5 Steps to prevent Heart Disease

Saturday, March 19, 2016

New advice on not taking Niacin at night

From chapter 26 in

  Dyslipidemias Pathophysiology, Evaluation and Management Editors: Garg, Abhimanyu (Ed.)

I think it's clear that Niacin is still indicated for high LDLc and also should not be given at night based on the information below. 

In Tubby Theory from Topeka I advise low dose over the counter niacin in the form of Endur-acin 500 mg tablets.

I did this to improve compliance in my patients.  It was very difficult to get patients to take high dose
brand drug Niaspan due to flushing side effects.

Niaspan was also very expensive.

Endur-acin is a wax matrix preparation with very little flushing and very little side effects at the low dose of 1.000 mg.

Some experts say 1.000 mg is homepathic but in my experience with 200 patients this is not true.
Also when I studied for the NLA boards in 2008 I was taught in the following:

 Also the COMPELL trial is often ignored

Other references: 

1- Management of residual risk after statin therapy
Christina Reith  and Jane Armitage
Atherosclerosis 245 (2016) 161- 170

Curr Atheroscler Rep. 2016 Feb;18(2):11. doi: 10.1007/s11883-016-0563-8.

Niacin Alternatives for Dyslipidemia: Fool's Gold or Gold Mine? Part I: Alternative Niacin Regimens.

Dunbar RL1,2,3,4,5, Goel H6.

If Used At All, How Should Niacin Be Used?

If niacin is to be used to prevent MI, we find it harder to support the exploratory regimen based around the ER alternative.

Instead, the overall evidence supports a return to the established cardioprotective regimen, namely 1 g thrice daily with meals.

Practically, we find it surprisingly easy to switch patients from the ER alternative 2 g nightly to IR-niacin 1 g thrice daily, probably because they have substantial tolerance to NASTy symptoms by the time they accommodate 2 g of the ER alternative.

For patients intolerant, averse, or non-responsive to statins, this regimen remains evidence-based monotherapy to prevent MI, whereas under-dosing the ER alternative before the overnight fast provides little such assurance.

Whether niacin per se would benefit statin-responsive patients remains unanswered, since the established cardioprotective regimen has never been tested against a statin background.
For that matter, when introduced the statins were never subjected to the same standard of being formally tested against a niacin background to determine incremental benefit.
Thus, formal testing of incremental effects of new lipid drugs remains in its infancy, with much work to be done.
We submit the exploratory ER regimen (≤2 g/day) has thus far failed to impress because it strays so far from the established regimen, but not because of the delayed-release formulation itself.

Since the niacin pro-drug pentaerythrityl tetranicotinate also delays niacin release, niacin release rates may well prove immaterial.

Accordingly, were the established cardioprotective regimen tested against a statin background, we predict even the ER alternative dosed 1 g thrice daily with meals would prevent CHD among subjects with suboptimal lipids, much as the longer-acting pentaerythrityl tetranicotinate did.

That said, we suspect a more efficacious approach would be to combine the established cardioprotective regimen with the lipid-targeting strategy.

Thus, subjects randomized to niacin would receive the established cardioprotective regimen as a condition of enrollment, but would then titrate upwards if they were short of study-determined non-HDL-C and HDL-C goals, capped at the highest tolerated approved dose (i.e., up to 2 g thrice daily).

Niacin Alternatives for Dyslipidemia: Fool's Gold or Gold Mine? Part II: Novel Niacin Mimetics.

Goel H1, Dunbar RL2,3,4,5,6.
Two cardiovascular outcome trials established niacin 3 g daily prevents hard cardiac events. However, as detailed in part I of this series, an extended-release (ER) alternative at only 2 g nightly demonstrated no comparable benefits in two outcome trials, implying the alternative is not equivalent to the established cardioprotective regimen. Since statins leave a significant maximal HDL-C raising took well beyond 3 months
4- Safety Profile of Extended-release Niacin in the AIM-HIG trial NEJM 2014 371 288-290 July 17, 2014 

In the Tubby Theory from Topeka I advise 1,000 mg of niacin (Endur-acin or Slo-niacin a day)

In these studies:

 2 g of extended-release niacin and 40 mg of laropiprant or a matching placebo daily.

AIM-HIGH trial 
We randomly assigned eligible patients to receive extended-release niacin, 1500 to 2000 mg per day, or matching placebo. 
All patients received simvastatin, 40 to 80 mg per day, plus ezetimibe, 10 mg per day, if needed, to maintain an LDL cholesterol level of 40 to 80 mg per deciliter (1.03 to 2.07 mmol per liter). 

Finally back to Dr. John R Guyton Chapter 26. 

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