Niacin [1:05:15]
Peter Attia: I want to come back to, I made a note here to come back to VLDL remnants. I got another question on that. But, I do want to finish our tour of drugs. The next drug to then get into we’ve already kind of talked about a little bit, but I want to come back to it because I know you have a strong point of view on it, and I’ve got to be honest, I’m a little bit ambivalent. I don’t know the last time I prescribed this drug, but just from an intellectual standpoint, I’m always interested in these drugs for people who can’t go down a mainstream route and that drug of course is niacin. I don’t think there’s anybody out there that says, “Hey, niacin is first line.” I don’t think anybody would argue that.
Peter Attia: I think the question is you take a statin intolerant patient who’s got normal triglyceride, who maybe doesn’t respond particularly well to monotherapy Zetia, who can’t afford a PCSK9 inhibitor and doesn’t meet the regs for approval, are these patients who should be on niacin? I’ll go back to where we were earlier. Niacin exists in an immediate release in a time release form.
Tom Dayspring: Two types of time release forms.
Peter Attia: Oh, I didn’t even realize that.
Tom Dayspring: Intermediate release and sustained release.
Peter Attia: So Niaspan, the AbbVie [formerly called Abbott] version.
Tom Dayspring: That’s intermediate. That’s a prescription only product which are not gonna get covered by anything.
Peter Attia: I learned that the hard way because I had a patient that was on it a few years ago and he got a bill for like, they wanted $3,000 for it. For B vitamins. It’s ridiculous.
Enduracin 500 mg BID costs $100 for a 1,000 pills
Tom Dayspring: But if you somehow believe in niacin or want to give it a trial, immediate release and you got to give it three or four times a day at massive doses, you’ll flush your brains out most people. You’re gonna take it because you’re not flushing and niacin isn’t working.
Enduracin has a matrix matrix formulation that reduces flushing. If taken at !,000 mg a day with statin and zetia there is a good additional LDLc, apo B and LDLp decrease. As Tom wrote on Zetia, the lower the LDLc the better. Zetia does not lower apoB so well, according to Tom.
Tom Dayspring: But the sustained release is cheap. You can get sustained release, but the biggest problem was in clinical trials, niacin being the toxic drug it is, there’s way more hepatotoxicity with sustained release niacin than there is with the short release or the extended release where there’s no hepatotoxicity.
Tom is referring to high dose niacin trials.
Matthew Ito has studied Endur-acin and side effects not so dramatic.
Tom showed the Compell trial years ago. Now he says niacin 1,000 mg is a homeopathic dose.
Peter Attia: So first of all, niacin became interesting as you talked about, because it’s been known for a long period of time it lowers cholesterol. It lowered LDL cholesterol.
Tom Dayspring: Yeah, and better yet raised HDL cholesterol. That’s what everybody always focused on, everybody. Since low HDL cholesterol is a risk factor, we now know apoB related, but whatever, therefore if low HDL cholesterol is bad, raising HDL cholesterol has to be good and niacin is the best product you had at the time.
Tom Dayspring: So trials were done with niacin and it was kind of funny because I listened to the podcast you and Ron Krauss was kind of cool because you made the case a little bit for niacin, Ron did, but at the end as you just said, you’re ambivalent to it, and even Ron says, “I don’t use it much anymore.” You maybe wind up, okay, it’s a fourth line drug if everything else has failed. All right, I’m not gonna smack you around too much if you say that. And you can’t prescribe a PCSK9 inhibitor because of cost, all right. But, I think at the end of your podcast, go back and listen, you both admit it. You don’t use the darn drug anymore.
Pill burden might be an issue. But expensive IV Rx vs PO triple LOW DOSE Tx with statin, zetia and Endur-acin can give great results with few side effects.
Peter Attia: But I think the difference is, and this is where I’d love to hear your take, I think Ron’s point of view was the niacin trials may have failed for the same reason. The discussions we talked about earlier which was overly “statinized” patients. Now, you kind of had a different point of view on that, right?
Dayspring’s earlier opinion before this podcast.
Another opinion below.
Tom Dayspring: No, niacin has one trial designed to use niacin as a monotherapy. It was that big Coronary Drug Project, which was a multi-prong therapeutic trial where they randomized people to a bunch of drugs. One group was given solely thyroid hormone. Thyroid hormone lowers LDL-cholesterol and all they did was kill people by with coronary disease you give them thyroid hormone.
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