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Niacin Therapy
By Chiayu Chen, M.D., F.A.C.C. and Jane Magro, F.N.P.,Riverside Cardiology Associates Medical GroupNiacin (nicotinic acid) has been used for many years to reduce elevated cholesterol and triglycerides. It is a B-vitamin (B-3), but when used in the doses necessary for blood cholesterol control, it is a drug and not a vitamin. It has side effects and should be treated with the same caution as other medications.
How Niacin Works
Niacin works by decreasing the liver's production of very low-density lipoprotein (VLDL), a relatively large particle comprised mainly of triglycerides and cholesterol. This leads to a decrease in the production of low density lipoprotein (LDL), which is the major carrier of cholesterol in your body. Another important and beneficial effect of Niacin is to raise the level of high-density lipoprotein (HDL) by decreasing the degradation rate of HDL. Finally, niacin also lowers triglycerides level.Clinical Studies and Indications
Niacin is most helpful in persons with LDL-pattern B (small dense LDL), low HDL cholesterol, high triglycerides, elevated Lp(a), and elevation in LDL cholesterol. Niacin has been shown to decrease cardiovascular events and mortality. Some degree of angiographic regression has also being shown with niacin when used with other cholesterol medications.Major Niacin Outcome Studies*:
| Study Name | Medication Regimen | Summary of Outcome |
| Coronary Drug Project (CDP) | Niacin alone | Decreased second infarct over 6 yrs; decreased total mortality at 15 years |
| Stockholm Ischaemic Heart Disease (IHD) Secondary Prevention Study | Niacin, clofibrate | Decreased total and cardiac mortality over 5 yrs. |
| Cholesterol-Lowering Atherosclerosis Study (CLAS I and II) | Niacin, colestipol | Decreased progression of atherosclerosis; regression in 16% of patients |
| Familial Atherosclerosis Treatment Study (FATS) | Niacin, colestipol | Regression of coronary disease; reduction in cardiovascular events |
| University of California-San Francisco Specialized Center of Research (UCSF-SCOR) | Niacin, colestipol, lovastatin | Regression of coronary disease |
| Harvard Atherosclerosis Reversibility Project (HARP) | Pravastatin, niacin, colestipol, gemfibrozil | 33% reduction in cardiovascular events; however, not statistically significant |
How is Niacin Supplied?
Niacin is available in immediate-release and extended-release forms. Immediate-release niacin can be purchased in drug stores and health food stores without a prescription. It is available in 100 mg, 250 mg, 500 mg, and 1000 mg tablets. We do not recommend the "no-flush" niacin.Sample brand of immediate-release niacin we recommend is:
Twinlab
Extended-release niacin we recommend is:
Niaspan® (KOS Pharmaceuticals, Inc.)- by prescription only
Side Effects
Remember that the use of niacin in high doses can cause serious side effects. Please only take niacin under the direct supervision of a physician. The most common side effect from niacin is flushing of the skin. This reaction is well documented and is mediated by a substance called prostaglandin.Flushing of the skin is commonly described as a redness or itching and tingling sensations that typically occurs on the face, neck, chest, and back. The flushing sensation can be a nuisance, but there is no cause to worry. The flushing sensation is usually transient and will go away within 10 to 60 minutes. As your body adjust to the niacin, the flushing will become milder and eventually resolve.
The following are some guidelines and tips to minimize the flushing side effects:
- Do not take niacin with hot beverage, alcohol, or spicy food.
- Titrate up the dosage VERY SLOWLY, every 3 to 7 days.
- Take the niacin with breakfast and dinner to avoid stomach upset and promote more even absorption.
- Take half of a regular adult aspirin twenty minutes before each niacin dose. You may need to take the aspirin for three to four weeks, until your system adjusts.
- Elevation in liver function test.
- Elevation in uric acid.
- Possible exacerbation of atrial arrhythmias.
- Rare occurrence of retinopathy.
- May exacerbate diabetes.
Sample dosing schedule for immediate-release niacin:
| Day # | Breakfast 100mg |
Dinner 100mg |
Total Dose per Day |
| 1 - 3 | 0 | 1 | 100 mg |
| 4 - 6 | 1 | 1 | 200 mg |
| 7 - 9 | 1 | 2 | 300 mg |
| 10 -12 | 2 | 2 | 400 mg |
| 13 - 15 | 2 | 3 | 500 mg |
| 16 - 18 | 3 | 3 | 600 mg |
| 19 - 21 | 3 | 4 | 700 mg |
| 22 - 24 | 4 | 4 | 800 mg ** |
The extended-release niacin we recommend is Niaspan®. Niaspan® was developed by Kos Pharmaceuticals, Inc., for a Once-a-Night ™ dosing. Niaspan® is available by prescription only up to 2000 mg a day. Niaspan® is much better tolerated as compared to the immediate-release niacin.
Warning
Do not switch between immediate-release niacin and the extended-release Niaspan® without notifying your physician. Serious side effects can result. Dosages of immediate-release and extended-release niacin are not interchangeable.Material copyright © 1999-2005 Riverside Cardiology Associates Medical Group
Reproduction in whole or in part in any form or medium without express written permission of Riverside Cardiology Associates Medical Group is prohibited.