes away after a few weeks.  

If you use it, email me and tell me what you think.  Is the flushing unacceptable or just a nuisance?

My husband has a low HDL despite treatment with a statin.  Hmmmmm…………

Be well,

Dr. C

www.insightmedicalconsultants.com

Topics: cardiology

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