Wednesday, February 1, 2012

Niacin " Aims High " and Missed

Hint - just read the bold print and save  77.2 seconds of your day

Niacin has never been one of my favorite medications and this study moved it a little further down, but did not completely drop it off of my list of medication to help lower Triglycerides and raise HDL. 

    ( Sorry ,   I am having a problem getting the chart to transfer )
I have attached a copy of an old study demonstrating the relationship between LDL cholesterol ,HDL Cholesterol and cardiovascular risk.  Look at the LDL of 100 and notice the small increment in cardiovascular risk reduction with 20mg/dl  increases in HDL . Now imagine  this same slide with and LDL of 70 mg/dl ( actually the LDL deceased from 74 to 62 ) and a 6mg/dl increase in HDL. It would be very difficult to pick up such a small difference in risk .

Also , with a Triglyceride  level of 164 mg/dl ( 1.85 mm/l ) your doctor would not have recommended Niacin. I would like to see a sub group analysis of patients with at least a triglyceride level over 200 mg/dl (2.2 MM/l )

Another study is in progress .HPS2-THRIVE , and may answer the question.

N Engl J Med. 2011 Dec 15;365(24):2255-67. Epub 2011 Nov 15.

Niacin in patients with low HDL cholesterol levels receiving intensive statin therapy.



In patients with established cardiovascular disease, residual cardiovascular risk persists despite the achievement of target low-density lipoprotein (LDL) cholesterol levels with statin therapy. It is unclear whether extended-release niacin added to simvastatin to raise low levels of high-density lipoprotein (HDL) cholesterol is superior to simvastatin alone in reducing such residual risk.


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). The primary end point was the first event of the composite of death from coronary heart disease, nonfatal myocardial infarction, ischemic stroke, hospitalization for an acute coronary syndrome, or symptom-driven coronary or cerebral revascularization.


A total of 3414 patients were randomly assigned to receive niacin (1718) or placebo (1696). The trial was stopped after a mean follow-up period of 3 years owing to a lack of efficacy. At 2 years, niacin therapy had significantly increased the median HDL cholesterol level from 35 mg per deciliter (0.91 mmol per liter) to 42 mg per deciliter (1.08 mmol per liter), lowered the triglyceride level from 164 mg per deciliter (1.85 mmol per liter) to 122 mg per deciliter (1.38 mmol per liter), and lowered the LDL cholesterol level from 74 mg per deciliter (1.91 mmol per liter) to 62 mg per deciliter (1.60 mmol per liter). The primary end point occurred in 282 patients in the niacin group (16.4%) and in 274 patients in the placebo group (16.2%) (hazard ratio, 1.02; 95% confidence interval, 0.87 to 1.21; P=0.79 by the log-rank test).


Among patients with atherosclerotic cardiovascular disease and LDL cholesterol levels of less than 70 mg per deciliter (1.81 mmol per liter), there was no incremental clinical benefit from the addition of niacin to statin therapy during a 36-month follow-up period, despite significant improvements in HDL cholesterol and triglyceride levels. (Funded by the National Heart, Lung, and Blood Institute and Abbott Laboratories; AIM-HIGH number, NCT00120289.).

Have fun , Be Smart and Defeat Heart disease and Diabetes.

 David Calder, MD

1 comment:

  1. This blog is great source of information which is very useful for me. Thank you very much.

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Your comments and questions are appreciated. David Calder,MD