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A fair trial of the potential effectiveness of a niacin preparation on top of statin therapy should test niacin in a clinical setting in which it is typically prescribed. I’m not going far out on a limb by asserting that the majority of niacin prescriptions are written for patients who have low levels of high-density lipoprotein cholesterol (HDL-C), typically < 40 mg/dL but often much lower than that. Yet the mean HDL-C in the HPS2-THRIVE study was a robust 44 mg/dL, and the mean LDL-C level was a well-controlled 63 mg/dL. The subjects who were randomized to receive either placebo or niacin/laropiprant on top of their preexisting statin therapy were simply not the typical patients who would normally be started on niacin.
The supposedly airtight case against niacin isn’t really so strong after all. Where does this leave us? Let’s not forget that there is a sizable population of individuals who cannot or will not take statins. Surely these individuals would be better off on niacin therapy than on no therapy, particularly if they have a combination of low HDL-C levels, elevated triglyceride levels, and elevated LDL-C levels.
I currently prescribe this combination in patients who have persistently elevated triglyceride levels even after their statins have been maxed out, because I believe that lowering triglycerides in such patients may well translate into lower cardiovascular risk. Some recent evidence suggests that the epidemiologic association of low HDL-C levels with cardiovascular events may not be due so much to the low HDL-C levels per se, but rather to the very frequent association of elevated triglyceride levels—the true culprit, with low HDL-C levels. So if you have a need to lower either triglyceride levels or LDL-C levels in a patient already taking as much statin as they can tolerate, niacin would be a very reasonable drug to consider. My romance with niacin has been rekindled, and perhaps you’ll want to give it a second look as well.
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The author reports no actual or potential conflicts of interest with regard to this article.
Disclaimer
The opinions expressed herein are those of the author and do not necessarily reflect those of Federal Practitioner, Frontline Medical Communications Inc., the U.S. Government, or any of its agencies. This article may discuss unlabeled or investigational use of certain drugs. Please review the complete prescribing information for specific drugs or drug combinations—including indications, contraindications, warnings, and adverse effects—before administering pharmacologic therapy to patients.