Your Cholesterol Profile - In Depth (cont.)
What is nicotinic acid (niacin)?
Nicotinic acid (niacin) is a B vitamin. An average American diet contains
15-30 mg of niacin per day. However, in treating blood cholesterol and
triglyceride disorders, high doses (1-3 grams a day) of nicotinic acid are
necessary. Nicotinic acid is available in several preparations that include
immediate release niacin, sustained release prescription brand Niaspan, and
over- the- counter (OTC) sustained release niacin. OTC preparations are not
federally regulated, and some OTC preparations may have no active ingredient.
Thus, they would be ineffective in either lowering LDL or raising HDL
cholesterol. Some formulations of OTC sustained release niacin have been
associated with liver toxicity and rare cases of fulminant (usually fatal
without liver transplantation) hepatitis have been reported. The prescription
brand sustained release Niaspan has been found in clinical trials to cause only
minor elevations in blood liver enzymes without causing significant liver
disease.
Nicotinic acid is most effective in increasing HDL cholesterol and it is also
modestly effective in lowering LDL cholesterol, Lp(a) cholesterol, and
triglyceride levels (see below). Nicotinic acid is most suited for individuals
whose only problem is low HDL cholesterol. Nicotinic acid used alone can raise
HDL cholesterol levels by 30% or more. Nicotinic acid is not as effective as a
statin in lowering LDL cholesterol levels. Therefore, when low HDL cholesterol
is accompanied by high LDL cholesterol, most doctors use a statin to decrease
the LDL cholesterol first. If necessary, nicotinic acid can be added to a statin
to further raise HDL cholesterol levels.
Advicor is a combination product approved for use in the United States. It is
a combination of sustained release niacin with lovastatin. Advicor is useful in
patients who need to both significantly lower their LDL cholesterol and increase
HDL cholesterol.
What are the side effects of niacin?
The most common side effect of nicotinic acid is a flushing (which can occur
in 80% of patients taking the immediate release crystalline preparations),
itching, and upset stomach. Other side effects include liver toxicity,
aggravating blood sugar levels in patients with diabetes mellitus, and
precipitating painful arthritis attacks in patients with gout.
The itching, flushing, and stomach upset can be partially alleviated by the
following measures:
- Taking nicotinic acid with meals.
- The sustained release Niaspan capsules release
nicotinic acid from the stomach into the blood circulation more gradually than
the immediate release preparations. Therefore, Niaspan produces a lower
incidence of upset stomach and skin flushing than the niacin immediate release
tablets.
- Pretreatment with aspirin 30 minutes prior to
nicotinic acid can reduce flushing.
- Initiating nicotinic acid treatment at low doses and
gradually increasing to the targeted dosage.
Liver toxicity with the immediate release nicotinic acid is usually mild and
in the form of abnormal elevation of liver enzymes in the blood, which
normalizes when nicotinic acid is stopped. Severe liver diseases, including
fulminant hepatitis (see above), have been reported, especially with the use of
over-the-counter sustained release formulations. The onset of liver damage with
nicotinic acid is unpredictable. Therefore, patients taking any nicotinic acid
preparations should have regular liver enzyme blood tests.
Next: What are fibric acid derivatives (fibrates)? »
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