Niacin

Aka: Niacin, Nicotinic Acid, Niacinamide, Vitamin B3, Simcor, Advicor, Cordaptive

1. See Also
   1. Hyperlipidemia
2. Indications
   1. Older indications that should be reconsidered in light of AIM-High Study (Niacin did not appear effective in these cases)
      1. Low HDL Cholesterol
      2. Combination therapy with Statin for Hyperlipidemia
   2. Indications that are reasonable as of 2013
      1. Hypertriglyceridemia
      2. Hyperlipidemia Management in patients intolerant to Statins
3. Effects
   1. HDL increased (15-35%)
      1. No other agent raises HDL as much as Niacin
      2. However Niacin related HDL increase did not effect outcomes in 2011 AIM-HIGH study (prematurely stopped)
   2. Triglycerides decreased (20-50%)
   3. LDL Cholesterol decreased (10-25%)
      1. Significantly lowers LDL only at high dose
      2. Not a first-line agent for lowering LDL
4. Efficacy
   1. Does not affect all cause mortality
   2. Statin with Niacin did not show benefit beyond Statin alone in AIM-HIGH study (2011)
   3. Studies since the 1980s to today have suggested coronary disease risk reduction, but benefit may be aside from affect on HDL Cholesterol
      1. Canner (1986) J Am Coll Cardiol, 8:1245 [PubMed]
      2. Lavigne (2013) J Am Coll Cardiol 61(4):440-6. [PubMed]
5. Adverse effects
   1. Flushing
   2. Pruritus
   3. Skin irritation of neck and face
   4. Gastrointestinal upset (Dyspepsia, Diarrhea)
   5. Blurred vision
   6. Fatigue
   7. Glucose intollerance
   8. Hyperuricemia and gout
   9. Peptic Ulcer Disease exacerbation
   10. Hepatic toxicity with sustained release forms
   11. Diabetes Mellitus (when Niacin is combined with a Statin)
       1. Increases risk of developing diabetes or worsening diabetes control
       2. (2014) N Engl J Med 2014 371:203-12 [PubMed]
6. Adverse Effects: Compliance and tolerance
   1. Poor Compliance: 40% discontinue use
   2. Reduced Flushing and Pruritus reaction
      1. Use Aspirin or Ibuprofen pretreatment
      2. Take dose with food
7. Contraindications
   1. Absolute
      1. Chronic Liver Disease
      2. Severe Peptic Ulcer Disease
   2. Relative
      1. Type II Diabetes Mellitus
      2. Severe gout
      3. Hyperuricemia
8. Preparations: Niacin
   1. Crystalline Niacin
      1. Dose: 1g PO tid ($5.50/mo) MAX: 6 g/day
      2. Example protocol (Use 500 mg tablets)
         1. Start: 250 mg at bedtime
         2. Titrate up over 6 weeks to 500 mg tid
      3. Pretreatment: Aspirin 81 mg before or Ibuprofen
   2. Niaspan (preferred)
      1. Safest of Niacins (only 4% GI side effects)
      2. More expensive than crystalline Niacin
      3. Example protocol for initiating doses
         1. One 500 mg tablet PO qhs for 1 month
         2. Two 500 mg tablets PO qhs for 1 month
         3. One 1000 mg tablet PO qhs for 1 month
         4. Check lFTs, Uric Acid, Glucose at 3 months
         5. Two 1000 mg tablets PO qhs
      4. References
         1. McBride (2003) New Therapeutics Lecture, Cable, WI
   3. Agents to avoid
      1. Avoid flush-free or no-flush Niacin
      2. Avoid Slow Niacin (Sustained Release)
         1. Decreased Safety due to hepatotoxicity
9. Preparations: Niacin combined with other agents
   1. Advicor: Niaspan (500-1000 mg) and Lovastatin (20-40 mg)
   2. Simcor: Niaspan (500-1000 mg) and Simvastatin (20 mg)
   3. Cordaptive: Niacin (extended release) with Laropiprant (to reduce Flushing)
10. Monitoring: Monitor while checking dose
    1. Glucose
    2. Liver transaminases
    3. Uric Acid
11. References
    1. Meyers (2003) Ann Intern Med 139:996-1002 [PubMed]
    2. Last (2011) Am Fam Physician 84(5): 551-8 [PubMed]
    3. Studer (2005) Arch Intern Med 165(7): 725-30 [PubMed]
    4. Sharma (2009) Ann Intern Med 151(9):622-30 [PubMed]