Features February 2012 Issue

How Much will Niacin Help if LDL Levels are Already Low?

Cleveland Clinic experts raise questions about a recent niacin study.

Adding niacin to your cholesterol-control regimen may not further reduce your risk of cardiovascular events, including stroke and heart attack. A study in the Nov. 15 issue of the New England Journal of Medicine found that even though niacin can have a positive impact on HDL (“good”) cholesterol levels and triglycerides, patients who took niacin and who already had an LDL (“bad”) cholesterol level of 70 or lower did not see a significant reduction in major events.

However, the highly anticipated Atherothrombosis Intervention in Metabolic Syndrome with Low HDL Cholesterol/High Triglyceride and Impact on Global Health Outcomes (AIM-HIGH) trial was stopped 18 months ahead of schedule—it was designed to be a five-year trial—because there appeared to be a slightly higher rate of stroke among trial participant taking niacin. But further analysis of the results up to that point indicate that the rate of stroke may have had more to do with chance than with the niacin use.

The decision to halt the AIM-HIGH trial was greeted with a mixed response from physicians and researchers at the American Heart Association conference in Orlando in November 2011. Cardiologist and lipid expert Steven Nissen, Chairman of the Department of Cardiovascular Medicine at Cleveland Clinic, says he disagrees with the decision to stop the trial.

“Now we have lost the opportunity to properly answer the very important question of whether niacin adds any benefit in this population with low LDL levels,” he explains.

Dr. Nissen’s colleague at Cleveland Clinic, cardiologist and lipid expert Stephen Nicholls, MD, suggests that despite AIM-HIGH’s inconclusive findings, physicians and patients should make any treatment decisions about niacin based solely on this study.

“Niacin has many other beneficial effects on lipids as well as raising HDL,” he says. “It reduces triglycerides and Lipoprotein(a), and we have seen regression of atherosclerosis in imaging studies… In my view, there are patients with lipid abnormalities that should be treated with niacin.”

Niacin is a B vitamin that can help raise your levels of HDL cholesterol, which helps the body get rid of LDL cholesterol. So taking niacin should help improve your overall cholesterol profile. However, the medications also carry with them some fairly common side effects, such as flushing—an uncomfortable sensation of heat in the face and elsewhere on the body. But those side effects can often be addressed with smaller doses or a change in when you take niacin during the day or evening.

If you are taking statins to control you cholesterol and your doctor recommends niacin therapy, ask about the goals for niacin and how you should respond if you start to experience side effects.