Death Knell For Niacin For Lipids Sounded by FDA?

The skeptical cardiologist stopped writing new prescriptions for niacin extended release tablets in 2011. For any patient who was taking niacin, I recommended stopping it.

Because niacin had favorable effects on the cholesterol profile, physicians had been utilizing it for many years in high risk patients on statins who had low HDL  (good cholesterol) and/or high triglycerides.

The rationale was that, since high HDL was associated with lower risk of heart attacks, raising the HDL would lower that risk. Similarly, lowering the triglycerides would improve cardiovascular risks.

While niacin certainly improved the cholesterol profile, there was no good evidence that starting it in a patient already on statin would improve cardiovascular outcomes. The cholesterol profile is a surrogate endpoint: the actual treatment goal is reducing cardiovascular disease.

In 2011, the AIM-HIGH study proved there was no benefit to adding niacin to good statin therapy despite increasing HDL from 35 to 42 mg/dl, lowering triglycerides and lowering LDL. This and other studies showing no benefit of niacin therapy (and worrisome adverse effects) should have resulted in the total cessation of niacin prescriptions, especially  in patients on statins.

Unfortunately, old habits die hard amongst physicians, and the allure of raising HDL and lowering triglycerides with niacin persisted despite a lack of evidence of any benefit in lowering cardiovacular risk.

Yesterday, the FDA announced it was removing from the market two  drugs made by Abbvie, Advicor and Simcor, which are combinations of extended release niacin plus lovastatin or simvastatin, and removed its approved indication for niacin ER plus statin for lowering CHD risk stating:

“Based on the collective evidence from several large cardiovascular outcome trials (Refs. 1-3), the Agency has concluded that the totality of the scientific evidence no longer supports the conclusion that a drug-induced reduction in triglyceride levels and/or increase in HDL-cholesterol levels in statin-treated patients results in a reduction in the risk of cardiovascular events. Consistent with this conclusion, FDA has determined that the benefits of niacin ER tablets and fenofibric acid DR capsules for coadministration with statins no longer outweigh the risks, and the approvals for this indication should be withdrawn.”

This is good news for patients whose physicians were keeping them on the unproven brand name combination drugs, Advicor and Simcor.

There are still legitimate uses of niacin to prevent vitamin deficiencies but If you are still taking some form of niacin ER for the purpose of preventing heart disease with or without a statin I recommend presenting your doctor with the link to the FDA pronouncement above and having a good discussion with him about the rationale for staying on it.

The other drug mentioned in the announcement, fenofibric acid,  is far less often prescribed and is not available as a combination. It is the most effective drug we have for extremely high triglyceride levels over 500 mg/dl which can cause pancreatitis. I have a few patients on the generic fenofibric acid strictly for the purpose of lowering their dangerously high triglycerides but not for the indication of lowering their cardiovascular risk.

Nonsurrogateingly Yours

-ACP

 

8 thoughts on “Death Knell For Niacin For Lipids Sounded by FDA?”

  1. Many Neuroendocrine Tumour patients take Niacin supplements as they are risk of a deficiency due to their surgery and or treatment (this in turn has the potential to cause malabsorption of key nutrients. I personally don’t but I know many who do. I was therefore interested in your statement “If you are still taking some form of niacin ER with or without a statin …….” Do you have any views on the use of Niacin supplements for those with potential nutrient deficiencies or has this aspect of Niacin got nothing to do with the FDA action? Thanks in advance,

    1. Thanks for that comment, Ronny. This post entirely was directed toward niacin for cardioprevention and lipid treatment.
      I modified the title and the sentence you referenced to clarify that.

  2. Thanks for the post Dr. Pearson. I’m curious what your view is for patients that are statin intolerant. My experience with a variety of statins was miserable. The solution, in terms of lowering my LDL (I won the lottery in the FH contest!), was Zetia and Niacin. These two medicines have lowered my LDL from 150ish to 80ish. However, your comment about the “actual treatment goal is reducing cardiovascular disease.” hits the mark. I’ve taken the approach of “doubling down;” using a low carb diet to reduce the “insulin hit” and taking the zetia/niacin combo. But, as an “N of one” (and having a cardiologist who is open to alternative solutions), I’m very interested on better treatment approaches. Thanks for you comments.

    1. Based on some intriguing findings from the GAUSS-3 trial at the recent ACC meetings (mentioned in a previous post) I have revisited muscle related statin intolerance and was hoping to write a post on it soon. I will assume your side effect from statins is muscle ache.
      I will also assume you have taken at least two statins and developed significant muscle ache on them that resolved within two weeks of stopping. The GAUSS trial showed a large number of patients developing muscle ache on placebo, the so-called nocebo effect.
      My approach is as follows in a patient who really needs cholesterol lowering therapy (see my posts on detecting subclinical atherosclerosis)
      -trial of crestor 5 mg twice weekly or livalo 2 mg twice weekly. In the past I have added coq10 and checked Vit D levels. If symptoms develop on this then I give up on statins
      -I offer patients zetia (see my post on finally seeing data that this drug lowers CV risk after 12 years on the market) or cholestyramine.
      -I don’t prescribe niacin, no data on outcomes.

    1. Thanks for your comments. I have reviewed HPS2-Thrive. Although Europeans did better than Chinese with niacin this was nonsignificant. Most participants were male and they fared a little better with niacin but again this was a nonsignificant difference.
      With multiple subgroup analyses the possibility of a chance difference becomes much more likely.
      The authors concluded that any subgroup differences were not clinically significant.
      Reviewing the study again I’m struck by the marked increase in side effects in patients receiving niacin, the lack of benefit in reducing vascular events and although, not quite reaching significant the 9% increase in total mortality on patients receiving niacin.
      After that study I stopped writing niacin prescriptions and stopped the drug on patients taking it and nothing since then has changed my practice pattern.

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