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Niacin
Aka: Niacin, Nicotinic Acid, Niacinamide, Vitamin B3, Simcor, Advicor, Cordaptive
- See Also
- Hyperlipidemia
- Indications
- Older indications that should be reconsidered in light of AIM-High Study (Niacin did not appear effective in these cases)
- Low HDL Cholesterol
- Combination therapy with Statin for Hyperlipidemia
- Indications that are reasonable as of 2013
- Hypertriglyceridemia
- Hyperlipidemia Management in patients intolerant to Statins
- Effects
- HDL increased (15-35%)
- No other agent raises HDL as much as Niacin
- However Niacin related HDL increase did not effect outcomes in 2011 AIM-HIGH study (prematurely stopped)
- Triglycerides decreased (20-50%)
- LDL Cholesterol decreased (10-25%)
- Significantly lowers LDL only at high dose
- Not a first-line agent for lowering LDL
- Efficacy
- Does not affect all cause mortality
- Statin with Niacin did not show benefit beyond Statin alone in AIM-HIGH study (2011)
- Studies since the 1980s to today have suggested coronary disease risk reduction, but benefit may be aside from affect on HDL Cholesterol
- Canner (1986) J Am Coll Cardiol, 8:1245 [PubMed]
- Lavigne (2013) J Am Coll Cardiol 61(4):440-6. [PubMed]
- Adverse effects
- Flushing
- Pruritus
- Skin irritation of neck and face
- Gastrointestinal upset (Dyspepsia, Diarrhea)
- Blurred Vision
- Fatigue
- Glucose intollerance
- Hyperuricemia and gout
- Peptic Ulcer Disease exacerbation
- Hepatic toxicity with sustained release forms
- Diabetes Mellitus (when Niacin is combined with a Statin)
- Increases risk of developing diabetes or worsening diabetes control
- (2014) N Engl J Med 2014 371:203-12 [PubMed]
- Adverse Effects: Compliance and tolerance
- Poor Compliance: 40% discontinue use
- Reduced Flushing and Pruritus reaction
- Use Aspirin or Ibuprofen pretreatment
- Take dose with food
- Contraindications
- Absolute
- Chronic Liver Disease
- Severe Peptic Ulcer Disease
- Relative
- Type II Diabetes Mellitus
- Severe gout
- Hyperuricemia
- Preparations: Niacin
- Crystalline Niacin
- Dose: 1g PO tid ($5.50/mo) MAX: 6 g/day
- Example protocol (Use 500 mg tablets)
- Start: 250 mg at bedtime
- Titrate up over 6 weeks to 500 mg tid
- Pretreatment: Aspirin 81 mg before or Ibuprofen
- Niaspan (preferred)
- Safest of Niacins (only 4% GI side effects)
- More expensive than crystalline Niacin
- Example protocol for initiating doses
- One 500 mg tablet PO qhs for 1 month
- Two 500 mg tablets PO qhs for 1 month
- One 1000 mg tablet PO qhs for 1 month
- Check lFTs, Uric Acid, Glucose at 3 months
- Two 1000 mg tablets PO qhs
- References
- McBride (2003) New Therapeutics Lecture, Cable, WI
- Agents to avoid
- Avoid flush-free or no-flush Niacin
- Avoid Slow Niacin (Sustained Release)
- Decreased Safety due to hepatotoxicity
- Preparations: Niacin combined with other agents
- Advicor: Niaspan (500-1000 mg) and Lovastatin (20-40 mg)
- Simcor: Niaspan (500-1000 mg) and Simvastatin (20 mg)
- Cordaptive: Niacin (extended release) with Laropiprant (to reduce Flushing)
- Monitoring: Monitor while checking dose
- Glucose
- Liver transaminases
- Uric Acid
- References
- Meyers (2003) Ann Intern Med 139:996-1002 [PubMed]
- Last (2011) Am Fam Physician 84(5): 551-8 [PubMed]
- Studer (2005) Arch Intern Med 165(7): 725-30 [PubMed]
- Sharma (2009) Ann Intern Med 151(9):622-30 [PubMed]