By: Thomas Pickering, MD, DPhil, FRCP, Director of Integrative and Behavioral Cardiology Program
of the Cardiovascular Institute at Mount Sinai School of Medicine, New York.

Niacin was the first cholesterol-lowering medication proven to lower the death rate from coronary heart disease. It has been in use since the 1950s, but has never been very popular because it causes flushing. To get round this problem, several forms of sustained-release niacin have been introduced, which do cause less flushing, but have another undesirable side effect, namely liver damage. This is usually mild and can only be detected by increased blood levels of some of the enzymes made in the liver. Niaspan is a new sustained release formulation of niacin designed to be taken at night.

In a study of 269 patients with high blood cholesterol levels, Niaspan was given as a single nighttime dose of up to 3,000 milligrams, which was gradually increased from a starting dose of 375 milligrams (the average final dose was 2,000 milligrams). If the blood lipid reduction was not enough, another lipid-lowering drug was added (either a statin or questran). At the end of two years, the average reductions in the blood lipids was as shown in the Table.

Effects of Niaspan Alone and in Combination on Blood Lipids

	Niaspan alone	Niaspan + Statin	Niaspan +Questran
Total Cholesterol	Down 10%	Down 24%	Down 15%
LDL Cholesterol	Down 17%	Down 32%	Down 28%
HDL Cholesterol	Up 32%	Up 25%	Up 31%
Triglycerides	Down 26%	Down 32%	Down 31%

About half of the patients experienced some flushing in the first few weeks, but this wore off with time. Just under 5 per cent of patients had to stop taking the Niaspan because of flushing. Changes in liver enzymes occurred in 2.6 per cent of patients, and only one patient had to stop taking Niaspan because of this.

Doctors' comments

There is no doubt that, if it can be taken in a large enough dose, niacin is a very effective drug for lowering blood lipids and preventing heart disease. It is also a lot cheaper than many of the other drugs. As this study shows, it can also be used in combination with other drugs such as the statins and questran. The problem with niacin has always been the side effects, and it appears from this study that these may be less common with Niaspan taken at night than with other forms of niacin.

Where it was published